How to Optimize Autonomic Nerve Preservation in Total Mesorectal Excision: Clinical Topography and Morphology of Pelvic Nerves and Fasciae |
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Authors: | Nicolas Clausen Tanja Wolloscheck Moritz A Konerding |
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Institution: | (1) Department of General and Visceral Surgery, Ketteler-Hospital, Lichtenplattenweg 85, 63071 Offenbach, Germany;(2) Department of Anatomy, Johannes Gutenberg-University of Mainz, Mainz, Germany |
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Abstract: | Background Urogenital dysfunction after rectal and pelvic surgery was significantly decreased with the introduction of nerve-preserving
dissection and total mesorectal excision (TME). Profound topographic knowledge of the pelvic connective tissue spaces is indispensable
for identification and preservation of autonomic pelvic nerves. The purpose of this cadaver study was to highlight the course
of important autonomous nerve structures and to identify potential injury sites.
Methods Eleven cadavers were dissected according to TME with subsequent preparation of the pelvic nerves. The pelves of further three
cadavers were sliced horizontally and cubed. Specimens were harvested and processed for light microscopy and immunohistochemistry
to analyze both fascia and the types of nerves and their localization.
Results The neurovascular bundle, arising from the inferior pelvic plexus, shows the highest nerve density. At the lateral edge of
Denonvilliers’ fascia, it pierces the parietal pelvic fascia. Several fine nerve branches spread into the loose periprostatic
tissue up to the prostate or pass the prostate toward the urinary bladder. En route, we consistently find perikarya of autonomic
nerves. Within the mesorectum, nerve fibers are distributed heterogeneously with laterally high densities, ventrally and dorsally
low densities.
Conclusion The highest risk for pelvic nerve damage—apart from lesions of the superior hypogastric plexus itself—is anterolaterally of
the rectum where the neurovascular bundle releases from the pelvic sidewall. Careful dissection helps to identify and protect
these nerve structures. The retroprostatic Denonvilliers’ fascia contains no important nerve structures.
Presented at the 42nd World Congress of the International Society of Surgery (ISS/SIC), 26–30 August 2007, Montréal, Canada. |
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