High ligation of the inferior mesenteric artery with hypogastric nerve preservation in rectal cancer surgery

A novel technique for NO.253 lymph node dissection and left colic artery preservation to avoid potential postoperative internal hernia in laparoscopic radical resection for rectal cancer

BACKGROUND

The preservation of the left colic artery (LCA) has emerged as a preferred approach in laparoscopic radical resection for rectal cancer. However, preserving the LCA while simultaneously dissecting the NO.253 lymph node can create a mesenteric defect between the inferior mesenteric artery (IMA), the LCA, and the inferior mesenteric vein (IMV). This defect could act as a potential "hernia ring," increasing the risk of developing an internal hernia after surgery. The objective of this study was to introduce a novel technique designed to mitigate the risk of internal hernia by filling mesenteric defects with autologous tissue.

METHODS

This new technique was performed on eighteen patients with rectal cancer between January 2022 and June 2022. First of all, dissected the lymphatic fatty tissue on the main trunk of IMA from its origin until the LCA and sigmoid artery (SA) or superior rectal artery (SRA) were exposed and then NO.253 lymph node was dissected between the IMA, LCA and IMV. Next, the SRA or SRA and IMV were sequentially ligated and cut off at an appropriate location away from the "hernia ring" to preserve the connective tissue between the "hernia ring" and retroperitoneum. Finally, after mobilization of distal sigmoid, on the lateral side of IMV, the descending colon was mobilized cephalad. Patients'preoperative baseline characteristics and intraoperative, postoperative complications were examined.

RESULTS

All patients' potential "hernia rings" were closed successfully with our new technique. The median operative time was 195 min, and the median intraoperative blood loss was 55 ml (interquartile range 30-90). The total harvested lymph nodes was 13.0(range12-19). The median times to first flatus and liquid diet intake were both 3.0 days. The median number of postoperative hospital days was 8.0 days. One patient had an injury to marginal arterial arch, and after mobolization of splenic region, tension-free anastomosis was achieved. No other severe postoperative complications such as abdominal infection, anastomotic leakage, or bleeding were observed.

CONCLUSIONS

This technique is both safe and effective for filling the mesenteric defect, potentially reducing the risk of internal hernia following laparoscopic NO.253 lymph node dissection and preservation of the left colic artery in rectal cancer surgeries.

Anatomical basis and clinical research of pelvic autonomic nerve preservation with laparoscopic radical resection for rectal cancer

The clinical effect of laparoscopic rectal cancer curative excision with pelvic autonomic nerve preservation (PANP) was investigated. This study evaluated the frequency of urinary and sexual dysfunction of 149 male patients with middle and low rectal cancer who underwent laparoscopic or open total mesorectal excision with pelvic autonomic nerve preservation (PANP) from March 2011 to March 2013. Eighty-four patients were subjected to laparoscopic surgery, and 65 to open surgery respectively. The patients were followed up for 12 months, interviewed, and administered a standardized questionnaire about postoperative functional outcomes and quality of life. In the laparoscopic group, 13 patients (18.37%) presented transitory postoperative urinary dysfunction, and were medically treated. So did 12 patients (21.82%) in open group. Sexual desire was maintained by 52.86%, un-ability to engage in intercourse by 47.15%, and un-ability to achieve orgasm and ejaculation by 34.29% of the patients in the laparoscopic group. Sexual desire was maintained by 56.36%, un-ability to engage in intercourse by 43.63%, and un-ability to achieve orgasm and ejaculation by 33.73% of the patients in the open group. No significant differences in urinary and sexual dysfunction between the laparoscopic and open rectal resection groups were observed (P>0.05). It was concluded that laparoscopic rectal cancer radical excision with PANP did not aggravate or improve sexual and urinary dysfunction.

New insights into autonomic nerve preservation in high ligation of the inferior mesenteric artery in laparoscopic surgery for colorectal cancer

AIM

To take a deeper insight into the relationship between the root of the inferior mesenteric artery (IMA) and the autonomic nerve plexuses around it by cadaveric anatomy and explore anatomical evidence of autonomic nerve preservation in high ligation of the IMA in laparoscopic surgery for colorectal cancer.

METHODS

Anatomical dissection was performed on 11 formalin-fixed cadavers and 12 fresh cadavers. Anatomical evidence-based autonomic nerve preservation in high ligation of the IMA was performed in 22 laparoscopic curative resections of colorectal cancer.

RESULTS

As the upward continuation of the presacral nerves, the bilateral trunks of SHP had close but different relationships with the root of the IMA. The right trunk of SHP ran relatively far away from the root of IMA. When the apical lymph nodes were dissected close to the root of the IMA along the fascia space in front of the anterior renal fascia, the right trunk of SHP could be kept in suit under the anterior renal fascia. The left descending branches to SHP constituted a natural and constant anatomical landmark of the relationship between the root of IMA and the left autonomic nerves. Proximal to this, the left autonomic nerves surrounded the root of the IMA. Distally, the left trunk of the SHP departed from the root of IMA under the anterior renal fascia. When high ligation of the IMA was performed distal to it, the left trunk of SHP could be preserved. The distance between the left descending branches to SHP and the origin of IMA varied widely from 1.3 cm to 2.3 cm.

CONCLUSIONS

The divergences of the bilateral autonomic nerve preservation around the root of the IMA may contribute to provide anatomical evidence for more precise evaluation of the optimal position of high ligation of the IMA in the future.

High ligation of the inferior mesenteric artery in rectal cancer surgery

In rectal cancer surgery, it is unclear whether the inferior mesenteric artery (IMA) should be ligated as high as possible, at its origin, or low, below the origin of the left colic artery. We reviewed all relevant articles identified from MEDLINE databases and found that despite a trend of improved survival among patients who underwent high ligation, there is no conclusive evidence to support this. High ligation of the IMA is beneficial in that it allows for en bloc dissection of the node metastases at and around the origin of the IMA, while enabling anastomosis to be performed in the pelvis, without tension, at the time of low anterior resection. High ligation of the IMA does not represent a source of increased anastomotic leak in rectal cancer surgery and postoperative quality of life is improved by preserving the hypogastric nerve without compromising the radicality of the operation. More importantly, high ligation of the IMA improves node harvest, enabling accurate tumor staging. Although the prognosis of patients with node metastases at and around the origin of the IMA is poor, the survival rate of patients with rectal cancer may be improved by performing high ligation of the IMA combined with neoadjuvant and adjuvant therapy.

Preservation of genital innervation in women during total mesorectal excision: which anterior plane?

BACKGROUND

Erectile dysfunction, principally related to injury of the autonomic nerve fibers in men, is a major cause of postoperative morbidity after anterolateral dissection during total mesorectal excision (TME) for rectal adenocarcinoma. However, the autonomic innervation of erectile bodies is less known in women, and the anterolateral plane of dissection during TME remains unclear. The existence of the rectovaginal septum(RVS) is controversial. The purpose of the present study was to identify the RVS in the human fetus and adult female by dissection, immunohistochemistry, and three-dimensional reconstruction, and to define its relationship with erectile nerve fibers so as to determine the anterolateral plane of dissection during TME, which could reduce postoperative sexual dysfunction in women.

METHOD

Macroscopic dissection, histologic studies, and immunohistochemistry examination with 3D reconstruction were performed in six fresh female adult cadavers and six female fetuses.

RESULTS

The RVS was clearly definable in all adult specimens. It was composed of multiple connective tissue, with smooth muscle fibers originating from the uterus and the vagina. It is closely applied to the vagina and has a relationship with the neurovascular bundles (NVBs) that contain erectile fibers intended for the clitoris. The NVBs are situated anteriorly to the posterior extension of rectovaginal septum. This posterior extension protects the NVBs during the anterior and anterolateral dissection for removal of rectal cancer.

CONCLUSIONS

To reduce the risk of postoperative sexual dysfunction in women undergoing TME for rectal cancer, we recommend careful dissection to the anterior mesorectum to develop a plane of dissection behind the posterior extension of the RVS if oncologically reasonable.

Where does pelvic nerve injury occur during rectal surgery for cancer?

AIM

Optimal treatment of rectal adenocarcinoma involves total mesorectal excision with nerve-preserving dissection. Urinary and sexual dysfunction is still frequent following these procedures. Improved knowledge of pelvic nerve anatomy may help reduce this and define the key anatomical zones at risk.

METHOD

The MEDLINE database was searched for available literature on pelvic nerve anatomy and damage after rectal surgery using the key words 'autonomic nerve', 'pelvic nerve', 'colorectal surgery', and 'genitourinary dysfunction'. All relevant French and English publications up to May 2010 were reviewed. Reviewed data were illustrated using 3D reconstruction of the foetal pelvis.

RESULTS

The ligation of the inferior mesenteric artery and dissection of the retrorectal space can cause damage to the superior hypogastric plexus and/or hypogastric nerve. Anterolateral dissection in the 'lateral ligament' area and division of Denonvilliers' fascia can damage the inferior hypogastric plexus and efferent pathways. Perineal dissection can indirectly damage the pudendal nerve.

CONCLUSIONS

In most cases, the pelvic nerves can be preserved during rectal surgery. Complete oncological resection may require dissection close to the nerves where the tumour is located anterolaterally where it is fixed and when the pelvis is narrow.

The ratio of metastatic to examined lymph nodes is a powerful independent prognostic factor in rectal cancer

OBJECTIVE

The aim of the study was to evaluate the prognostic value of the ratio of metastatic to examined lymph nodes (LNR) in patients with rectal cancer.

SUMMARY BACKGROUND DATA

Lymph nodes ratio (LNR) has been shown to have prognostic value in patients with colon cancer. The impact of LNR on disease-free and overall survival in patients with rectal cancer is unknown.

PATIENTS AND METHODS

From 1998 to 2004, 307 patients underwent rectal resection for adenocarcinoma. The relationships between overall and disease-free survival at 3 years and 15 variables, including the presence or absence of metastatic lymph nodes, the total number of lymph nodes examined, and LNR, were analyzed by multivariate analysis. Patients were then assigned to 4 groups based on LNR: LNR = 0 (N0 patients), LNR = 0.01 to 0.07, LNR >0.07 to 0.2, LNR >0.2.

RESULTS

The mean number of lymph nodes examined was 22 +/- 12. In the multivariate analysis, LNR was a significant prognostic factor for both disease-free (P = 0.006) and overall survival (P = 0.0003), whereas the presence or absence of metastatic lymph nodes was not. LNR remained a significant prognostic factor in the 59 patients in whom fewer than 12 lymph nodes were examined (P = 0.0058). According to LNR values, disease-free and overall survival decreased significantly with increasing LNR (P < 0.001).

CONCLUSIONS

LNR is the most significant prognostic factor for both overall and disease-free survival in patients with rectal cancer, even in patients with fewer than 12 lymph nodes examined.

Variability in superior hypogastric plexus morphology and its clinical applications: a cadaveric study

BACKGROUND

The superior hypogastric plexus (SHP) that is formed anterior to the aorta and the sacral promontory and is located anterior to the L5-S1 vertebrae, normally continues as the inferior hypogastric plexus. Several variations have been described from a single trunk to a plexiform arrangement.

MATERIALS AND METHODS

The SHP was dissected in 35 formalized cadavers.

RESULTS

A single thin and rounded nerve was found in 17.14% of subjects. The type of a wide reticular formation was observed in 28.57% of specimens. Interestingly, a band-like nerve trunk consisting of nerve bundles connected with loose connective tissue was evident in 22.85% of cadavers. Eventually, two distinct nerves at a short distance with each other were found in 31.44% of subjects. Furthermore, we found that branches of the major and minor splanchnic nerves contributed to SHP constitution. We provided, additionally, the topographic anatomy of the SHP with regard to the sacral promontory and the abdomen midline.

CONCLUSION

A detailed knowledge of the course, the morphology, the various forms and the topography of the SHP is of outmost significance for several clinical specialties.

Topography of the pelvic autonomic nervous system and its potential impact on surgical intervention in the pelvis

Bladder, bowel, and sexual dysfunction caused by iatrogenic lesions of the inferior hypogastric plexus (IHP) are well known and commonly tolerated in pelvic surgery. Because the pelvic autonomic nerves are difficult to define and dissect in surgery, and their importance often ignored, we conducted a gross anatomic study of 90 adult and four fetal hemipelves. Using various non-surgical approaches, the anatomic relations and pathways of the IHP were dissected. The IHP extended from the sacrum to the genital organs at the level of the lower sacral vertebrae. It originated from three different sources: the hypogastric nerve, the sacral splanchnic nerves from the sacral sympathetic trunk (mostly the S2 ganglion), and the pelvic splanchnic nerves, which branched primarily from the third and fourth sacral ventral rami. These fibers converge to form a uniform nerve plate medial to the vascular layer and deep to the peritoneum. The posterior portion of the IHP supplied the rectum and the anterior portion of the urogenital organs; nerve fibers traveled directly from the IHP to the anterolateral wall of the rectum and to the inferolateral and posterolateral aspects of the urogenital organs. The autonomic supply from the IHP was supplemented by nerves accompanying the ureter and the arteries. An understanding of the location of the autonomic pelvic network, including important landmarks, should help prevent iatrogenic injury through the adoption of surgical techniques that reduce or prevent postoperative autonomic dysfunction.