The difficulty of transanal total mesorectal excision (TME) is to find the correct dissection plane of perirectal space. As a complex new surgical procedure, the fascial anatomic landmarks of transanal approach operation are more likely to be ignored. It is often found that dissection plane is false after the secondary injury occurs during the operation, which results in the damage of pelvic autonomic nerves. Meanwhile, the mesorectum is easily damaged if the dissection plane is too close to the rectum. Thus, the safety of oncologic outcomes could be limited by difficulty achieving adequate TME quality. The promotion and development of the theory of perirectal fascial anatomy provides a new thought for researchers to design a precise approach for transanal endoscopic surgery. Transanal total mesorectal excision based on fascial anatomy offers a solution to identify the transanal anatomic landmarks precisely and achieves pelvic autonomic nerve preservation. In this paper, the authors focus on the surgical experience of transanal total mesorectal excision based on the theory of perirectal fascial anatomy, and discuss the feature of perirectal fascial anatomy dissection and technique of pelvic autonomic nerve preservation during transanal approach operation.
Autonomic Pathways/surgery* ; Humans ; Proctectomy ; Rectal Neoplasms/surgery* ; Rectum/surgery* ; Transanal Endoscopic Surgery

Rectal cancer is a common malignant tumor of the digestive tract, and surgery is the main treatment strategy. Disorders of bowel, anorectal and urogenital function remain common problems after total mesorectal resection (TME), which seriously decreases the quality of life of patients. Surgical nerve damage is one of the main causes of the complications, while TME with pelvic autonomic nerve preservation is an effective way to reduce the occurrence of adverse outcomes. Intraoperative nerve monitoring (IONM) is a promising method to assist the surgeon to identify and protect the pelvic autonomic nerves. Nevertheless, the monitoring methods and technical standards vary, and the clinical use of IONM is still limited. This review aims to summarize the researches on IONM in rectal and pelvic surgery. The electrical nerve stimulation technique and different methods of IONM in rectal cancer surgery are introduced. Also, the authors discuss the limitations of current researches, including methodological disunity and lack of equipment, then prospect the future direction in this field.
Autonomic Pathways ; Humans ; Pelvis/surgery* ; Quality of Life ; Rectal Neoplasms/surgery* ; Rectum/surgery*

OBJECTIVETo elucidate the course of pelvic autonomic nerves and its relationship with pelvic fascia in order to identify the safe plane to reduce the damage of pelvic autonomic nerves in total mesorectum I excision(TME).

METHODSThe course and distribution of pelvic autonomic nerves were observed and their relationship with pelvic interfascial space was examined through the anatomy of 12 adult pelvic specimens.

RESULTSThe entire course of hypogastric nerves ran within the anterior sacral fascia and the inferior hypogastric plexus ran within parietal fascia. Inferior hypogastric plexus crossed the fusion line of Denonvilliers fascia and parietal fascia in the 10 o'clock and 2 o'clock directions of the rectum, and joined urogenital vessel bundle finally. Laterigrade traffic nerves could be found in Denonvilliers fascia.

CONCLUSIONThe safe plane should be chosen between rectal proper fascia and anterior sacral fascia near rectal proper fascia in posterior dissection and lateral dissection of rectum. More attention should be paid to protect the neurovascular bundle in the 10 o'clock and 2 o'clock directions of rectum and traffic nerve within Denonvilliers fascia in anterior dissection.

Autonomic Pathways ; anatomy & histology ; surgery ; Female ; Humans ; Male ; Pelvis ; innervation ; Rectum ; surgery

BACKGROUNDIn order to simplify the complicated procedure of nerve-sparing radical hysterectomy, a novel technique characterized by integral preservation of the autonomic nerve plane has been employed for invasive cervical cancer. The objective of this study was to introduce the nerve plane-sparing radical hysterectomy technique and compare its efficacy and safety with that of nerve-sparing radical hysterectomy.

METHODSFrom September 2006 to August 2010, 73 consecutive patients with International Federation of Gynecology and Obstetrics stage IB to IIA cervical cancer underwent radical hysterectomy with two different nerve-sparing approaches. Nerve-sparing radical hysterectomy was performed for the first 16 patients (nerve-sparing radical hysterectomy group). The detailed autonomic nerve structures were identified and separated by meticulous dissection during this procedure. After January 2008, the nerve plane-sparing radical hysterectomy procedure was developed and performed for the next 57 patients (nerve plane-sparing radical hysterectomy group). During this modified procedure, the nerve plane (meso-ureter and its extension) containing most of the autonomic nerve structures was integrally preserved. The patients' clinicopathologic characteristics, surgical parameters, and outcomes of postoperative bladder function were compared between the two groups.

RESULTSThere were no significant differences between the nerve plane-sparing radical hysterectomy and nerve-sparing radical hysterectomy groups regarding age, International Federation of Gynecology and Obstetrics stage, pathological type, preoperative treatment, or need for intraoperative blood transfusion. The nerve plane-sparing radical hysterectomy group had a higher body mass index than that of the nerve-sparing radical hysterectomy group (P = 0.028). The mean surgical duration in the nerve plane-sparing radical hysterectomy and nerve-sparing radical hysterectomy groups were (262 ± 46) minutes and (341 ± 36) minutes (P < 0.01). On the 8th postoperative day, 41 (71.9%) patients in the nerve plane-sparing radical hysterectomy group and nine (56.3%) patients in the nerve-sparing radical hysterectomy group had a postvoid residual urine volume of < 100 ml (P = 0.233). The median duration of catheterization was eight days (range 8 - 23 days) for the nerve plane-sparing radical hysterectomy group and eight days (range 8 - 22 days) for the nerve-sparing radical hysterectomy group (P = 0.509). Neither surgery-related injury nor pathologically positive margins were reported in either group.

CONCLUSIONNerve plane-sparing radical hysterectomy is a reproducible and simplified modification of nerve-sparing radical hysterectomy, and may be preferable to nerve-sparing radical hysterectomy for treatment of early-stage invasive cervical cancer.

Adult ; Aged ; Autonomic Pathways ; surgery ; Female ; Humans ; Hysterectomy ; methods ; Middle Aged ; Uterine Cervical Neoplasms ; pathology ; surgery

Colorectal cancer is one of the most common cancers in the world, and surgery is the mainstage treatment. Urogenital and sexual dysfunction after radical resection of rectal cancer has become an important problem for patients, which seriously affects the quality of life. Some patients give up radical surgery for rectal cancer because of the concerns about sexual and urinary dysfunction. The cause of this problem is intraoperative of injury pelvic autonomic nerve. The preservation of the hypogastric nerve during the surgery is important for the male ejaculation. Pelvic splanchnic nerves are mainly responsible for the male erection. The anatomical origin, distribution, and urogenital function of these two nerves are detailed described in this article. At the same time, this article introduces the classification, key points of the operation and the evaluation of autonomic nerve preservation surgery. With the rapid development of minimally invasive surgery, performing radical surgery for rectal cancer is important, we also need to fully understand the anatomical concept of pelvic autonomic nerves, and apply modern minimally invasive surgical techniques to preserve the patient's pelvic autonomic nerves as well. It is an compulsory course and an important manifestation for the standardization of rectal cancer surgery.
Humans ; Male ; Clinical Relevance ; Quality of Life ; Autonomic Pathways/surgery* ; Rectal Neoplasms/surgery* ; Pelvis/innervation*

The procedure of total mesorectal excision (TME) becomes a gold standard for the treatment of rectal cancer. The reason is the marvelously low incidence of local recurrence after TME even without other adjuvant treatment, which has been reported by several independent groups. Although controversy still exists about the role of TME in upper rectal cancer, it is now widely accepted for cancers of the middle and lower third. There are number of histopathological evidences that cancer cells can spread distally several centimeters from the lower margin of cancer, and cancer bearing lymph nodes are found in the distal portion of the mesorectal tissues far from the cancer. Therefore, the distal clearance of mesorectum should be peformed downwardly to the level of pelvic diaphragm (puborectalis) and the rectum is divided within a few centimeters from the pelvic floor musculature. TME defines an en-bloc procedure, along the plane between parietal and visceral pelvic fasciae. If the dissection plane is breached, the chance of visceral pelvic fascia tearing is raised and mesorectal tissue might reside in the pelvis. There are problems in auditing the procedure. As many surgeons agree, this procedure requires a learning curve. Theoretically, the autonomic nerves run between the visceral and parietal pelvic fasciae since the nerves must be preserved to make visceral fascial envelop. Any patient who become incontinent or impotent after the surgery should have received decorticating surgery other than TME. Thus, the high quality of TME should fulfill two clinical measurements: absence of impotence or incontinence and at least single digit, 5-year, cumulative recurrence rate regardless of adjuvant therapy.
Autonomic Pathways ; Digestive System Surgical Procedures/*methods ; Humans ; Rectal Neoplasms/*surgery ; Rectum/*innervation

OBJECTIVETo explore the feasibility and application value of the preservation of vegetative nervous functions in radical resection for right-sided colon cancer.

METHODSClinical data of 55 cases with right-sided colon cancer undergoing laparoscopic D3+ complete mesocolic excision (CME) radical resection from January 2016 to July 2017 at Department of Gastrointestinal Surgery of Guangdong Province Hospital of Traditional Chinese Medicine were retrospectively analyzed. Exclusion criteria included emergency surgery for various reasons, intestinal obstruction or perforation, distant metastasis or locally advanced cancer, previous history of abdominal surgery and preoperative neoadjuvant chemoradiotherapy. Twenty-nine cases underwent lymphadenectomy with intrathecal dissection of superior mesenteric artery (SMA) and part of superior mesenteric plexus was resected (nerve partial resection group, NPR group). Twenty-six cases received lymphadenectomy with the clearance of lymphatic adipose tissue on the right side of SMA by sharp or obtuse method outside the sheath; the sheath of superior mesenteric vein (SMV) was entered at the junction of SMA and SMV; the SMV was naked in the sheath; the third station lymph node dissection was completed with preservation of superior mesenteric plexus (nerve preserved group, NP group). Intra-operative and postoperative complications were compared between two groups.

RESULTSThe baseline data were not significantly different between two groups (all P>0.05). The operation time in NP group was significantly shorter than that in NPR group [(164.0±19.8) minutes vs. (176.0±19.7) minutes, t=2.249, P=0.029]. No significant differences in operative blood loss, operative vessel damage, postoperative time to flatus, postoperative hospital stay and abdominal pain were observed between two groups(all P>0.05). The number of harvested lymph node in two groups was 28.5±7.8 and 27.6±6.5 respectively without significant difference(P>0.05). As compared to NPR group, NP group had lower incidence of chylous leakage[3.8%(1/26) vs. 37.9%(11/29), χ²=9.337, P=0.002] and postoperative diarrhea [15.4%(4/26) vs. 41.4%(12/29), χ²=4.491, P=0.034].

CONCLUSIONAutonomic nerve-preserving D3+ CME radical resection for right-sided colon cancer is safe and feasible, and can prevent the postoperative gastrointestinal dysfunction caused by nerve injury and decrease the risk of chylous leakage.

Autonomic Pathways ; surgery ; Colonic Neoplasms ; surgery ; Humans ; Laparoscopes ; Laparoscopy ; methods ; Lymph Node Excision ; Mesocolon ; surgery ; Retrospective Studies

The efficacy of laparoscopic total mesorectum excision (TME) has been confirmed by many clinical trials and guidelines. But two issues on laparoscopic TME are still questioned, including the integrity of specimen membrane of TME and the incidence of postoperative sexual dysfunction. According to my experiences and the primary results of the multicenter clinical trial (LASRE, clinicaltrials.gov identifier: NCT01899547) conducted by me, the integrity of the specimen membrane of laparoscopic TME is not inferior to the open TME. With the further understanding of surgical membrane anatomy, the quality of surgical specimen after laparoscopic TME could be improved, and the incidence of postoperative sexual dysfunction could be lowered. With the combination of my laparoscopic experiences and the theory of surgical membrane anatomy, this article introduces the peri-rectal space dissection during TME and its relationship with the membrane anatomy for reference. It suggests that laparoscopic TME should be performed with the guidelines of surgical membrane anatomy: (1) To cut membrane bridge of left para-rectal furrow and enter left retroperitoneal space; (2) Along the autonomic nerve, to separate retrorectal space first, then rectal front space, and bilateral rectal space finally; (3) To cut anterior lobe of Denonvilliers fascia using U shape 0.5 to 1 cm away from the bottom of seminal vesicle, if existence of tumor invasion in fascia, to separate downward in front; (4) To separate mesorectum to the edge of hiatus of levator ani muscle and then bare.
Adult ; Autonomic Pathways ; Digestive System Surgical Procedures ; Dissection ; Fascia ; Female ; Humans ; Laparoscopy ; Male ; Mesocolon ; surgery ; Pelvic Floor ; Rectal Neoplasms ; surgery

Urinary and sexual dysfunctions due to intraoperative pelvic autonomic nerve injury have become the most common complications of rectal cancer surgery, seriously affecting postoperative quality of life. How to protect the nerve and urogenital function while ensuring radical resection for rectal cancer has become the focus of research. We previously carried out a series of systematic studies on Denonvilliers fascia, an important anatomical structure closely related to protection of pelvic autonomic nerve, and demonstrated the importance of Denonvilliers fascia in preservation of intraoperative pelvic autonomic nerve and protection of postoperative urogenital function from aspects of anatomy, physiology, tissue, operation practice and so on. Meanwhile, based on the interim results of our multicenter randomized controlled study, we confirmed that total mesorectal excision with preservation of Denonvilliers fascia (innovative TME, iTME) could effectively reduce the incidence of postoperative urinary and sexual dysfunctions in male patients with mid-low rectal cancer, without sacrificing oncologic outcome. In this article, combined with our research results, we review the literature on anatomy research progress of Denonvilliers fascia to demonstrate the significance and research prospect of Denonvilliers fascia in the pelvic autonomic nerve preservation surgery for rectal cancer.
Autonomic Pathways ; Fascia ; Humans ; Male ; Multicenter Studies as Topic ; Pelvis/surgery* ; Quality of Life ; Randomized Controlled Trials as Topic ; Rectal Neoplasms/surgery* ; Rectum/surgery*

Autologous submandibular gland (SMG) transplantation has been proved to ameliorate the discomforts in patients with severe keratoconjunctivitis sicca. The transplanted glands underwent a hypofunctional period and then restored secretion spontaneously. This study aims to investigate whether autonomic nerves reinnervate the grafts and contribute to the functional recovery, and further determine the origin of these nerves. Parts of the transplanted SMGs were collected from the epiphora patients, and a rabbit SMG transplantation model was established to fulfill the serial observation on the transplanted glands with time. The results showed that autonomic nerves distributed in the transplanted SMGs and parasympathetic ganglionic cells were observed in the stroma of the glands. Low-dense and unevenly distributed cholinergic axons, severe acinar atrophy and fibrosis were visible in the patients' glands 4-6 months post-transplantation, whereas the cholinergic axon density and acinar area were increased with time. The acinar area or the secretory flow rate of the transplanted glands was statistically correlated with the cholinergic axon density in the rabbit model, respectively. Meanwhile, large cholinergic nerve trunks were found to locate in the temporal fascia lower to the gland, and sympathetic plexus concomitant with the arteries was observed both in the adjacent fascia and in the stroma of the glands. In summary, the transplanted SMGs are reinnervated by autonomic nerves and the cholinergic nerves play a role in the morphological and functional restoration of the glands. Moreover, these autonomic nerves might originate from the auriculotemporal nerve and the sympathetic plexus around the supplying arteries.
Animals ; Autonomic Pathways ; growth & development ; Fascia ; innervation ; Female ; Humans ; Keratoconjunctivitis Sicca ; surgery ; Male ; Models, Animal ; Rabbits ; Recovery of Function ; Secretory Rate ; Submandibular Gland ; innervation ; transplantation ; Transplantation, Autologous