Copyright
©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
Where is the optimal plane to mobilize the anterior rectal wall in female patients undergoing total mesorectal excision?
Wei Jin, Jun Yang, Xin-Yu Li, Wei-Cheng Wang, Wen-Jian Meng, You Li, Yi-Chao Liang, Yi-Ming Zhou, Xin-Dong Yang, Yang-Yang Li, Shao-Tang Li
Wei Jin, Jun Yang, Wei-Cheng Wang, Department of Colorectal and Anal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
Xin-Yu Li, Department of Gastrointestinal Surgery, The First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou 362002, Fujian Province, China
Wen-Jian Meng, Department of Gastrointestinal Surgery, West China Hospital. Sichuan University, Chengdu 610041, Sichuan Province, China
You Li, Department of General Surgery, Shanghai Jiao Tong University Medical School Affiliated Ruijin, Shanghai 201800, China
Yi-Chao Liang, Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang 111300, Liaoning Province, China
Yi-Ming Zhou, Department of General Surgery, Huashan Hospital Fudan University, Shanghai 201800, China
Xin-Dong Yang, School of Basic Medicine, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
Yang-Yang Li, Department of Pathology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
Shao-Tang Li, National Key Clinical Specialty (General Surgery), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
Author contributions: Li ST contributed to the study conceptualization and completed the dissection of cadavers; Li XY, Li Y, Liang YC, Zhou YM and Li ST provide clinical data; Li XY and Li Y reviewed the surgical videos; Jin W wrote the original draft of the manuscript and made the figures; Wang WC and Jin W finished the analysis of the data; Li XY, Zhou YM, and Yang J directly accessed and verified the underlying data; Li YY finished the pathological research; Yang XD finished the biostatistics jobs; All authors critically revised and approved the final manuscript.
Supported by Huadong Medicine Joint Funds of the Zhejiang Provincial Natura Science Foundation of China, No. LHDMY22H160002.
Institutional review board statement: The study was reviewed and approved by the Ethics Committee in Clinical Research of the First Affiliated Hospital of Wenzhou Medical University Institutional Review Board, No. KY2022-R088.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at lishaotang163@163.com.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Shao-Tang Li, MD, PhD, Chief Doctor, Doctor, Instructor, Professor, Surgeon, National Key Clinical Specialty (General Surgery), The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang Street, Ouhai District, Wenzhou 325000, Zhejiang Province, China. lishaotang163@163.com
Received: February 6, 2023
Peer-review started: February 6, 2023
First decision: March 20, 2023
Revised: April 3, 2023
Accepted: April 20, 2023
Article in press: April 20, 2023
Published online: May 21, 2023
BACKGROUND
Since Heald proposed the total mesorectal excision (TME) procedure, the prognosis of patients with rectal cancer has been significantly improved. But Heald did not specifically describe the anterior surgical plane in female patients. And the surgical plane for mobilizing the anterior rectal wall during TME surgery in female patients remains controversial.
AIM
To investigate the anatomy of the female pelvis and identify the optimal plane for mobilizing the anterior rectal wall.
METHODS
We retrospectively collected surgical procedure videos and clinical data of female patients diagnosed with middle or low rectal cancer who underwent the TME procedure between January 2020 and October 2022 across six hospitals. The patients were divided into two groups based on the surgical approach used to mobilize the anterior rectal wall: The experimental group was to open the peritoneum at the lowest point of the peritonea reflection and enter the plane for mobilizing, while the control group was cut at 0.5-1 cm above the peritoneal reflection and enter another plan. Then, we compared the preoperative and postoperative information between the two groups. We also dissected and observed ten adult female pelvises to analyze the anatomic structure and compare the entry plane between the two approaches. Finally, we researched the pathological structure between the rectum and the vagina.
RESULTS
Finally, 77 cases that met the criteria were included in our study. Our observations revealed that the experimental group underwent a smooth procedure, entering the plane amidst the mesorectal fascia and adventitia of the vagina, whereas the control group entered the plane between the vaginal adventitia and muscle layers. Compared to the control group, the experimental group showed a significant decrease in intraoperative bleeding [22.5 (19.5-50) mL vs 17 (5-20) mL, P = 0.01], as well as a shorter duration of hospitalization [9 (7-11.25) d vs 7 (6-10) d, P = 0.03]. Through the examination of surgical videos and cadaveric studies, we discovered that Denonvilliers' fascia is absent in females. Additionally, pathological sections further revealed the absence of Denonvilliers' fascia in females, with only loose connective tissue present between the mesorectal fascia and adventitia of the vagina.
CONCLUSION
The plane amidst the mesorectal fascia and vaginal adventitia is the optimal surgical plane to mobilize the anterior rectal wall for female patients undergoing the TME procedure.
Core Tip: In combination with the macroscopic and microscopic perspectives, we discovered that liberating the anterior rectal wall within a certain plane not only guarantees negative perirectal margins but also mitigates the potential for hemorrhage. This plane, situated amidst the mesorectal fascia and vaginal adventitia, proves to be the most advantageous approach for female patients undergoing total mesorectal excision.
