Dissection layer selection based on an understanding of pelvic fascial anatomy in transanal total mesorectal excision

Daichi Kitaguchi; Masaaki Ito

doi:10.3393/ac.2024.00178.0025

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Review Colorectal cancer Dissection layer selection based on an understanding of pelvic fascial anatomy in transanal total mesorectal excision: Daichi Kitaguchi, Masaaki Ito; Annals of Coloproctology 2024;40(4):375-383.
DOI: https://doi.org/10.3393/ac.2024.00178.0025
Published online: August 30, 2024

Department of Colorectal Surgery, National Cancer Center Hospital East, Chiba, Japan

Correspondence to: Daichi Kitaguchi, MD, PhD Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kahiwa, Chiba 277-8577, Japan Email: dkitaguc@east.ncc.go.jp
Co-correspondence to: Masaaki Ito, MD, PhD Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kahiwa, Chiba 277-8577, Japan Email: maito@east.ncc.go.jp

• Received: March 12, 2024 • Revised: June 21, 2024 • Accepted: June 24, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
HISTORICAL CHANGES IN RECTAL CANCER SURGERY
RECENT EVIDENCE ON TaTME
STEP-BY-STEP DISSECTION BASED ON ANATOMICAL LANDMARKS
ANASTOMOSIS FOLLOWING TaTME
LEARNING CURVE OF TaTME
CONCLUSION
ARTICLE INFORMATION
REFERENCES

Abstract

This study aimed to review the historical transition of rectal cancer surgery and recent evidence regarding transanal total mesorectal excision (TaTME). Additionally, it outlined the anatomical landmarks and technical considerations essential for successful TaTME. Anatomical studies and surgical techniques were analyzed to identify key landmarks and procedural steps crucial for TaTME. TaTME offers improved visibility and maneuverability even in the deep and narrow pelvis and is expected to contribute to tumor radical cure rates. By securing the circumferential resection margin and distal margin while preserving pelvic autonomic nerve function, TaTME holds promise for maintaining postoperative urinary and sexual functions. Key anatomical landmarks include the endopelvic fascia posteriorly, the S4-pelvic splanchnic nerve laterally, and the prostate or posterior vaginal wall anteriorly. Selecting the appropriate dissection layer based on tumor depth and ensuring precise incision of the tendinous arch of the pelvic fascia contributes to successful TaTME outcomes. TaTME represents a significant advancement in rectal cancer surgery, offering improved outcomes through meticulous attention to anatomical detail and precise dissection techniques. Understanding the historical context of rectal cancer surgery alongside recent evidence on TaTME is essential for optimizing patient outcomes and expanding the safe implementation of this innovative approach.
Keywords: Transanal endoscopic surgery; Proctectomy; Rectal neoplasms; Pelvis; Hypogastric plexus

INTRODUCTION

Transanal total mesorectal excision (TaTME) is a relatively new surgical approach for rectal cancer and is characterized by the transanal bottom-to-up dissection of the mesorectum via a platform inserted into the anus [1]. TaTME can provide excellent visibility and maneuverability even in a deep and narrow pelvis and is expected to contribute to the radical cure of tumors by securing the circumferential resection margin (CRM) and distal margin. Moreover, TaTME holds promise in preserving postoperative urinary and sexual function by protecting the integrity of the pelvic autonomic nerve system [2]. Another advantage of TaTME is that it can provide a highly reproducible transanal surgical field even under adverse conditions such as obesity, a narrow pelvis, a very large tumor, a massive uterine myoma, postradiation states, and previous pelvic surgical history. However, due to the intricate and relatively unfamiliar anatomy involved, the widespread adoption of TaTME has been limited by the need for comprehensive training and understanding for safe implementation [3].

Recently, the results of the Ta-LaTME study, a multicenter randomized controlled trial (RCT) comparing laparoscopic TME (LapTME) with TaTME versus LapTME alone for mid- and low-rectal adenocarcinoma, were published. The findings demonstrated a significantly lower rate of open conversion in the LapTME with TaTME group than in the LapTME alone group [4]. In contrast, there currently remains insufficient evidence regarding whether TaTME in combination with LapTME for mid- and low-rectal cancer improves oncologic outcomes, such as reduced CRM positivity and lower local recurrence (LR) rates, compared to conventional LapTME alone. Therefore, definitive conclusions must await findings from large multicenter RCTs, such as the COLOR III trial [5] and ETAP-GRECCAR11 trial [6], for definitive conclusions. However, if TaTME is shown to contribute to a lower CRM positivity, this can only be achieved with an appropriate and intentional selection of the dissection layer in the vicinity of the tumor. This means that the oncological benefits of TaTME cannot be fully exploited without a thorough understanding of transanal pelvic fascial anatomy.

This review aims to outline the historical evolution of rectal cancer surgery, provide an overview of recent evidence concerning TaTME, and delineate the transanal anatomical landmarks and step-by-step technical considerations necessary for selecting the dissection layer in TaTME. This involves anatomically dividing the circumference of the mesorectum into posterior, lateral, and anterior aspects.

HISTORICAL CHANGES IN RECTAL CANCER SURGERY

In 1908, Miles [7] published his method of performing abdominoperineal excision for rectal cancer in The Lancet. This was the first attempt to develop a radical operation that could cure rectal cancer; thereafter, Heald [8] first described TME in 1979. He also reported the importance of carefully and en bloc removing the rectum and mesorectum, surrounded by the mesorectal fascia (MRF), and recognizing the fascial layer, the “holy plane” that is the interface between the mesorectal and parietal fascia [9, 10]. In 1986, coinciding with the introduction of TME, Quirke et al. [11] introduced the concept of CRM as a major prognostic factor for rectal cancer resection specimens. The concepts of both TME and CRM have significantly contributed to fewer positive margins and, consequently, fewer cases of LR to this day [12].

One of the major historical changes in rectal cancer surgery was the introduction of intersphincteric resection, which was first proposed by Schiessel et al. [13] in 1994. Intersphincteric resection offers an excellent alternative to abdominoperineal resection, and many rectal cancer patients have been able to avoid permanent colostomy and achieve both satisfactory oncological outcomes and preservation of anal function [14–16]. The invention of the double stapling technique (DST) was also a major revolution in rectal cancer surgery. In 1980, Knight and Griffen [17] reported a rectal anastomotic technique in which the rectum was transected with a linear stapler, and the staple line was punched out with a circular stapler. In 1983, Cohen et al. [18] named this anastomotic technique “DST”. The establishment of DST enabled safe, reliable, and rapid anastomosis.

The introduction of minimally invasive surgery, including laparoscopic and robotic surgery, was another major advancement in rectal cancer surgery. The laparoscopic approach has enabled the recognition of fine anatomy through its magnifying visual effect and the performance of precise dissection, which could not be achieved with open surgery. Four large RCTs, ACOSOG Z6051 [19, 20], AlaCaRT [21, 22], COLOR II [23, 24], and COREAN [25, 26], are essential to the discussion of laparoscopic rectal cancer surgery. Although laparoscopic surgery did not meet the noninferiority criteria in the ACOSOG Z6051 and ALaCaRT trials in terms of composite pathological endpoints, all 4 trials successfully demonstrated no significant differences in 2- or 3-year survival outcomes between laparoscopic and open surgery.

Performing conventional laparoscopic surgery for low-rectal cancers within the constraints of a narrow pelvis poses technical challenges due to the restricted angulation of laparoscopic instruments. This challenge is particularly pronounced in obese patients and when the tumor is bulky [27]. Robotic assistance has the potential to overcome these limitations encountered in laparoscopic rectal cancer surgery. With its ability to offer an immersive three-dimensional depth of field, articulating instruments, and a stable camera platform, robotic surgery is anticipated to improve surgical precision and quality [28–31]. The 2 largest RCTs comparing robotic TME versus LapTME are ROLARR [32] and REAL [33]. The primary outcome assessed in ROLARR was conversion to open laparotomy. However, ROLARR did not demonstrate a significant reduction in this risk. In contrast, the secondary endpoints of REAL were CRM positivity and 30-day postoperative complications, and the REAL successfully demonstrated that robotic surgery resulted in better oncological quality of resection than conventional laparoscopic surgery, with less surgical trauma and better postoperative recovery. One contributing factor considered was that all participating surgeons in REAL were required to be highly skilled, performing a minimum of 100 laparoscopic or robotic operations for colorectal cancer annually.

RECENT EVIDENCE ON TaTME

TaTME is a minimally invasive surgical technique for performing rectal and mesorectal dissection from a “bottom-up” approach through a transanal platform. TaTME is commonly performed in conjunction with abdominal dissection to achieve comprehensive rectal and mesorectal mobilization, a surgical approach often referred to as "2-team surgery." In 2010, Patricia Sylla and Antonio Lacy performed the first hybrid TaTME on a patient with middle rectal cancer [1]. TaTME is widely regarded as superior to the conventional laparoscopic approach for rectal cancer treatment. Its advantages include ensuring an adequate distal margin and CRM, providing clear visibility of the pelvic autonomic nerves, and enabling the creation of a reproducible surgical field [34]. TaTME has gained popularity following reports of its feasibility and short-term effectiveness, which have been associated with promising results [35]. However, data from Norway indicating a high rate of early multifocal LR led to a national moratorium [3, 36]. Similarly, the Netherlands experienced an elevated LR rate during the implementation phase, particularly in the initial 10 cases [37]. Nevertheless, a recent systematic review concluded that the LR for LapTME and TaTME may be comparable. This suggests that TaTME can be performed without influencing locoregional oncological outcomes in patients treated at specialized institutions and who have been cautiously selected [38].

As for RCTs, although the results for the COLOR III trial [5] and the ETAP-GRECCAR11 trial [6] remain unreleased, the results of 2 RCTs—the Ta-LaTME study [4] and the TaLaR trial [39]—have already been published. The Ta-LaTME study from Spain was a prospective, multicenter, open-label RCT, enrolling 57 and 59 mid- to low-rectal adenocarcinoma patients who underwent TaTME and LapTME, respectively [4]. The primary outcome was conversion to open surgery, and secondary outcomes were postoperative morbidity, mortality, pathological and oncological results, and survival. Conversion to open surgery took place in 11 patients in the TaTME group and 1 patient in the LapTME group (P=0.003). No significant differences were found in terms of postoperative recovery, morbidity at 30 days, and LR. The Ta-LaTME study concluded that because the conversion rate was significantly lower in TaTME than in LapTME, the use of TaTME at centers with experienced surgeons could avoid conversion to open surgery. The TaLaR trial from China was an open-label, phase 3, noninferiority RCT performed at 16 different hospitals in 10 Chinese provinces [39]. The primary endpoints were 3-year disease-free survival and 5-year overall survival. The TaLaR trial is notable for its large patient cohort, with 544 patients enrolled in the TaTME group and 545 patients in the LapTME group, all diagnosed with clinical stage I to III rectal cancer located below the peritoneal reflection. There were no significant differences between the 2 groups in intraoperative complications, postoperative morbidity, mortality, and R0 resection rate; therefore, the TaLaR trial concluded that experienced surgeons could safely perform TaTME in selected patients with rectal cancer.

STEP-BY-STEP DISSECTION BASED ON ANATOMICAL LANDMARKS

Posterior dissection caudal to the rectosacral fascia

In TaTME, during posterior dissection caudal to the rectosacral fascia, the 2 fascial layers to be identified are the endopelvic fascia (EPF) and the MRF [40] (Fig. 1). However, because the mesorectum attached to the dorsal side of the rectum is thinner on the caudal side than on the cranial side, excessive dissection along the MRF sometimes poses the risk of straying into the mesorectum and consequently exposing the posterior rectal wall. Therefore, the EPF should be the anatomical landmark in the selection of the posterior dissection layer caudal to the rectosacral fascia.

The EPF is defined in the field of colorectal surgery as the fascia covering the surface of the levator ani muscle; however, it is worth noting that there can be discrepancies among different medical specialties, such as urology and gynecology, regarding its definition and scopes [41]. The EPF has a constant thickness of approximately 0.5 to 1 mm; therefore, in cases with T3 or deeper locally advanced rectal cancers located on the posterior side, it is possible to secure a thicker CRM by selecting the dissection layer below the EPF. On the other hand, excessive continued dissection in the layer below the EPF poses the risk of unintentional pelvic plexus injury. Therefore, it is appropriate to select a dissection layer above the EPF in cases of T1 or T2 tumors. Even if the tumor is classified as T3 or deeper, it is crucial to intentionally return to the dissection layer above the EPF. This should be done by making an incision in the EPF once the dissection has sufficiently progressed past the tumor toward the cranial side (Fig. 2A).

In summary, during posterior dissection caudal to the rectosacral fascia, the EPF is the most important anatomical landmark, and the dissection layer should be selected above or below the EPF depending on the depth of the tumor.

Posterior dissection cranial to the rectosacral fascia

On the posterior side and cranial to the rectosacral fascia, the fasciae are divided into 3 layers in dorsal order: the presacral fascia (continues to the EPF), the prehypogastric nerve fascia, and the MRF [7] (Fig. 1). As shown in Fig. 1, irrespective of whether the initial selection of the dissection layer is above or below the EPF, it typically leads to entering the dissection layer below the prehypogastric nerve fascia.

While the orientation of the rectum runs horizontally to the direction of dissection on the caudal side of the rectosacral fascia, it changes its course and ascends ventrally on the cranial side. Consequently, continued straight dissection in this area may risk injuring the median sacral vessels. By altering the direction of dissection ventrally and deliberately making an incision in the prehypogastric nerve fascia while identifying the translucent yellow mesorectum posteriorly, it becomes feasible to access the dissection layer above the prehypogastric nerve fascia from below it (Fig. 2B). In 2-team TaTME, the transanal dissection layer is often connected with the transabdominal dissection layer by incising the prehypogastric nerve fascia (Fig. 3A).

In summary, it is important to be aware of whether the dissection layer is above or below the prehypogastric fascia. This requires understanding the change in the course of the rectum, identifying the yellow mesorectum, which is transparent over the prehypogastric nerve fascia, and intentionally incising the prehypogastric nerve fascia.

Dissection on the lateral side

The thickened area of fascia found at the transition area between different fasciae is called the tendinous arch. The tendinous arch of the pelvic fascia is the area where the vesicohypogastric fascia and ureterohypogastric nerve fascia (both visceral pelvic fasciae) fuse and then collide with the EPF [42], which can also be described as the goal of transabdominal lateral pelvic lymph node dissection [43]. The tendinous arch of the pelvic fascia is an important anatomical landmark for lateral dissection in TaTME.

The pelvic splanchnic nerve, which branches from the S4 nerve, courses ventrally and reaches its deepest point at the juncture of the ureterohypogastric nerve fascia. This location coincides precisely with the tendinous arch of the pelvic fascia [44, 45]. In a typical TaTME, the dissection layer along the MRF identified on the posterior side is continued to the lateral side, thereby preserving the pelvic plexus, including the S4-pelvic splanchnic nerve, which is important for postoperative urogenital function.

In transanal lateral lymph node dissection, this S4-pelvic splanchnic nerve can be used as an anatomical landmark to incise the tendinous arch of the pelvic fascia, thereby allowing entry into the lateral pelvic cavity by dissecting along the surface of the levator ani muscle [45, 46]. In cases in which the MRF of the lateral side exhibits tumor involvement, the trick to securing the CRM on the lateral side is to incise the tendinous arch of the pelvic fascia in a similar fashion and enter the outer layer of visceral pelvic fascia (i.e., the lateral pelvic space) (Fig. 3B).

In summary, the tendinous arch of the pelvic fascia (i.e., the S4-pelvic splanchnic nerve) is the most important anatomical landmark for lateral dissection in TaTME, and the outer dissection layer of the visceral pelvic fascia should be selected in cases with MRF involvement on the lateral side.

Anterior dissection

Important anatomical landmarks for anterior dissection in TaTME are the prostate in men and the posterior vaginal wall in women. Since there are no autonomic nerves on the anterior side (i.e., 11 to 1 o’clock), it is not necessary to dissect along the MRF. Dissection should be along the dorsal side of the prostate (or posterior vaginal wall), which is a more reliable anatomical landmark. As a result, the ventral side of Denonvilliers fascia is generally chosen as the anterior dissection layer in TaTME.

If the starting point of rectotomy on the anterior side is more cranial to the anorectal junction (ARJ), the dorsal side of the prostate (or posterior vaginal wall) can be easily reached by incising the longitudinal muscle of the anterior rectal wall. However, if the starting point of rectotomy on the anterior side is more caudal to the ARJ, the presence of complex smooth muscle structures, including the rectourethral muscle, beyond the longitudinal muscle of the anterior rectal wall makes it exceedingly challenging to determine the appropriate dissection layer. There is a risk of urethral injury if the dissection layer is close to the ventral side and a risk of rectal injury if the dissection layer is close to the dorsal side.

In contrast to the area at 12 o'clock, where thick, smooth muscle is present, there is a region at 11 and 1 o'clock characterized by relatively sparse smooth muscle [34]. Therefore, to circumvent the challenging region at 12 o'clock, the initial step involves accessing the relatively spacious areas at 11 and 1 o'clock. Subsequently, identifying the dorsal surface of the prostate (or posterior vaginal wall) becomes pivotal in accurately identifying the dissection layer on the anterior side in TaTME. The key lies in utilizing the characteristic vascular structures present on the surface of the prostate (or posterior vaginal wall) as a guiding clue (Fig. 4A).

Upon successfully identifying the dorsal aspect of the prostate (or posterior vaginal wall) within the region at 11 and 1 o'clock, the subsequent step involves incising the rectourethral (or rectovaginal) muscle at 12 o'clock. This maneuver aims to ensure the continuity of the dissection layers from 11 to 1 o'clock. As dissection along the dorsal side of the prostate progresses cranially, Denonvilliers fascia becomes visible anteriorly. Incising this fascia exposes the seminal vesicle. Further dissection towards the cranial aspect reveals the peritoneal reflection, and incising the peritoneum establishes communication with the abdominal cavity (Fig. 4B).

In summary, the most important anatomical landmarks for anterior dissection in TaTME are the prostate in men and the posterior vaginal wall in women, and to identify them, it is important to access the space at 11 and 1 o'clock rather than 12 o’clock.

ANASTOMOSIS FOLLOWING TaTME

Penna et al. [47] introduced 4 different anastomotic techniques following TaTME in 2016. One was a conventional hand-sewn coloanal anastomosis, and the other 3 were stapled anastomosis combining a transanal purse-string closure for the rectal cuff and circular stapler firing, which is referred to as double purse-string circular stapled anastomosis or the single stapling technique (SST). SST is expected to reduce anastomosis-related complications and increase safety during rectal cancer surgery by overcoming the limitations of conventional DST, such as multiple stapler firing and the dog-ear technique [48]. SST is classified into the following 2 methods according to the view when the center rod of the anvil and the center shaft of the circular stapler are connected. One method is the abdominal double purse-string circular stapled anastomosis with an abdominal endoscopic view, where the center shaft of the circular stapler is inserted into the abdominal cavity and then connected with the anvil. The other is transanal pull-through double purse-string circular stapled anastomosis with a transanal direct view, where the center rod of the anvil is pulled out toward the anal side and then connected with the circular stapler.

In the original article, the SST was recommended for patients where the tumor distance from the ARJ was 2 cm or higher, and hand-sewn anastomosis was recommended for coloanal anastomosis [47]; however, with the technical establishment of SST in TaTME, the SST can now be safely performed even if the tumor distance from the ARJ is 2 cm or lower. We defined SST performed in such patients as “super SST,” and according to our definition, the anastomotic line of super SST is located near or below the ARJ. Currently, the Super SST trial (UMIN-CTR identifier: UMIN000047818), a multicenter RCT comparing super SST versus hand-sewn anastomosis in intersphincteric resection with TaTME, is underway [49]. The primary outcome of this trial is anastomosis-related complications within 30 days postoperatively. The secondary endpoints include all early and late complications, operating time, reoperation, mortality rate, length of postoperative hospital stay, readmission, the incidence of anal pain and rectal mucosal prolapse, length of temporary stoma retention, the proportion of patients with a temporary stoma at 1 year after surgery, and anorectal function at 1 year after surgery.

LEARNING CURVE OF TaTME

Although TaTME has many advantages, the unfamiliar transanal surgical field sometimes leads to TaTME-specific adverse events, such as urethral injury [50]. One of the most substantial challenges to the widespread adoption of TaTME included a supposedly steeper learning curve. Consequently, studies analyzing the learning curve of TaTME have been conducted. In the analysis of 121 consecutive TaTME procedures by Persiani et al. [51], 71 cases were needed to overcome the learning curve sufficiently for operative time, and the incidence of major complications started to decrease after the 54th case. In another analysis of 104 consecutive patients by Xu et al. [52], the learning curve for total operative time started declining after 42 cases, and the learning curve for postoperative complications declined significantly after the 75th case. Matsuda et al. [53] also reported in the study analyzing 128 patients that 70 operations were needed to reach the mastery phase of TaTME based on the operation time and intraoperative adverse events. According to the consensus on a structured training curriculum for TaTME, having an educational mentor for TaTME as a prerequisite necessitates the performance of at least 30 TaTME cases independently. However, summarizing the results of previous reports analyzing the learning curve of TaTME, as described above, indicates that an experienced caseload of 50 to 70 cases might be required, which is more than previously assumed [54]. These results also indicate that a sufficient anatomical understanding is necessary before performing TaTME.

CONCLUSION

We summarized the historical transition of rectal cancer surgery and recent evidence regarding TaTME. Furthermore, we described the anatomical landmarks and step-by-step technical intricacies that should be understood in the selection of the dissection layer in TaTME, separately for the posterior, lateral, and anterior sides. While this principle extends beyond TaTME, the dissection layer should ideally be selected preoperatively, leveraging information from magnetic resonance imaging scans. Intraoperatively, strict adherence to the preoperative plan is crucial. This entails meticulously identifying anatomical landmarks, guided by a comprehensive understanding of pelvic fascial anatomy, and proceeding with dissection only after establishing a proper orientation. We hope that this article will contribute to a better understanding of the selection of the dissection layer in TaTME.

ARTICLE INFORMATION

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

Conceptualization: all authors; Formal analysis: all authors; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Fig. 1.

Pelvic fascial anatomy around the rectum. On the posterior side caudal to the rectosacral fascia, the fasciae are divided into 2: the endopelvic fascia and mesorectal fascia. On the posterior side cranial to the rectosacral fascia, the fasciae are divided into 3: presacral fascia, prehypogastric nerve fascia, and mesorectal fascia.

Fig. 2.

Posterior dissection and incision of the rectosacral fascia. (A) Posterior dissection caudal to the rectosacral fascia. Using the exposed levator ani muscle (dashed circle) and the endopelvic fascia (arrowheads) as anatomical landmarks, the dissection layer is selected to be above or below the endopelvic fascia. (B) On the posterior side, the rectosacral fascia is incised (dashed circle), revealing a transparent view of the yellow mesorectum through the prehypogastric nerve fascia.

Fig. 3.

Incision of prehypogastric nerve fascia and the total mesorectal excision plane. (A) The prehypogastric nerve fascia is incised (dashed circle), establishing a connection with the abdominal cavity. Cranially, the rectum ascends ventrally. (B) Laterally, the boundary is defined by the visceral pelvic fascia, which includes the S4-pelvic splanchnic nerve (arrowheads). Inside this boundary is the total mesorectal excision plane, while outside lies the lateral pelvic cavity (dashed circle).

Fig. 4.

Anterior dissection and peritoneal incision. (A) On the anterior side, dissection of the rectourethral muscle (or rectovaginal muscle) is performed at 12 o'clock to expose the dorsal surface of the prostate (or posterior vaginal wall). Characteristic vascular structures (arrowheads) on the surface of the prostate (or posterior vaginal wall) serve as identifying markers. (B) On the anterior side, the peritoneal reflection is incised (dashed circle), establishing continuity with the abdominal cavity.

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Dissection layer selection based on an understanding of pelvic fascial anatomy in transanal total mesorectal excision

Ann Coloproctol. 2024;40(4):375-383. Published online August 30, 2024

DOI: https://doi.org/10.3393/ac.2024.00178.0025

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Figure

Dissection layer selection based on an understanding of pelvic fascial anatomy in transanal total mesorectal excision

Fig. 1. Pelvic fascial anatomy around the rectum. On the posterior side caudal to the rectosacral fascia, the fasciae are divided into 2: the endopelvic fascia and mesorectal fascia. On the posterior side cranial to the rectosacral fascia, the fasciae are divided into 3: presacral fascia, prehypogastric nerve fascia, and mesorectal fascia.

Fig. 2. Posterior dissection and incision of the rectosacral fascia. (A) Posterior dissection caudal to the rectosacral fascia. Using the exposed levator ani muscle (dashed circle) and the endopelvic fascia (arrowheads) as anatomical landmarks, the dissection layer is selected to be above or below the endopelvic fascia. (B) On the posterior side, the rectosacral fascia is incised (dashed circle), revealing a transparent view of the yellow mesorectum through the prehypogastric nerve fascia.

Fig. 3. Incision of prehypogastric nerve fascia and the total mesorectal excision plane. (A) The prehypogastric nerve fascia is incised (dashed circle), establishing a connection with the abdominal cavity. Cranially, the rectum ascends ventrally. (B) Laterally, the boundary is defined by the visceral pelvic fascia, which includes the S4-pelvic splanchnic nerve (arrowheads). Inside this boundary is the total mesorectal excision plane, while outside lies the lateral pelvic cavity (dashed circle).

Fig. 4. Anterior dissection and peritoneal incision. (A) On the anterior side, dissection of the rectourethral muscle (or rectovaginal muscle) is performed at 12 o'clock to expose the dorsal surface of the prostate (or posterior vaginal wall). Characteristic vascular structures (arrowheads) on the surface of the prostate (or posterior vaginal wall) serve as identifying markers. (B) On the anterior side, the peritoneal reflection is incised (dashed circle), establishing continuity with the abdominal cavity.

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Fig. 4.

Dissection layer selection based on an understanding of pelvic fascial anatomy in transanal total mesorectal excision