Published online Jul 27, 2023. doi: 10.4240/wjgs.v15.i7.1465
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
The concept of membrane anatomy has been widely used in clinical practice, especially in rectal surgery and gynecology, but there are many differences between them. The hysterectomy includes a variety of procedures, and the radicality of hysterectomy was classified according to Querleu-Morrow classification. However, total mesorectal excision (TME) is currently the only surgical option for rectal cancer, regardless of tumor size, localization or even tumor stage. Therefore, it is necessary to establish a variety of surgical procedures apart from Heald’s TME for tailoring rectal cancer surgery.
Previous work has shown that there is an onion-like multilayered fascial structure around the rectum, with multiple spaces formed. According to the principle of membrane anatomy, we can take different spaces as the surgical plane to achieve radical resection according to local invasion of the tumor.
This study aims to establish a new classification for radical rectal cancer surgery on the basis of clarifying the three-dimensional membrane anatomy of the pelvic cavity.
Detailed pelvic dissections were performed on 26 cadavers, and surgical observations were conducted in 212 rectal patients undergoing laparoscopic TME with or without lateral lymph node dissection (LLND). A three-dimensional model of member anatomy of the pelvis was established, and the related anatomical nomenclatures were clearly clarified. Then, we proposed a membrane anatomical and staging-oriented classification for radical rectal cancer surgery.
Both cadaveric dissection and laparoscopic observation show that, 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). Thus, a new classification system for radical rectal cancer surgery was proposed based only on the lateral extent of resection. We described three types of radical surgery for rectal cancer, which can be precisely defined on a three-dimensional anatomical template, including a few subtypes that consider nerve preservation. The surgical planes of the proposed radical surgeries (types A to C) were located in the medial, middle, and lateral spaces, respectively. Types A surgery is a urogenital fascia-preserving procedure, type B surgery corresponds to the classical TME, and type C surgery is equivalent to TME plus LLND.
In this study, a new anatomical and staging-oriented classification system for rectal cancer surgery was established, and may serve as a valuable tool for unifying terminology and tailoring the radicality during surgery for rectal cancer.
We proposed a new and promising classification for radical rectal cancer surgery. However, this classification is established on the basis of anatomical and surgical concept and lacks the support of clinical outcome data, and therefore further clinical investigations are warranted to confirm its role.