OBJECTIVETo study the relationship of mesorectum with fasciae and nerves in the pelvic cavity and to specify the proper planes of dissection in total mesorectal excision.

METHODSTwenty-four pelvises (12 males and 12 females) harvested from cadavers were studied by dissection.

RESULTSThere were three planes surrounding the rectum as the visceral fascia, vesicohypogastric fascia and parietal fascia. The pelvic plexus and its branches situated between the visceral fascia and the vesicohypogastric fascia. Pelvic splanchnic nerves and hypogastric nerves were observed between the visceral fascia and the parietal fascia.

CONCLUSIONSThe posterior plane of total mesorectal excision lies between the visceral fascia and the parietal fascia. The lateral dissection should be conducted in a plane between the visceral fascia and the vesicohypogastric fascia. The proper planes for posterior and lateral resection can be identified by the hypogastric nerve and the pelvic plexus respectively.

Fascia ; anatomy & histology ; Fasciotomy ; Female ; Humans ; Male ; Mesentery ; anatomy & histology ; surgery ; Pelvis ; anatomy & histology ; surgery

As total mesorectal excision (TME) for rectal cancer is widely carried out in China, lateral ligament of rectum, as an important anatomical structure of the lateral rectum with certain anatomical value and clinical significance, has been the focus of attention. In this paper, by comparing and analyzing the characteristics about ligaments of the abdomen and pelvis, reviewing the membrane anatomy and the theory of primitive gut rotation, and combining clinical observations and histological studies, the author came to a conclusion that lateral ligament of rectum does not exist, but is only a relatively dense space on the rectal side accompanied by numerous tiny nerve plexuses and small blood vessels penetrating through it.
Humans ; Rectum/anatomy & histology* ; Pelvis/anatomy & histology* ; Rectal Neoplasms/surgery* ; Peritoneum ; Collateral Ligaments ; Cognition

OBJECTIVETo explore the regional anatomy of the rectum including the perirectal fasciae and spaces.

METHODSTwenty-one cadavers (15 males and 6 females) were embalmed and their vessels were visualized by injection with color dye. From the cadavers, 30 hemipelvis and 6 three-quarter pelvis were harvested. The perirectal fasciae and spaces and the pelvic autonomic nerves were dissected and examined.

RESULTSThree tissue layers were dissected from the inside to the periphery including the proper rectal fascia enveloping the mesorectum, the presacral fascia, and the piriformis fascia fused with the sacral periosteum. The mesorectum comprised 2 parts with the classical posterolateral fat covered by the proper rectal fascia posteriorly and the anterior fat covered by the posterior layer of Denonvilliers fascia anteriorly. Extending anteriorly to the anterior layer of Denonvilliers fascia, the presacral fascia bisected the space between the mesorectum and the piriformis fascia into the retrorectal space and the presacral space. The retrorectal space extended cranially to the left retrocolic space, anterior to the space between the 2 layers of Denonvilliers fascia(prerectal space).

CONCLUSIONSFrom the inside to the periphery, the proper rectal fascia, the presacral fascia, and the muscular fascia are distributed in an annular pattern around the mesorectum. The presacral fascia divides the perirectal space into 2 annular parts, the central retrorectal space and the peripheral presacral space. The retrorectal space is the ideal surgical plane for total mesorectal excision.

Adult ; Aged ; Cadaver ; Fascia ; anatomy & histology ; Female ; Humans ; Male ; Mesocolon ; anatomy & histology ; surgery ; Middle Aged ; Pelvis ; anatomy & histology ; Rectum ; anatomy & histology

OBJECTIVETo investigate the feasibility of the classification of the spino-pelvic sagittal alignment in adluts according to lumbar lordosis (LL) and inflection point (IP).

METHODSWhole spine, standing radiographs of 223 adult volunteers were taken from July to August in 2011 .There were 111 cases(56 female and 55 male) enrolled in the study based on the inclusion criteria. The pelvic and spinal parameters, including thoracic kyphosis(TK), thoracolumbar kyphosis(TLK), LL, sacral slope(SS), pelvic tilt(PT), pelvic incidence(PI), intervertebral endplate angle, sagittal vertical axis (SVA), spino-sacral angle (SSA) and IP were measured. The spino-pelvic sagittal alignment were classified in to 3 types according to LL and IP. Type I: LL > -40°, IP located below L2 ∼ 3; Type II: -60° ≤ LL ≤ -40°, IP located in L1 ∼ 2 or T12 ∼ L1; Type III: LL < -60°, P located above T11 ∼ 12. Pearson correlation analysis was used to test the correlation between the variables. The parameters in each type were compared by oneway-ANOVA respectively,then additional multiple comparisons were performed.

RESULTSThe mean value of LL was -49° ± 10°, TK was 36° ± 7°, TLK was 6° ± 7°, PT was 11° ± 7°, SS was 34° ± 8°, PI was 45° ± 9°, SSA was 127° ± 9° and SVA was (-2.7 ± 22.8)mm, respectively. Only LL had significant statistical correlation with all the other parameters. Negative correlation presented between LL and TK, PI, SS, SSA (r = -0.387, -0.536, -0.858, -0.801,P < 0.05). Positive correlation presented between LL and TLK, SVA, PT (r = 0.319, 0.296, 0.262, P < 0.05). All the volunteers were classified into the 3 types: Type I1 9 cases, Type II 75 cases,Type III 17 cases. Oneway-ANOVA results showed statistical difference in LL, TK, TLK, PT, SS, PI, SSA, SVA among the 3 types, (F = 164.559, 7.431, 14.099, 4.217, 53.856, 6.252, 35.995, 8.626, P < 0.05 ). Multiple comparisons showed that LL, SS, SSA, PI had statistical difference between each two types comparison (P < 0.05).

CONCLUSIONSLL is the central parameter of the spino-pelvic sagittal balance. The patterns of the spino-pelvic sagittal alignment in adults could be classified into three types, according to LL and IP. The classification could describe the morphological differences and balance of the spino-pelvic sagittal alignment.

Adult ; Analysis of Variance ; Anthropometry ; Female ; Healthy Volunteers ; Humans ; Male ; Middle Aged ; Pelvis ; anatomy & histology ; Postural Balance ; Radiography ; Spine ; anatomy & histology

OBJECTIVETo provide detailed information of corona mortis for ilioinguinal approach as an anterior approach to the acetabulum and pelvis.

METHODSThe course, branches and distribution of the vascular connection between the obturator system and the external iliac or inferior epigastric systems located over the superior pubic ramus were observed on 50 hemipelvises with intact soft tissues.

RESULTSDuring the dissections, 72% of the cadaveric sides had at least one communicating vessel between the obturator system and the external iliac or inferior epigastric systems on the superior pubic ramus. The average diameter of the connecting vessel was 2.6 mm (range, 2.0-4.2 mm). It coursed over the superior pubic ramus or iliopubic eminence vertically to enter the obturator foramen and exit the pelvis. The average distance from pubic symphysis to the vascular connections between the obturator and external iliac systems was 52 mm (range, 38-68 mm).

CONCLUSIONSVascular connections between the obturator system and the external iliac or inferior epigastric systems were found over the superior pubic ramus with a high incidence. They are prone to damage during the ilioinguinal approach as an anterior approach to the acetabulum and pelvis. Thus, corona mortis located over the superior pubic ramus deserves great attention during the ilioinguinal approach.

Adult ; Aged ; Epigastric Arteries ; anatomy & histology ; Female ; Humans ; Iliac Vein ; anatomy & histology ; Male ; Middle Aged ; Obturator Nerve ; anatomy & histology ; Pelvis ; blood supply ; Pubic Symphysis ; blood supply

OBJECTIVETo further understand the anatomical basis of pelvic autonomic nerve preservation.

METHODSAutopsy of five adult male donated cadavers was performed. Meanwhile, ten videos of laparoscopic total mesorectal excision for male mid-low rectal cancer admitted from January to June 2012 were observed and studied. Anatomical features of pelvic autonomic nerve were compared between autopsy and laparoscopic appearance.

RESULTSAutopsy observations indicated that:the abdominal aortic plexus was situated upon the sides and front of the aorta, between the origins of the superior and inferior mesenteric arteries. The superior hypogastric plexus was a plexus of nerves situated on the the bifurcation of the abdominal aorta to sacrum; after incision of sacrum fascia was done cling to the sacrum; the pelvic splanchnic nerves and sacral splanchnic nerves were demonstrated; pelvic splanchnic nerves were splanchnic nerves that arised from ventral rami of the second, third, and often the fourth sacral nerves to provide preganglionic parasympathetic innervation to the hindgut;sacral splanchnic nerves providing postganglionic fibers, emerged from the sympathetic trunk, were then joined by the pelvic splanchnic nerves to form the inferior hypogastric plexuses which were placed lateral to the rectum.Laparoscopic observations showed that:abdominal aortic plexus and superior hypogastric plexus were unclear; at the level of sacroiliac joint, the hypogastric nerve began where the superior hypogastric plexus split into a right and left plexus, situated under the loose connective tissue, and continued inferiorly on its corresponding side of the body at the level of the 3rd sacral vertebra;left hypogastric nerve was closed to posterior of mesorectum;denonvilliers fascia was thin, reflective fascial structure, and easily removed together with mesorectum excision because of anterior loose structure.

CONCLUSIONSLigation of the inferior mesenteric artery at its origin is safe.Excessive dissection of the connective tissue covering the surface of the aorta should be avoided to protect the abdominal aortic plexus.Sharp dissection performed by pursuing the outer surface of the mesorectum maintaining the integrity of mesorectum, could avoid the superior hypogastric plexus and hypogastric nerves injury posteriorly, and protect the inferior hypogastric plexues while cutting lateral ligament laterally. The integrity of Denonvilliers fascia during anterior resection of rectum should be confirmed to avoid urogenitalis aparatus branches damage.

Adult ; Autonomic Nervous System ; anatomy & histology ; Autopsy ; Humans ; Laparoscopy ; Male ; Pelvis ; innervation ; Rectal Neoplasms ; 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

OBJECTIVEObserve the course,distribution and variation of inferior gluteal artery to provide an anatomic basis.

METHODS18 specimen (11 male and 7 female. 9 left and 9 right) were perfused with red latex to show inferior gluteal arteries and the tissue around them.

RESULTSUsually inferior gluteal artery travels through infrapiriform foramen and goes down along ischiadicus nerve. It gives three main branches as ramus of articularis, ramus of ischiadicus, ramus of muscularis at average distances of 17.3 mm, 33.2 mm and 51.8 mm to infrapiriform foramen and nourishes them respectively. However, variation was found in 7 of 18 specimen (5 are female) .

CONCLUSIONSThe course of inferior gluteal artery is steady in most cases, but sometimes variation can be found. Special examinations such as colour Doppler ultrasound are suggested to find the course of inferior gluteal artery on the whole level before operation.

Arteries ; anatomy & histology ; Buttocks ; blood supply ; Female ; Humans ; Male ; Pelvis ; blood supply ; Surgical Flaps ; blood supply

Because the classification system of radical surgery for rectal cancer has not been established, it is impossible to select the appropriate surgical method according to the clinical stage of the tumor. In this paper, we explained the theory of " four fasciae and three spaces " of pelvic membrane anatomy and then combined this theory with the membrane anatomical basis of Querleu-Morrow classification for radical cervical cancer resection. Based on this theory and the membrane anatomy of Querleu-Morrow classification of radical cervical cancer resection, we proposed a new classification system of radical rectal cancer surgery based on membrane anatomy according to the lateral lymph node dissection range of the rectum. This system classifies the surgery into four types (ABCD) and defines corresponding subtypes based on whether the autonomic nerve was preserved. Among them, type A surgery is total mesorectal excision (TME) with urogenital fascia preservation, type B surgery is classical TME, type C surgery is extended TME, and type D surgery is lateral extended resection. This classification system unifies the anatomical terminology of the pelvic membrane, validates the feasibility of using the " four fasciae and three fascial spaces " theory to classify rectal cancer surgery, and lays the theoretical foundation for the future development of a unified and standardized classification of radical pelvic tumor surgery.
Female ; Humans ; Uterine Cervical Neoplasms ; Rectal Neoplasms/pathology* ; Rectum/anatomy & histology* ; Pelvis/innervation* ; Proctectomy

This study aims to explore the inferior adhesion of the renal fascia (RF), and the inferior connectivity of the perirenal spaces (PS) with multidetector computed tomography (MDCT), and to investigate the diagnostic value of CT for showing this anatomy. From May to July 2012, eighty-two patients with acute pancreatitis presented in our hospital were enrolled into this study and underwent contrast-enhanced CT scans. All the image data were used to perform three dimensional reconstruction to show the inferior attachment of RF and the inferior connectivity of PS. The fusion of anterior renal fascia (ARF) and posterior renal fascia (PRF) next to the plane of iliac fossa were found on the left in 71.95% (59/82) cases, and on the right in 75.61% (62/82). In these cases, bilateral perirenal spaces, and anterior and posterior pararenal spaces were not found to be connected with each other. No fusion of ARF and PRF below the level of bilateral kidneys occurred on the left side in 28.05% (23/82) cases and on the right side in 24.39% (20/82). In these patients, the PS extended to the extraperitoneal space of the pelvic cavity and further to the inguinal region, and bilateral anterior and posterior pararenal spaces were not found to be connected with each other. Three-dimensional reconstruction on contrast-enhanced MDCT could be a valuable procedure for depicting inferior attachment of RF, and the inferior connectivity of PS.
Abdominal Cavity ; anatomy & histology ; Adult ; Contrast Media ; Fascia ; anatomy & histology ; Humans ; Image Processing, Computer-Assisted ; Kidney ; anatomy & histology ; Multidetector Computed Tomography ; Pancreatitis ; pathology ; Pelvis ; anatomy & histology ; Tomography, X-Ray Computed