PMID- 34109532
OWN - NLM
STAT- MEDLINE
DCOM- 20211116
LR  - 20240213
IS  - 1873-4626 (Electronic)
IS  - 1091-255X (Linking)
VI  - 25
IP  - 10
DP  - 2021 Oct
TI  - An Optimal Surgical Plane for Laparoscopic Functional Total Mesorectal Excision 
      in Rectal Cancer.
PG  - 2726-2727
LID - 10.1007/s11605-021-05035-9 [doi]
AB  - BACKGROUND: Intraoperative damage of pelvic autonomic nerves is the primary 
      reason for postoperative sexual and urinary dysfunction after rectal cancer 
      surgery,1,2 especially in patients with low rectal cancer. In the present study, 
      we developed the nerve plane as a novel concept in rectal cancer surgery, which 
      served as a landmark for better preservation of pelvic autonomic nerves in 
      standardized total mesorectal excision (TME) surgery. The nerves never exist 
      alone, and are always surrounded by tiny capillaries and adipose tissue, which 
      are covered by a thin layer of membranous tissue, leading to a continuous plane, 
      which we defined as the nerve plane. The nerve plane could be preserved from 
      thermal damage, ischemic injury, nerve stretching, and chemical factors produced 
      by local inflammatory effects. We also found loose connective tissue (the first 
      gap) between the proper fascial of the rectum and the nerve plane, which was also 
      a natural avascular holy's plane. Using the concept of nerve plane, the proposed 
      functional TME procedure could help surgeons to better protect pelvic autonomic 
      nerves from injury. Herein, we present a brief video to describe the technical 
      aspects of a laparoscopic functional TME in rectal cancer surgery. METHODS: 
      Fifty-eight consecutive male patients without preoperative sexual and urinary 
      dysfunction underwent laparoscopic functional TME surgery for histologically 
      confirmed adenocarcinoma at our hospital since 2018. The present study was 
      approved by the institutional review board of the Renmin Hospital of Wuhan 
      University (2018-X-08), and written informed consent was obtained from all 
      patients. Urinary and sexual function was evaluated using the international 
      prostatic symptom score (IPSS)3 and the 5-item version of International Index of 
      Erectile Function (IIEF-5)4 questionnaires, respectively, which are 
      internationally recognized as well-structured and reliable questionnaires to 
      evaluate urinary and sexual function. Moderate-to-severe urinary dysfunction was 
      defined as IPSS score >8 points,2 while erectile dysfunction was defined as 
      IIEF-5 score </= 11points.5 The laparoscopic functional TME procedure shown in the 
      video is described as follows. First, the incision line was marked on the 
      peritoneum from the lower edge of the duodenum to the pelvic entrance with an 
      electric hook using a medium approach. The holy's plane was divided into five 
      structures by enforcing traction and anti-traction, which included fascia propria 
      of the rectum, the loose areolar connective tissue over the nerve plane (the 
      first gap), the nerve plane, the loose areolar connective tissue below the nerve 
      plane (the second gap), and the Gerota's fascia or the presacral fascia. Second, 
      dissection over the nerve plane was performed from the lower edge of the duodenum 
      to the pelvic entrance. Superior hypogastric plexus nerve plane, abdominal aortic 
      plexus nerve plane, and inferior mesenteric plexus nerve plane were clearly 
      displayed. Dissection was continued in this way, and the left and right 
      hypogastric nerve planes were also preserved. Finally, the pelvic cavity was 
      entered, and posterior dissection was continued downward to the Waldeyer fascia. 
      We selected to go over the Waldeyer fascia along the nerve plane instead of 
      transecting it to enter the superior levator space, thereby some small nerves 
      such as efferent branches of hypogastric nerves in this area were protected from 
      injury. The lateral pelvic dissection was continued over the pelvic plexus nerve 
      plane, anterior pelvic dissection was continued, and the Denonvillier's 
      interfascial space was entered between the anterior layer and the posterior layer 
      of Denonvilliers' fascia. The left and right neurovascular bundles (NVB) were 
      avoided and not intentionally exposed during the operation, thereby protecting 
      them from injury. Although some steps of the procedure are displayed very close 
      to the anatomical landmarks, patience and higher-resolution laparoscopic 
      equipment are needed for surgeons to find the nerve plane. For less experienced 
      surgeons, we suggest that the harmonic with the "hot" blade should be as far away 
      from the nerves as possible during the radical resection of tumor. After the 
      rectum was dissected, superior hypogastric plexus nerve plane, abdominal aortic 
      plexus nerve plane, inferior mesenteric plexus nerve plane, hypogastric nerve 
      plane, pelvic plexus nerve plane, left ureter, and genital vessels were displayed 
      and completely preserved. The intraoperative nerve plane and mesorectum of the 
      postoperative specimen were intact and smooth. RESULTS: The median age of 
      patients was 53 years, with a body mass index (BMI) of 24.0 kg/m(2). The median 
      total operation time was 198 min (range 128-248 min). The median volume of blood 
      loss was 30 ml (range 10-50 ml). The median number of retrieved lymph nodes was 
      31 (range 13-65). No patient showed postoperative moderate-to-severe urinary 
      dysfunction at 6 months. The incidence of postoperative erectile dysfunction was 
      5.17% (3/58) at 12 months. No patient was lost during 1-year of follow-up. 
      CONCLUSION: Nerve plane is an optimal surgical landmark for laparoscopic 
      functional total mesorectal excision in rectal cancer. It provides a superior 
      surgical technique for pelvic autonomic nerve protection.
CI  - (c) 2021. The Society for Surgery of the Alimentary Tract.
FAU - Li, Kai
AU  - Li K
AD  - Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, 
      Wuhan, Hubei, 430060, People's Republic of China.
FAU - He, Xiaobo
AU  - He X
AD  - Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, 
      Wuhan, Hubei, 430060, People's Republic of China.
FAU - Zheng, Yongbin
AU  - Zheng Y
AUID- ORCID: 0000-0002-4227-7599
AD  - Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, 
      Wuhan, Hubei, 430060, People's Republic of China. yongbinzheng@whu.edu.cn.
LA  - eng
PT  - Journal Article
DEP - 20210609
PL  - Netherlands
TA  - J Gastrointest Surg
JT  - Journal of gastrointestinal surgery : official journal of the Society for Surgery 
      of the Alimentary Tract
JID - 9706084
SB  - IM
MH  - Humans
MH  - *Laparoscopy/adverse effects
MH  - Male
MH  - *Mesocolon
MH  - Middle Aged
MH  - Pelvis/surgery
MH  - *Rectal Neoplasms/surgery
MH  - Rectum/surgery
OTO - NOTNLM
OT  - Nerve plane
OT  - Rectal cancer
OT  - Sexual dysfunction
OT  - Total mesorectal excision
OT  - Urinary function
EDAT- 2021/06/11 06:00
MHDA- 2021/11/17 06:00
CRDT- 2021/06/10 06:57
PHST- 2021/03/30 00:00 [received]
PHST- 2021/05/03 00:00 [accepted]
PHST- 2021/06/11 06:00 [pubmed]
PHST- 2021/11/17 06:00 [medline]
PHST- 2021/06/10 06:57 [entrez]
AID - S1091-255X(23)00811-9 [pii]
AID - 10.1007/s11605-021-05035-9 [doi]
PST - ppublish
SO  - J Gastrointest Surg. 2021 Oct;25(10):2726-2727. doi: 10.1007/s11605-021-05035-9. 
      Epub 2021 Jun 9.