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
ARTICLE HIGHLIGHTS
Research background
Currently, there are no comprehensive descriptions available regarding the approach for dissecting the anterior wall of the female rectum. Many surgeons encounter intraoperative bleeding due to the lack of an appropriate dissection plane.
Research motivation
The surgical approach for mobilizing the anterior rectal wall during total mesorectal excision surgery in female patients remains controversial. However, with a more profound comprehension of the pelvic anatomy, we can identify the avascular plane, reducing intraoperative bleeding and preventing harm to physiological structures.
Research objectives
We aim to gain a better understanding of the female pelvic anatomy to identify an optimal approach for dissecting the anterior wall of the rectum. This will facilitate improved surgical outcomes for female patients with middle or low rectal cancer.
Research methods
Firstly, we retrospectively grouped patients based on different approaches after reviewing surgical videos. Clinical information was collected and pre-and post-operative data were compared, along with reviewing surgical videos to understand the anatomy and intraoperative situation. Subsequently, the female pelvic structure was studied through cadaveric dissection and histological sections.
Research results
We discovered that opening the peritoneum at the lowest point of peritoneal reflection allows access to the plane between the vaginal adventitia and mesorectal fascia. Opening the peritoneum 0.5-1 cm above the peritoneal reflection enters another plane located between the vaginal adventitia and vaginal muscle layer. The first approach has lower intraoperative bleeding and shorter hospital stay compared to the second approach. Neither cadaveric dissection nor pathological examination revealed the existence of Denonvilliers' fascia. Only loose connective tissue exists between the rectosacral fascia and the vaginal adventitia.
Research conclusions
Denonvilliers' fascia is absent in females. The plane amidst the mesorectal fascia and vaginal adventitia is the optimal surgical plane to mobilize the anterior rectal wall for female patients.
Research perspectives
In future studies, we will explore the long-term prognosis of the two approaches for women, as well as the impact on postoperative sexual and vaginal function.
