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388
12.5 Abdominoperineal Excision or Amputation of the Rectum
tumor and the dentate line is less than 4 cm. Transanal excision only of full wall thickness surrounding the tumor is not
indicated, and there is no infiltration into neighboring structures.
− Palliative abdominoperineal excision or amputation of the
rectum in the presence of hepatic and/or pulmonary
metastases without infiltration into neighboring organs in
the pelvis.
− After a previous transanal excision of the full thickness lesion
and findings of lymph node invasion, abdominoperineal excision or amputation of the rectum is indicated as a clean-up
procedure. This may be achieved by a laparoscopically assisted abdominoperineal excision of the rectum with high
ligation of the inferior mesenteric artery.
Contraindications
In the presence of severe cardiopulmonary systemic disorders,
laparoscopic surgery is contraindicated due to the adverse effects of the pneumoperitoneum on cardiovascular and pulmonary function. See chapter 2.5 for anesthetic risk factors.
Low rectal carcinomas with the following characteristics are
best treated by transanal rectum-preserving full wall thickness
excision.
− Diameter 2−3 cm.
− G1−G2 histological differentiation.
− No ulceration.
− Endosonography reveals maximum penetration to the mucosa and submucosa (T
laris propria (T
− No sign of lymph-node metastases.
Rectal carcinomas that fulfill these selection criteria do not require abdominoperineal excision for T
only a relative indication for the radical operation in T
if the cardiopulmonary risk factors are not prohibitive. If final
histological findings after a rectum-preserving operation show
lymphatic involvement, abdominoperineal rectum excision is
indicated as a complementary, definitive procedure. This operation may then be performed laparoscopically. The current recommended treatment for rectal carcinomas that have infiltrated neighboring structures and organs or that exhibit exten-
sive infiltration of the mesorectum and/or lymph-node
metastases involves an initial combination of adjuvant radiation
and chemotherapy. This is followed by conventional abdominoperineal excision or amputation of the rectum.
Note: Laparoscopic abdominoperineal rectum excision with
high ligation of the inferior mesenteric artery as a curative procedure should only be performed as a part of global clinical studies until its safety and therapeutic efficiency have been proven
to be equivalent to the open procedure.
).
2
), or to the inner layer of the muscu-
1
lesions and represent
1
lesions,
2
should be made aware of any possible complications, both
general and specific to the procedure. Possible benefits should
be presented and weighed against the risks that the procedure
involves. The possible need for conversion to an open procedure
should be explained and planned for.
Special Preparations
Preoperative staging is the current basis for the rational choice
of a given procedure among those presently available in the
management of rectal cancer. This requires careful preoperative
diagnostic studies. In addition to digital palpation of the rectum,
this includes:
− Determining the location of the carcinoma with a rigid endoscope.
− Total colonoscopy to study the condition of the remaining
colon if the rectal neoplasm is sufficiently patent to allow
this examination.
− Biopsy and histological verfication of the adenocarcinoma.
− Endosonography to assess the depth of penetration of the
carcinoma and possible existence of lymph-node
metastases.
− Abdominal CT scan to exclude hepatic metastases.
− Chest radiograph to exclude pulmonary metastases.
We recommend preoperative oral bowel preparation with 4−5 L
of GOLYTELY. The addition of 50 g of high-molecular-weight
dextran per liter can significantly reduce fluid absorption that is
usually about 2 L. Even elderly patients without disturbed
motility tolerate this oral bowel preparation without complications. In the presence of a rectal carcinoma with stenosis, prepare the patient with parenteral feeding and no oral nutrition
for a period of several days and conventional bowel preparation
with laxatives and enemas.
Anesthesia
General anesthesia.
Patient Positioning
(Fig. 12.5.1).
To facilitate the perineal phase of the operation, the buttocks
are maximally retracted with adhesive tape in a modified
lithotomy position. The urinary catheter is draped over the left
leg. After palpating the cancer once more to assess its location,
the surgeon closes the anus with a double pursestring suture to
minimize the risk or tumor cell spillage.
Surgical Risks and Informing the Patient
The patient must be informed that laparoscopic abdominoperineal rectum excision is not yet an established procedure with
full credentials in surgical oncological practice. Inform the
patient of the surgeon’s personal experience with this technique, within the broader scope of his or her conventional and
laparoscopic surgical experience. Due to the small number of
operations performed in most facilities, reliable data on the incidence of complications are not yet available. The patient
Position of the Operating Team
(Fig. 12.5.2).
Trocar Placement
Placing the trocars in a semicircle around the pelvis (Fig. 12.5.3)
has become an established technique in all laparoscopic operations involving the sigmoid colon and rectum. Disposable
Fig. 12.5.1 Abdominoperineal excision or amputation of the rectum.
Patient positioning.
For laparoscopic abdominoperineal excision or amputation of the rectum,
place the patient on an operating table for rectal surgery in an extreme
Trendelenburg position (inclined 30−40°). Shoulder and pelvic supports
are used to restrain the patient and permit inclining the operating table in
any plane during the procedure. To reduce the risk of compartment syndrome and compressive neuropathies, enclose the patient’s knees and
calves in thick foam rubber cushions. Use compressive venodyne boots
and leggies to prevent venous stasis and thrombosis.
Trocar Placement
389
Fig. 12.5.2 Abdominoperineal excision or amputation
of the rectum. Position of the
operating team and equipment.
Performing abdominoperineal
excision or amputation of the
rectum requires two equally
experienced surgeons, who
stand on either side of the
patient. Depending on the situation, the surgeons work
with one or both hands. Since
there is no room next to the
surgeons for the assistant
holding the laparoscope, he
or she stands at the patient’s
draped left shoulder. The
patient’s right arm is ex-
tended to provide vascular
access for anesthesia. A sec-
ond assistant stands next to
the patient’s right leg, and
the operating room nurse
stands next to the patient’s
left leg with the instrument
table. The monitor, insufflator,
and light source are located
between the patient’s ab-
ducted legs. The electro-
cautery unit and the aspirator/
irrigator set can be positioned
more or less as desired.
Assistant holding the
laparoscope and camera
Aspirator/
irrigator set
Surgeon
Surgeon
Electrocautery
unit
Assistant
Instrument table
10/12-mm trocars equipped with flap valves, reducing caps, and
threaded holding collars are generally recommended for use in
laparoscopic colorectal surgery. During protracted colorectal
procedures involving frequent instrument changes and the use
of 10-mm blunt holders and dissectors, the trocars must be se-
curely fixed to the abdominal wall with the aid of the threaded
collar to eliminate the risk of trocars slipping out and allowing
for subcutaneous emphysema. Since both surgeons generally
work with both hands, the additional assistant will not be able
to hold all four trocars when instruments are changed. Reducing
caps should be used in place of instrument sleeves. The laparoscope/camera trocar should be inserted into the left upper ab-
Monitor
Insufflator
domen instead of the umbilicus to maintain sufficient distance
to the pelvis. Insert the trocar several finger breadths superior
to the umbilicus and slightly left of the midline to avoid insufflating the round ligament of the liver. After placing the laparoscope/camera trocar and using transillumination to locate
poorly vascularized areas, place two instrument trocars each in
the left and right lower quadrants. Place the superior instrument trocars slightly more medial and the inferior trocars
slightly more lateral to form a semicircle. All of these are also
10/12-mm disposable trocars with threaded collars and reducing caps. Place the left superior trocar at the predetermined optimal site for the descending colon stoma, which the surgeon
390
T2
T3
Fig. 12.5.3 Abdominoperineal excision or amputation of the rectum.
Trocar placement.
T1 10/12-mm laparoscope/camera trocar: slightly superior to the umbilicus
and left of and lateral to the median line.
T2−5 10/12-mm instrument trocars: forming a semicircle with the laparo-
scope/camera trocar around the pelvis.
should mark prior to prepping the patient for operation. The re-
maining trocars are placed according to this predetermined
position to eliminate the need for an additional port site. When
inserting the instrument trocars and the laparoscope/camera
trocar, make sure that the trocar penetrates perpendicular to
the abdominal wall. Diagonal insertion of the trocar will not en-
sure sufficient freedom of movement for the instruments. Since
all ports will subsequently be closed with a fascial suture, the
Z technique of inserting the trocars is not required. If the abdomen is sterilely draped, make sure that the abdomen remains
uncovered far laterally so that the instrument trocars are far
enough apart to avoid “duelling.”
Open trocar placement is an alternative.
12.5 Abdominoperineal Excision or Amputation of the Rectum
T1
T4
T5
Complications
Intraoperative Complications
In addition to the typical complications associated with establishing the pneumoperitoneum and placing the trocars, intraoperative complications specific to laparoscopic rectum exci-
sion/amputation can occur.
− Iatrogenic injuries to the large or small intestine.
Improper use of electrocautery or the use of traumatic grasping instruments can result in tears in the wall of the large intestine, rectum, or small intestine. To reduce the risk of such
injuries, we recommend using atraumatic blunt “peanut”
swabs mounted on adequately sized clamps in colorectal
surgery.
Corrective action: If an iatrogenic injury to the large or small
intestine occurs, conversion to an open procedure will
generally be necessary. Only surgeons with extensive experience in laparoscopic colorectal surgery should attempt
to suture small lesions.
− Bleeding.
Improper dissection technique during the transection of the
inferior mesenteric artery at its origin and during mesenteric
and pelvic dissection can result in massive bleeding.
Corrective action: Such bleeding can usually be controlled
quickly by applying compression with a swab. Any larger
arterial or venous bleeding warrants immediate conversion
to open laparotomy. Avoid protracted attempts at controlling
bleeding laparoscopically. Major bleeding in these regions
can lead to serious problems even in conventional open
operations.
− Injury to the ureter.
Like in conventional operations, the ureter must be exposed
on the left in any laparoscopic operation on the sigmoid
colon or rectum.
Corrective action: In our opinion, failure to be able to expose
the ureter, as may occur in obese patients or if the dissection
is performed in the wrong tissue level, warrants conversion
to a conventional open procedure. Careful preservation of
the ureter is possible only if it can be exposed and protected.
Injury to the ureter despite exposure also requires immediate conversion to open laparotomy. Ureteral lesions should
be corrected as discussed elsewhere.
Postoperative Complications
All the same postoperative complications can occur as in conventional abdominoperineal excision or amputation of the rectum. These include:
− Postoperative bleeding.
This can include bleeding from the ligation of the inferior
mesenteric artery, the mesentery, bleeding from the trocar
sites involving injury to the epigastric vessels, generalized
oozing or major bleeding in the pelvis, or bleeding in the
sacral dissection area.
Corrective action: Depending on the situation, reoperation
via laparotomy or reopening of the perineal-sacral wound
may be indicated. If the bleeding cannot be controlled immediately by suturing the damaged vessel, it may become necessary to place a tamponade in the pelvis.
− Peritonitis and/or abscesses.
Corrective action: If injuries to the small or large intestine or
hematomas with secondary infections go unnoticed, septic
complications may occur that require immediate laparotomy
or perineal-presacral reexploration.
− Stricture of the ureter.
Electrocautery too close to the ureter or careless application
of clips in the presence of bleeding in the pelvis can result in
stricture of the ureter with retention of urine and sepsis.
Corrective action: Depending on the situation, intraoperative
splinting of the ureters may be helpful. Post-injury lysis and/
or reconstruction of a ureter may become necessary.
− Ileus of the small bowel.
When the procedure involves complete wide pelvic dissection, loops of the small bowel can form adhesions and produce postoperative obstruction of the small bowel. This complication appears to be more likely if an attempt is made to
close the peritoneal covering of the pelvis with incomplete
peritoneal flaps and minor defects in the suture occur.
Complications
391
Corrective action: Where nonoperative therapy cannot eliminate the obstruction, repeat laparotomy is indicated.
− Urogenital dysfunction.
Urogenital complications following extensive rectum resection and extirpation occur very frequently.
Corrective action: By tailoring the pelvic dissection technique
to the anatomy and the mode of dissemination of the rectal
carcinoma, we attempt to reduce the incidence of injury to
the autonomic nervous system. Depending on the size of the
tumor, this may not always be successful. The magnified
image of the surgical site provided by the laparoscope helps
the surgeon visualize and carefully preserve the fine fibers of
the autonomic nervous system.
Step-by-Step Procedure
1. Insert the trocars under laparoscopic visualization.
2. Explore the abdomen to exclude hepatic metastases and/or
peritoneal metastases.
3. In women, elevate the uterus against the abdominal wall and
suspend it with a transabdominal suture sling.
4. Separate the sigmoid colon from embryonic adhesions to the
lateral abdominal wall along the white line of Toldt.
5. Expose the left ureter.
6. Dissect the mesosigmoid off Gerota’s fascia all the way to the
aorta and the iliac bifurcation.
7. Swing the sigmoid colon to the left and incise the lateral rec-
tal peritoneum at the level of the promontory.
8. Incise and separate the mesenteric attachment from the
anterior aspect of the aorta to expose the trunk of the inferior
mesenteric artery.
9. Using a linear vascular stapler or large strong clips, ligate and
divide the inferior mesenteric artery at its origin.
10. Using a linear stapler, gradually transect the colon and mesocolon at the junction of the descending colon with the sigmoid colon.
11. Begin the pelvic dissection by entering the posterior fascial
cleavage plane all the way to the floor of the pelvis.
12. Make a U-shaped incision anteriorly around the rectum in the
vesicorectal or uterorectal fold.
13. Enter and open the anterior fascial cleavage space as far as
possible toward the floor of the pelvis.
− Infection of the sacral wound.
Since the perineal phase of the procedure is identical to the
perineal stage of a conventional rectum excision/amputation, the incidence of infection of the sacral wound and associated problems is likely to be similar.
Corrective action: If infection and/or abscess formation occurs in the sacral wound, the wound should be generously
debrided and washed and cleaned daily.
− Stoma complications.
Long-term stoma complications such as peristomal hernias
and stoma prolapse, should occur less frequently following
laparoscopic procedures since laparoscopy preserves the integrity of the abdominal wall.
14. Gradually dissect the lateral ligaments off the lateral pelvic
wall, remaining as close as possible to the pelvic wall in this
dissection.
15. Locate, clip or staple, and transect the middle rectal artery.
16. Completely mobilize the rectum to the floor of the pelvis,
leaving it enclosed in its surrounding mantle of connective,
fatty, and lymph tissues.
17. Replace the 12-mm trocar at the marked site with a 20-mm
recovery trocar.
18. Pull the proximal end of the colon into the recovery trocar
with a laparoscopic grasper. Let the pneumoperitoneum
down and draw the end of the proximal colon out of the
abdominal cavity.
19. After opening the proximal end of the colon outside the
abdominal cavity, suture the colon circumference to the
abdominal wall opening to form a terminal stoma for the descending colon.
20. Perform the perineal phase of the operation, delivering the
rectum as in a conventional rectum excision/amputation.
21. Close the wound in layers and place a suction drain in the
sacral hollow.
22. Reestablish a reduced pressure pneumoperitoneum at 8 mm
Hg.
23. Irrigate the pelvis and control residual bleeding with electrocautery.
24. Place a suction drain in the pelvis through the right or left inferior trocar site.
25. Remove the trocars under laparoscopic vision and close the
wounds in layers.
392
12.5 Abdominoperineal Excision or Amputation of the Rectum
Operative Technique
Fig. 12.5.4 Abdominoperineal excision or amputation of the rectum.
Elevating and suspending the uterus, fallopian tubes, and ovaries to and
from the abdominal wall in the female patient.
After exploring the abdomen to exclude hepatic and peritoneal
metastases, inspect the pelvis. With a urinary catheter in place, the posteriorly convex wall of the bladder will be visible. In male patients, the peri-
toneal fold (rectovesical pouch) can be inspected. In female patients, the
uterus and appendages will block access to the rectouterine pouch. To improve exposure, we suture the uterus and its appendages to the anterior
abdominal wall. Introduce a straight needle through the abdominal wall,
and hold it with a grasper and needle holder. Push the needle through the
broad ligament to the right of the uterus and feed it around the uterus.
Then push the needle back through the broad ligament to the left of the
uterus behind the left appendages, and feed it back through the abdominal wall. Now tie an extracorporeal knot to lift the uterus and appendages
up against the anterior abdominal wall. This exposes the rectouterine
pouch.
T3
T2
Fig. 12.5.5 Abdominoperineal excision or amputation of the rectum. Incision of the white line of Toldt and elevation of the sigmoid colon.
Begin mobilization by separating the sigmoid colon and mesocolon from
the lateral abdominal wall by incising along the white line of Toldt. Retract
the sigmoid colon and elevate the mesosigmoid to the right with blunt
swabs (T2) and transect strands of connective tissue with hooked-electrode electrocautery (T3) or electrocautery scissors. Dissect along the undersurface of the mesosigmoid to avoid penetrating deeper layers and reduce the risk of injury to major vascular structures or the ureter by staying
in the right layer.
Complications
5
393
T3
.
.
.
.
a
Fig. 12.5.6a, b Abdominoperineal excision or amputation of the rec-
tum. Mobilization of the sigmoid colon, exposure of the ureter, and incision of the mesosigmoid overlying the aorta.
The colon and mesocolon are separated by a loose, poorly vascularized
layer of connective tissue from Gerota’s fascia, which covers the fatty cap-
sule of the kidneys, the ureters, and major vascular structures. The sig-
moid colon and the descending colon are mobilized in this loose, poorly
vascularized layer of connective tissue (5) as far medial as the abdominal
aorta, gradually elevating and freeing the sigmoid colon and the mesosig-
moid to the right with swabs (6). Only after the mesocolon has been liber-
12
.
6
3
.
4
2
ated to the abdominal aorta, is the ureter carefully located on the left
where it crosses the common iliac artery posterior to Gerota’s fascia and
medial to the testicular or ovarian vein. Expose the ureter by blunt dissection with a 5-mm grasper and swab (T3). The exposed ureter can be positively identified because it will contract when touched with the swab.
1 Sigmoid colon
2 Left ureter
3 Inferior mesenteric artery
4 Abdominal aorta
Fig. 12.5.7 Abdominoperineal excision or amputation of the rectum. In-
cision of the sigmoid mesentery.
After the mesosigmoid has been mobilized as far as the aorta and the iliac
bifurcation, its roof is still attached medially to the anterior aspect of the
aorta and the iliac bifurcation. The inferior mesenteric artery or the super-
ior rectal artery runs parallel to the medial mesosigmoid attachment for a
short distance. The mesentery inferior to this vascular axis is practically
avascular. This means that the attachment of the mesentery to the ante-
rior aspect of the aorta or the iliac bifurcation can be gradually incised
with a hooked electrode or electrocautery scissors inferior to the vascular
branches. Incising the full thickness of the mesocolon creates a window
inferior to the mesenteric vessels and the lymph nodes and lymphatic
channels disposed along these structures (see Fig. 12.5.3 for key to instrument numbers).
1 Superior rectal lymph nodes
2 Superior rectal artery
3 Sigmoid arteries
4 Inferior mesenteric lymph nodes
5 Inferior mesenteric artery
394
T4
12.5 Abdominoperineal Excision or Amputation of the Rectum
T5
T3
1
2
Fig. 12.5.8 Abdominoperineal excision or amputation of the rectum.
Lifting the sigmoid colon.
The dissection is continued superiorly in the avascular attachment of the
mesosigmoid to the anterior aspect of the aorta, toward the trunk of the
inferior mesenteric artery. To do so, the mesentery is lifted with a swab in-
serted into the retroperitoneal aperture from the left and stretched superiorly with a second swab inserted from the left. This places tension on
the tissue surrounding the inferior mesenteric artery, which can then be
cautiously cleared with electrocautery. The magnified image of the surgi-
cal site provided by the laparoscope permits visualization of the auton-
omic nerve plexuses along the aorta. These should be carefully preserved
(see Fig. 12.5.3 for key to instrument numbers).
T5
T3
Fig. 12.5.9 Abdominoperineal excision or amputation of the rectum. Exposing the inferior mesenteric artery.
Transecting the surrounding tissues exposes the trunk of the inferior
mesenteric artery immediately at its origin from the abdominal aorta. The
dissection to expose the artery is completed to render ligation safe before
transection. The surrounding adventitial and remaining connective-tissue
attachments around the entire circumference of the vessel are cleared by
gentle stretching and spreading with a laparoscopic grasper inserted from
the right. If necessary, surrounding tissue to the left of the artery may be
divided using electrocautery (see Fig. 12.5.3 for key to instrument numbers).
1 Inferior mesenteric artery
2 Abdominal aorta
a
Fig. 12.5.10 a, b Abdominoperineal excision or amputation of the rectum.
Ligating and transecting the inferior mesenteric artery.
In our experience, safely ligating the inferior mesenteric artery requires
the use of either a linear stapler (a) or endoscopic clips (b). To eliminate
the risk of injuring the vessel, use a linear stapler whenever the surrounding tissue cannot be completely dissected off the trunk of the artery. To
ligate the vessel, place the jaws of the stapler around the artery. Before fir-
b
ing, verify that no other structures (i. e., ureter) are between the jaws.
When using endoscopic clips to ligate the artery, first dissect all surrounding tissue off the vessel to ensure that the clips will close properly and will
not slide on loose areolar tissue left around the artery. We place three
clips toward the aorta and two toward the mesentery (see Fig. 12.5.3 for
key to instrument numbers).
T4
T4
Complications
395
T2
Fig. 12.5.11 Abdominoperineal excision or amputation of the rectum.
Transection of the colon.
Ligating the inferior mesenteric artery close to the aorta defines the proximal margin of the extended lymph-node dissection. Using linear staplers,
gradually transect and staple both sides of the colon and mesocolon at
the junction of the descending and sigmoid colon by cutting and stapling
in the direction of a point a few centimeters superior to the ligated inferior
mesenteric artery (see Fig. 12.5.3 for key to instrument numbers).
.
4
.
5
.
.
3
Fig. 12.5.12 Abdominoperineal excision or amputation of the rectum.
Dividing the mesocolon.
While dividing the mesocolon at the junction of the descending and sigmoid colon, the ascending branch of the inferior mesenteric artery (left
colic artery) is left with the future specimen. The mesocolon superior to
the left colic artery is transected and sealed with a linear stapler. The
marginal artery of Drummond and the inferior mesenteric vein are ligated
and transected in the mesocolon. To reduce the risk of bleeding from the
edges of the mesocolon, use appropriate staple sizes to securely close the
mesocolon. In case of doubt, use a multifire stapler (see Fig. 12.5.3 for key
to instrument numbers).
1 Ligated inferior mesenteric artery
2 Abdominal aorta
3 Left colic artery
4 Sigmoid artery
5 Superior rectal artery
.
2
1
396
13
12
14
11
10
9
Fig. 12.5.13 Abdominoperineal excision or amputation of the rectum.
Overview of the anatomy showing fascias and connective-tissue spaces.
After transecting the colon and mesocolon, the pelvic dissection is begun.
Mobilizing the rectum represents the most important phase of the
various techniques: anterior, low anterior, and low sphincter-preserving
rectal resection procedures and of the rectum excision/amputation when
treating rectal cancer. Performing a radical resection of the cancer that
preserves as much of the pelvic anatomy as possible and reasonable re-
quires that the surgeon be familiar with the spread of rectal carcinoma
and the topographic and functional anatomy of the pelvis and pelvic organs. The tight connective tissue of the pelvis typically surrounds neu-
rovascular structures in their course towards and into the pelvic organs.
The resulting anatomic formations are referred to as neurovascular
bundles. The surrounding connective tissue separates these bundles from
the loosely organized tissues, most often fat and fibrous trabeculae filling
the spaces between the bundles. The boundaries between the two consist
of fascia-like structures of connective tissue that cover neurovascular
bundles and line the loosely filled spaces. These spaces contain rare ves-
sels and nerves; they are especially suited to facilitate safe dissection and
wide mobilization. The connective-tissue sheaths represent the visible envelopes of the neurovascular bundles. Tight linings of connective tissue
surround the organs of the pelvis, the musculature of the floor of the pelvis, and the lateral pelvic wall. The entire musculature of the lateral pelvic
wall and the sacrum is covered by the parietal pelvic fascia. The fascias
12.5 Abdominoperineal Excision or Amputation of the Rectum
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1
2
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3
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8
5
6
7
covering the pelvic organs are collectively referred to as the visceral pelvic
fascia. The parietal pelvic fascia and the visceral pelvic fascia merge and
attach to the tip of the coccyx. The rectovesical septum of Denonvilliers
separates the rectum from the prostate gland. This septum covers the
posterior prostate gland and the seminal vesicles. Laterally, the rectovesical septum merges with the parietal pelvic fascia. This fascia can be extremely fibrous in the area between the rectum and the prostate gland.
Between the rectovesical septum and the rectum lies a space filled with
fatty tissue.
Urinary and sexual dysfunction regularly occurs after major pelvic operations and represents a problem for the patient. Performing the pelvic dissection along anatomic planes while taking care to preserve autonomic
neural structures can help reduce the incidence of complications without
compromising the radical character of the dissection.
The autonomic nervous system of the pelvis consists of sympathetic
nerve fibers from spinal nerve segments T12, L1, and L2, and parasympa-
4
thetic nerve fibers of the sacral spinal nerves. The fibers of the autonomic
nervous system form the superior hypogastric plexus. The superior hypogastric plexus lies anterior to the lumbar vertebra V and inferior to the iliac
bifurcation. The superior hypogastric plexus extends to the fifth sacral
vertebra via the hypogastric nerves. Together with the pelvic splanchnic
nerves (S2−4), it joins the inferior hypogastric plexus, located in the rectal
column anterior to the rectum.
Nerves originating from this plexus course anteriorly within the rectal
column to form the vesical plexus, prostatic plexus, and deferential
plexus. The prostatic plexus is the origin of the cavernous nerves of the
penis, which supply the cavernous body of the penis. The inferior hypogastric plexus is located in the far lateral pelvis, level with the lower third of
the rectum. The nerves of the inferior hypogastric plexus that supply the
bladder and sexual organs also lie in the deep plane, enclosed in the
parietal pelvic fascia that also surrounds the pelvic blood vessels. This
means that the nerves of this plexus supplying the bladder and sexual organs can be spared during sharp dissection of the paraproctia (rectal
columns or neurovascular laminae of the rectum) when the parietal pelvic
fascia surrounding the branches of the internal iliac artery is preserved.
The prostatic plexus and the cavernous nerves can also be injured during
dissection of the rectovesical or rectouterine space. The nerves lie in a
neurovascular bundle posterolaterally to the prostate gland and the seminal vasicles. The neurovascular bundle lies in the connective-tissue
sheaths of the parietal pelvic fascia together with the capsule of the prostate gland, the rectovesical fascia.
1 Urinary bladder
2Ureter
3 Neurovascular bundle
4 Fibrous prerectal space
5 Rectum
6 Rectal fascia
7 Fibrous retrorectal space
8 Sacrum
9 Rectal carcinoma
10 Metastases
11 Anterior boundary of the rectal column
12 Seminal vesicle
13 Spermatic cord
14 Rectovesical fascia
Fig. 12.5.14 Abdominoperineal excision or amputation of the rectum.
Mobilizing the posterior rectum.
The pelvic dissection in laparoscopic rectum excision/amputation begins
with the mobilization of the posterior rectum. To gain access into the fascial cleavage plane, the dissection is continued downwards at the transition of Gerota’s fascia into Waldeyer’s fascia, by bluntly sweeping the mesorectum anteriorly. Using a hooked-electrode or electrocautery scissors,
the dissection should progress downward within the correct anatomical
space along the posterior fascia and protect the hypogastric plexus and its
two branches, posterior to this dissection or within Waldeyer’s fascia. To
advance in a caudal direction, by pulling the rectum upwards, the
tightened strands of connective tissue extending between the two fascial
layers are transected with electrocautery scissors. Continue the dissection
down to the tip of the coccyx, carefully preserving the parietal pelvic fascia. Using electrocautery scissors or a hooked electrode, the transition
fold of the visceral into parietal pelvic fascia is divided at the level of the
tip of the coccyx. After dividing this posterior fold, the dissection is extended laterally, away from the mesorectum, by following the levator ani
muscles anteriorly. This mobilizes the rectum and mesorectum posteri-
orly and laterally in a semicircular fashion and exposes the posterior and
lateral margins of the perirectal tissues remaining within the specimen
(see Fig. 12.5.3 for key to instrument numbers).
1 Promontory.
T5
Complications
1
397
T4
Fig. 12.5.15 Abdominoperineal excision or amputation of the rectum.
Incising the pelvic peritoneum.
An inverted U-shaped incision of the peritoneal fold around the rectum
anteriorly, in the rectovesical pouch in males or rectouterine pouch in
females, slightly superior to the actual fold, liberates the rectum from the
posterior wall of the bladder or uterus. From there, the anterior dissection
continues into the prerectal space posterior to the rectovesical septum in
males or the posterior wall of the vagina in females. Continue the dissec-
tion in the anterior fascial cleavage plane using electrocautery scissors or
hooked electrode, carefully preserving the neurovascular bundle at the
lateral margin of the rectovesical or rectovaginal septum. The rectum remains only attached to the perirectal tissues surrounding the middle rec-
tal artery (see Fig. 12.5.3 for key to instrument numbers).
T3
T5