Optimal Complete Rectum Mobilization Focused on the Anatomy of the Pelvic Fascia and Autonomic Nerves: 30 Years of Experience at Severance Hospital

Essential knowledge and technical tips for total mesorectal excision and related procedures for rectal cancer

Total mesorectal excision (TME) has greatly improved rectal cancer surgery outcomes by reducing local recurrence and enhancing patient survival. This review outlines essential knowledge and techniques for performing TME. TME emphasizes the complete resection of the mesorectum along embryologic planes to minimize recurrence. Key anatomical insights include understanding the rectal proper fascia, Denonvilliers fascia, rectosacral fascia, and the pelvic autonomic nerves. Technical tips cover a step-by-step approach to pelvic dissection, the Gate approach, and tailored excision of Denonvilliers fascia, focusing on preserving pelvic autonomic nerves and ensuring negative circumferential resection margins. In Korea, TME has led to significant improvements in local recurrence rates and survival with well-adopted multidisciplinary approaches. Surgical techniques of TME have been optimized and standardized over several decades in Korea, and minimally invasive surgery for TME has been rapidly and successfully adopted. The review emphasizes the need for continuous research on tumor biology and precise surgical techniques to further improve rectal cancer management. The ultimate goal of TME is to achieve curative resection and function preservation, thereby enhancing the patient's quality of life. Accurate TME, multidisciplinary-based neoadjuvant therapy, refined sphincter-preserving techniques, and ongoing tumor research are essential for optimal treatment outcomes.

Elderly Rectal Cancer: An Updated Review

PURPOSE OF REVIEW

Treatment of rectal cancer patients of advanced age should be modulated by life expectancy and tolerance. Due to the rapid advance of this field, we aim to conduct an updated review of this topic.

RECENT FINDINGS

The field of elderly rectal cancer has advanced a lot. This review covers all the treatment aspects of elderly rectal cancer, including the prognostic factor, surgery, radiotherapy, chemotherapy, and palliative treatment. We also provide the future aspect of the management of elderly rectal cancer. The advancement of prognostic factor research, surgery, radiotherapy, chemotherapy, and palliative treatment has made the care of elderly rectal cancer patients better. The future of these fields should focus on the definition of the elderly and the application of particle therapy.

Customized Denonvilliers' Fascia Excision: An Advanced Total Mesorectal Excision Technique for Anteriorly Located Rectal Cancer

BACKGROUND

The role of Denonvilliers' fascia in achieving a negative circumferential resection margin during anterior total mesorectal excision has been controversial. Opinions on whether to dissect in the anterior or posterior surgical plane varies among researchers.

IMPACT OF INNOVATION

We performed total mesorectal excision with selective en bloc resection of Denonvilliers' fascia based on preoperative MRI staging, preoperative clinical tumor stage, and tumor level in selected patients with anterior rectal tumors adherent to Denonvilliers' fascia.

TECHNOLOGY MATERIALS AND METHODS

Between March and August 2021, 5 patients who underwent robotic (n = 4) and laparoscopic (n = 1) total mesorectal excision for anteriorly located low rectal adenocarcinomas after neoadjuvant chemoradiotherapy were enrolled in this study. Transabdominal total mesorectal excision dissection is performed by changing to a plane anterior to Denonvilliers' fascia, with partial or total excision tailored to the tumor level and depth of invasion as a further step in circumferential resection margin clearing. Customized excision of Denonvilliers' fascia was performed by dissecting through the extramesorectal plane. This anterior plane permits resection of Denonvilliers' fascia, exposing the prostate and seminal vesicles.

PRELIMINARY RESULTS

Two tumors were located at the seminal vesicle level and 3 were found at the prostate level. The mean distance from the anal verge to the distal margin of the tumor was 4.8 ± 0.9 cm. Denonvilliers' fascia was preserved in 1 patient and partially excised in 4. Customized Denonvilliers' fascia excision was performed in 3 robotic ultralow anterior resections with coloanal anastomosis, 1 laparoscopic ultralow anterior resection with coloanal anastomosis, and 1 robot-assisted abdominoperineal resection. The circumferential resection margins in all patients were negative.

CONCLUSIONS AND FUTURE DIRECTIONS

Anterior dissection in front of Denonvilliers' fascia can be selectively performed during total mesorectal excision based on preoperative planning, tumor location, and clinical tumor stage. Preoperative MRI and magnified operative views in minimally invasive platforms provide access to more precise surgical planes for clear circumferential resection, achieving optimal functional outcomes and oncological safety.

The Mesentery in Robot-Assisted Total Mesorectal Excision

In recent decades, surgery for rectal cancer has evolved from an operation normally performed under poor vision with a lot of blood loss, relatively high morbidity, and mortality to a safer operation. Currently, minimally invasive rectal procedures are performed with limited blood loss, reduced morbidity, and minimal mortality. The main cause is better knowledge of anatomy and adhering to the principle of operating along embryological planes. Surgery has become surgery of compartments, more so than that of organs. So, rectal cancer surgery has evolved to mesorectal cancer surgery as propagated by Heald and others. The focus on the mesentery of the rectum has led to renewed attention to the anatomy of the fascia surrounding the rectum. Better magnification during laparoscopy and improved optimal three-dimensional (3D) vision during robot-assisted surgery have contributed to the refinement of total mesorectal excision (TME). In this chapter, we describe how to perform a robot-assisted TME with particular attention to the mesentery. Specific points of focus and problem solving are discussed.

Surgical Treatment of Low-Lying Rectal Cancer: Updates

Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.