Observational Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Jul 27, 2023; 15(7): 1465-1473
Published online Jul 27, 2023. doi: 10.4240/wjgs.v15.i7.1465
New classification system for radical rectal cancer surgery based on membrane anatomy
Hui-Hong Jiang, Zhi-Zhan Ni, Yi Chang, A-Jian Li, Wen-Chao Wang, Liang Lv, Jian Peng, Zhi-Hui Pan, Hai-Long Liu, Mou-Bin Lin
Hui-Hong Jiang, Zhi-Zhan Ni, Yi Chang, A-Jian Li, Wen-Chao Wang, Liang Lv, Jian Peng, Zhi-Hui Pan, Hai-Long Liu, Mou-Bin Lin, Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai 200090, China
Hui-Hong Jiang, Yi Chang, Hai-Long Liu, Mou-Bin Lin, Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai 200090, China
Author contributions: Lin MB conceived the study; Jiang HH, Li AJ, Wang WC and Lin MB performed the study; Lv L, Peng J and Pan ZH helped collect the data; Chang Y and Liu HL analyzed and interpreted the data; Jiang HH and Ni ZZ drafted the manuscript and shared first co-authorship; and all authors have read and approved the final manuscript.
Supported by the National Natural Science Foundation of China, No. 81874201; Technology Plan Project, No. 20Y11908300; Shanghai Medical Key Specialty Construction Plan, No. ZK2019A19; Shanghai Municipal Commission of Health and Family Planning, No. 202040122; and Shanghai Pujiang Program, No. 21PJD066.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of Yangpu Hospital, Tongji University (LL-2020-SCI-001).
Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrollment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE statement, and the manuscript was prepared and revised according to the STROBE statement.
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: Mou-Bin Lin, MD, Surgical Oncologist, Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, No. 450 Tengyue Road, Shanghai 200090, China. 1500142@tongji.edu.cn
Received: February 1, 2023
Peer-review started: February 1, 2023
First decision: April 3, 2023
Revised: April 24, 2023
Accepted: May 25, 2023
Article in press: May 25, 2023
Published online: July 27, 2023
Processing time: 170 Days and 10.1 Hours
Abstract
BACKGROUND

Total mesorectal excision along the “holy plane” is the only radical surgery for rectal cancer, regardless of tumor size, localization or even tumor stage. However, according to the concept of membrane anatomy, multiple fascial spaces around the rectum could be used as the surgical plane to achieve radical resection.

AIM

To propose a new membrane anatomical and staging-oriented classification system for tailoring the radicality during rectal cancer surgery.

METHODS

A three-dimensional template of the member anatomy of the pelvis was established, and the existing anatomical nomenclatures were clarified by cadaveric dissection study and laparoscopic surgical observation. Then, we suggested a new and simple classification system for rectal cancer surgery. For simplification, the classification was based only on the lateral extent of resection.

RESULTS

The fascia propria of the rectum, urogenital fascia, vesicohypogastric fascia and parietal fascia lie side by side around the rectum and form three spaces (medial, middle and lateral), and blood vessels and nerves are precisely positioned in the fascia or space. Three types of radical surgery for rectal cancer are described, as are a few subtypes that consider nerve preservation. The surgical planes of the proposed radical surgeries (types A, B and C) correspond exactly to the medial, middle, and lateral spaces, respectively.

CONCLUSION

Three types of radical surgery can be precisely defined based on membrane anatomy, including nerve-sparing procedures. Our classification system may offer an optimal tool for tailoring rectal cancer surgery.

Keywords: Radical rectal cancer surgery; Classification system; Membrane anatomy; Total mesorectal excision; Lateral lymph node dissection

Core Tip: Total mesorectal excision (TME) is the only surgical option for rectal cancer. It is necessary to establish a variety of surgical procedures apart from Heald’s TME to tailor radical surgery for rectal cancer patients. In this study, we clarified the three-dimensional membrane anatomy of the pelvis and proposed a new anatomical and staging-oriented classification system comprising three types of radical rectal cancer surgery (types A to C). This classification may provide a useful tool for uniting terminology and tailoring rectal cancer surgery.