Fascial space priority approach for the management of the lateral ligaments in laparoscopic total mesorectal excision of
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Fascial space priority approach for the management of the lateral ligaments in laparoscopic total mesorectal excision of the rectum Y. Sun1 · Z. C. Zhang1 · Y. D. Zhou1 · P. Li1 · Q. S. Zeng1 · X. P. Zhang1 Received: 8 September 2020 / Accepted: 10 October 2020 © Springer Nature Switzerland AG 2020
Currently, nerve-sparing total mesorectal excision (TME) surgery is the most popular surgical procedure for lower rectal cancer. The posterior rectal space and anterior rectal space are widely recognized in TME surgery, but there is still controversy regarding the lateral rectal space and the lateral rectal ligaments [1]. Historically, surgeons believed that the lateral ligament of the rectum was where the neurovascular bundle and lymphatics entered the rectum, was located laterally to the mid-rectum, and needed to be sufficiently separated and dissected during the operation. However, anatomists argued that there is no traditional ligamentous structure, it is the fusion of parietal and visceral fascia laterally to the rectum and it is hard to identify in a fresh cadaver. The common ground is that it is a compact structure lateral to the rectum, hard to identify, in close relation to the hypogastric nerves and pelvic plexus [2, 3]. Thus, it is an important part of nerve sparing TME surgery and a challenging one. While recognizing the importance of the lateral ligaments, surgeons do not yet have an effective and universal method for the intraoperative management of these structures. With our technique, we excise the lateral ligaments with a fascial space priority procedure. This means we dissect the loose anatomical fascial space surrounding the rectum
first, so the lateral ligament is isolated like a bridge communicating between the fascia propria of rectum and the pelvic plexus, and can finally be detached along the top of the triangle shaped by the anterior and posterior plane of fascia propria of rectum (Fig. 1). The procedure is demonstrated in the attached video step by step. By giving priority to separation of the avascular anatomical spaces surrounding the rectum, a bloodless visual field is maintained, the fasciae surrounding the rectum are isolated intact, the integrity of the mesorectum is well maintained, and meanwhile the nerve fascia is well protected. Both hypogastric nerve trunks and the pelvic splanchnic nerves (S2–4) could be identified with naked eye, and the pelvic plexus and the NVBs were preserved bilaterally (Figs. 2 and 3). With this technique, the dissection of the lateral ligament is simplified and clear.
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s10151-020-02360-0) contains supplementary material, which is available to authorized users. * X. P. Zhang [email protected] 1
Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin 300000, China
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Fig. 1 The lateral ligament is isolated like a bridge communicating between the propria of rectum and the pelvic plexus. a The left lat
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