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Ryu S, Imaizumi Y, Goto K, Iwauchi S, Kobayashi T, Ito R, Nakabayashi Y. Artificial intelligence-enhanced navigation for nerve recognition and surgical education in laparoscopic colorectal surgery. Surg Endosc 2025; 39:1388-1396. [PMID: 39762611 PMCID: PMC11794642 DOI: 10.1007/s00464-024-11489-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 12/14/2024] [Indexed: 02/06/2025]
Abstract
BACKGROUND Devices that help educate young doctors and enable safe, minimally invasive surgery are needed. Eureka is a surgical artificial intelligence (AI) system that can intraoperatively highlight loose connective tissues (LCTs) in the dissected layers and nerves in the surgical field displayed on a monitor. In this study, we examined whether AI navigation (AIN) with Eureka can assist trainees in recognizing nerves during colorectal surgery. METHODS In left-sided colorectal surgery (n = 51, between July 2023 and February 2024), Eureka was connected to the laparoscopic system side by side, and the nerve was highlighted on the monitor during the surgery. We examined the rate of failure to recognize nerves by trainee surgeons over a total of 101 scenarios after it was recognized intraoperatively by the supervising surgeon (certified by the Japanese Society of Endoscopic Surgery). We also examined the frequency of nerve recognition by the trainee physicians viewing the Eureka monitor when recognition was not possible (recognition assistance rate). RESULTS The nerve recognition failure rate and recognition assistance rate with AIN were as follows: right hypogastric nerve during sigmoid colon mobilization, 44/101 (43.6%) and 19/44 (43.2%); left hypogastric nerves during dissection of the dorsal rectum, 27/101 (26.7%) and 13/27 (48.1%); right lumbar splanchnic nerves, 32/101 (31.7%) and 29/32 (90.6%); left lumbar splanchnic nerves, 44/101 (43.6%) and 39/44 (88.6%); and pelvic visceral nerves during dissection of the dorsal rectum, 29/45 (64.4%) and 6/29 (20.7%), respectively. CONCLUSION Although the rate of recognition with assistance from AIN differed for the different nerves, this system can potentially assist in anatomic recognition, enhance surgical education, and contribute to nerve preservation. TRIAL REGISTRATION Improvement of AI navigation in minimally invasive surgery and examination of its intraoperative support and educational effectiveness. Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2022-27.
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Affiliation(s)
- Shunjin Ryu
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, Kawaguchi City, Saitama, 180, Nishiaraijuku333-0833, Japan.
| | - Yuta Imaizumi
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, Kawaguchi City, Saitama, 180, Nishiaraijuku333-0833, Japan
| | - Keisuke Goto
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, Kawaguchi City, Saitama, 180, Nishiaraijuku333-0833, Japan
| | - Sotaro Iwauchi
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, Kawaguchi City, Saitama, 180, Nishiaraijuku333-0833, Japan
| | - Takehiro Kobayashi
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, Kawaguchi City, Saitama, 180, Nishiaraijuku333-0833, Japan
| | - Ryusuke Ito
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, Kawaguchi City, Saitama, 180, Nishiaraijuku333-0833, Japan
| | - Yukio Nakabayashi
- Department of Digestive Surgery, Kawaguchi Municipal Medical Center, Kawaguchi City, Saitama, 180, Nishiaraijuku333-0833, Japan
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Chen C, Zhang X, Li X, Wang YL. Clinical application of eight-zone laparoscopic dissection strategy for rectal cancer: Experience and discussion. World J Gastroenterol 2024; 30:3574-3583. [PMID: 39193567 PMCID: PMC11346151 DOI: 10.3748/wjg.v30.i30.3574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/05/2024] [Accepted: 07/24/2024] [Indexed: 08/08/2024] Open
Abstract
BACKGROUND The incidence of rectal cancer is increasing worldwide, and surgery remains the primary treatment modality. With the advent of total mesorectal excision (TME) technique, the probability of tumor recurrence post-surgery has significantly decreased. Surgeons' focus has gradually shifted towards minimizing the impact of surgery on urinary and sexual functions. Among these concerns, the optimal dissection of the rectal lateral ligaments and preservation of the pelvic floor neurovascular bundle have become critical. To explore the optimal surgical technique for TME and establish a standardized surgical protocol to minimize the impact on urinary and sexual functions, we propose the eight-zone dissection strategy for pelvic floor anatomy. AIM To compare the differences in surgical specimen integrity and postoperative quality of life satisfaction between the traditional pelvic floor dissection strategy and the innovative eight-zone dissection strategy. METHODS We analyzed the perioperative data of patients who underwent laparoscopic radical resection of rectal cancer at Qilu Hospital of Shandong University between January 1, 2021 and December 1, 2023. This study included a total of 218 patients undergoing laparoscopic radical surgery for rectal cancer, among whom 109 patients underwent traditional pelvic floor dissection strategy, and 109 patients received the eight-zone dissection strategy. RESULTS There were no significant differences in general characteristics between the two groups. Patients in the eight-zone dissection group had higher postoperative specimen integrity (88.1% vs 78.0%, P = 0.047). At the 3-month follow-up, patients in the eight-zone surgery group had better scores in urinary issues (6.8 ± 3.3 vs 5.3 ± 2.5, P = 0.045) and male sexual desire (2.2 ± 0.6 vs 2.5 ± 0.5, P = 0.047) compared to the traditional surgery strategy group. CONCLUSION This study demonstrates that the eight-zone dissection strategy for laparoscopic lateral ligament dissection of rectal cancer is safe and effective. Compared with the traditional pelvic floor dissection strategy, this approach can reduce the risk of nerve injury and minimize the impact on urinary and sexual functions. Therefore, we recommend the clinical application of this strategy to better serve patients with rectal cancer.
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Affiliation(s)
- Chang Chen
- Department of General Surgery, Rongchang People's Hospital, Chongqing 250012, China
| | - Xiang Zhang
- Department of Colorectal Surgery, Qilu Hospital, Shandong University, Jinan 250012, Shandong Province, China
| | - Xin Li
- Department of General Surgery, Huantai Branch of Qilu Hospital of Shandong University, Zibo 255000, Shandong Province, China
| | - Yan-Lei Wang
- Department of Colorectal Surgery, Qilu Hospital, Shandong University, Jinan 250012, Shandong Province, China
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Uçaner B, Buldanli MZ, Çimen Ş, Çiftçi MS, Demircioğlu MM, Kaymak Ş, Hançerlioğullari O. Investigation of postoperative erectile dysfunction in colorectal surgery patients and comparison of results. Medicine (Baltimore) 2024; 103:e38281. [PMID: 38788022 PMCID: PMC11124661 DOI: 10.1097/md.0000000000038281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Although surgical treatment is curative for colorectal cancers, erectile dysfunction (ED) is one of the complications that affect the patient quality of life. The present study aimed to evaluate sexual dysfunction in patients who underwent anterior resection (AR) and low AR (LAR) surgery secondary to rectosigmoid pathologies in our clinic, to analyze the effective variables, and to compare the results. METHODS In the retrospectively designed study, male patients who underwent surgery for malignancy or other surgical pathologies in the General Surgery Clinic between January 2017 and December 2022 were examined. Female gender, patients under 18 years of age, and patients who refused to participate in the study were excluded. RESULTS The high age of the patient increased the risk of severe ED in the postoperative period. However, surgical technique, alcohol use, American Society of Anesthesiologists (ASA) score, and Clavien-Dindo class were not determinants in the presence of severe ED. CONCLUSION ED is an emerging medical problem that affects patients who undergo colorectal surgery adversely both in social and psychological aspects. Discussions on the issue are still ongoing. Clinicians' concerns can be addressed in the future as the number of prospectively designed studies involving more homogeneous and larger populations increases.
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Affiliation(s)
- Burak Uçaner
- Department of General Surgery, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Mehmet Zeki Buldanli
- Department of General Surgery, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Şebnem Çimen
- Department of General Surgery, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Mehmet Sabri Çiftçi
- Department of General Surgery, Sincan Training and Research Hospital, Ankara, Turkey
| | - Mehmet Mert Demircioğlu
- Department of General Surgery, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Şahin Kaymak
- Department of General Surgery, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Oğuz Hançerlioğullari
- Department of General Surgery, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
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Wang J, Liu H, Li A, Jiang H, Pan Y, Chen X, Yin L, Lin M. A new membrane anatomy-oriented classification of radical surgery for rectal cancer. Gastroenterol Rep (Oxf) 2023; 11:goad069. [PMID: 38145104 PMCID: PMC10739184 DOI: 10.1093/gastro/goad069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/08/2023] [Accepted: 11/10/2023] [Indexed: 12/26/2023] Open
Abstract
For patients with different clinical stages of rectal cancer, tailored surgery is urgently needed. Over the past 10 years, our team has conducted numerous anatomical studies and proposed the "four fasciae and three spaces" theory to guide rectal cancer surgery. Enlightened by the anatomical basis of the radical hysterectomy classification system of Querleu and Morrow, we proposed a new classification system of radical surgery for rectal cancer based on membrane anatomy. This system categorizes the surgery into four types (A-D) and incorporates corresponding subtypes based on the preservation of the autonomic nerve. Our surgical classification unifies the pelvic membrane anatomical terminology, validates the feasibility of classifying rectal cancer surgery using the theory of "four fasciae and three spaces," and lays the theoretical groundwork for the future development of unified and standardized classification of radical pelvic tumor surgery.
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Affiliation(s)
- Jiaqi Wang
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Hailong Liu
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Ajian Li
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
| | - Huihong Jiang
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Yun Pan
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Xin Chen
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Lu Yin
- Department of General Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, P. R. China
| | - Moubin Lin
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
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Kojima S, Kitaguchi D, Igaki T, Nakajima K, Ishikawa Y, Harai Y, Yamada A, Lee Y, Hayashi K, Kosugi N, Hasegawa H, Ito M. Deep-learning-based semantic segmentation of autonomic nerves from laparoscopic images of colorectal surgery: an experimental pilot study. Int J Surg 2023; 109:813-820. [PMID: 36999784 PMCID: PMC10389575 DOI: 10.1097/js9.0000000000000317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/21/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND The preservation of autonomic nerves is the most important factor in maintaining genitourinary function in colorectal surgery; however, these nerves are not clearly recognisable, and their identification is strongly affected by the surgical ability. Therefore, this study aimed to develop a deep learning model for the semantic segmentation of autonomic nerves during laparoscopic colorectal surgery and to experimentally verify the model through intraoperative use and pathological examination. MATERIALS AND METHODS The annotation data set comprised videos of laparoscopic colorectal surgery. The images of the hypogastric nerve (HGN) and superior hypogastric plexus (SHP) were manually annotated under a surgeon's supervision. The Dice coefficient was used to quantify the model performance after five-fold cross-validation. The model was used in actual surgeries to compare the recognition timing of the model with that of surgeons, and pathological examination was performed to confirm whether the samples labelled by the model from the colorectal branches of the HGN and SHP were nerves. RESULTS The data set comprised 12 978 video frames of the HGN from 245 videos and 5198 frames of the SHP from 44 videos. The mean (±SD) Dice coefficients of the HGN and SHP were 0.56 (±0.03) and 0.49 (±0.07), respectively. The proposed model was used in 12 surgeries, and it recognised the right HGN earlier than the surgeons did in 50.0% of the cases, the left HGN earlier in 41.7% of the cases and the SHP earlier in 50.0% of the cases. Pathological examination confirmed that all 11 samples were nerve tissue. CONCLUSION An approach for the deep-learning-based semantic segmentation of autonomic nerves was developed and experimentally validated. This model may facilitate intraoperative recognition during laparoscopic colorectal surgery.
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Affiliation(s)
- Shigehiro Kojima
- Surgical Device Innovation
- Department of Colorectal Surgery, National Cancer Center Hospital East, Chiba
- Division of Frontier Surgery, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Daichi Kitaguchi
- Surgical Device Innovation
- Department of Colorectal Surgery, National Cancer Center Hospital East, Chiba
| | - Takahiro Igaki
- Surgical Device Innovation
- Department of Colorectal Surgery, National Cancer Center Hospital East, Chiba
| | - Kei Nakajima
- Surgical Device Innovation
- Department of Colorectal Surgery, National Cancer Center Hospital East, Chiba
| | | | | | | | | | | | | | - Hiro Hasegawa
- Surgical Device Innovation
- Department of Colorectal Surgery, National Cancer Center Hospital East, Chiba
| | - Masaaki Ito
- Surgical Device Innovation
- Department of Colorectal Surgery, National Cancer Center Hospital East, Chiba
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Li K, Pang P, Cheng H, Zeng J, He X, Cao F, Luo Q, Tong S, Zheng Y. Protective effect of laparoscopic functional total mesorectal excision on urinary and sexual functions in male patients with mid-low rectal cancer. Asian J Surg 2023; 46:236-243. [PMID: 35361550 DOI: 10.1016/j.asjsur.2022.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/26/2022] [Accepted: 03/17/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Urinary and sexual dysfunctions are among the most common complications in rectal cancer surgery. This study aimed to investigate the protective effect of laparoscopic functional total mesorectum excision (TME) on urinary and sexual functions in male patients. METHODS A total of 248 male patients with mid-low rectal cancer were recruited in this study between February 2017 and July 2020. To overcome selection bias, we performed a 1:1 match using six variables, including age, BMI, ASA score, tumor distance, clinical T stage, and tumor size. The urinary function was assessed by the International Prostate Symptom Score (IPSS), sexual function was assessed by a 5-item version of the International Index of Erectile Function (IIEF-5) and ejaculation grading at postoperative 3 and 12 months. RESULTS 79 patients received functional TME surgery (FTME group), and 169 patients received routine TME surgery (RTME group). After the propensity score, 79 pairs were balanced and analyzed. Patients in the FTME group showed a lower IPSS score and higher IIEF-5 score than patients in the RTME group at postoperative 3 and 12 months. The incidence of ejaculation dysfunction for patients in the FTME group was lower than patients in the RTME group at postoperative 3 and 12 months. CONCLUSION Laparoscopic functional total mesorectal excision was beneficial to faster recovery of urinary and sexual function for patients with rectal cancer, and it could be used as a superior surgical technique for pelvic autonomic nerve preservation in mid-low rectal cancer.
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Affiliation(s)
- Kai Li
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Pengcheng Pang
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Hua Cheng
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Junjie Zeng
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xiaobo He
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Fengyu Cao
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Qiang Luo
- Division of Nephrology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Shilun Tong
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yongbin Zheng
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China.
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Laohawiriyakamol S, Chewatanakornkul S, Wanichsuwan W, Ruangsin S, Sunpaweravong S, Bejrananda T. Urogenital dysfunction after laparoscopic surgery for rectal or sigmoid colon cancer. Asian J Surg 2023; 46:492-500. [PMID: 35717291 DOI: 10.1016/j.asjsur.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 05/29/2022] [Accepted: 06/01/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/OBJECTIVE Urogenital dysfunction is a common complication after surgery for sigmoid colon or rectal cancers and may result from various causes. Herein, we evaluated urogenital dysfunction and the associated factors after laparoscopic surgery at different follow-up times. METHODS We conducted a prospective study on 91 patients who were diagnosed with sigmoid colon and rectal cancers and underwent laparoscopic surgery during 2014-2016. Voiding and male and female sexual dysfunctions following surgery were evaluated by the International Prostate Symptom Score (IPSS), International Index of Erectile Function-5 (IIEF-5), and Female Sexual Function Index-6 (FSFI-6), respectively. Urogenital function was compared at pre-surgery and 3 and 12 months postoperatively, and factors associated with urogenital dysfunction were identified. RESULTS The overall urinary function after surgery was better when compared to that at pre-surgery; however, there was deterioration in both male and female sexual functions. The mean preoperative IPSS, IIEF-5, and FSFI-6 scores were 9.35, 12.18, and 6.09, respectively. The mean differences among IPSS, IIEF-5, and FSFI-6 at 12 months postoperatively and pre-surgery were -3.08 (95% confidence interval [CI] -4.77 to -1.40), -2.57 (95% CI -4.33 to -0.80), and -2.58 (95% CI -4.73 to 0.42), respectively. Multivariate analysis demonstrated that age ≤60 years (odds ratio 4.22) and postoperative complications (odds ratio 2.77) were correlated with erectile dysfunction. CONCLUSION Voiding function improved after laparoscopic surgery in both sigmoid colon and rectal cancer patients. However, sexual function in both male and female patients was worse. Age ≤60 years and postoperative complications were strongly associated with male sexual dysfunction.
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Affiliation(s)
- Supparerk Laohawiriyakamol
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
| | - Siripong Chewatanakornkul
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Worawit Wanichsuwan
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Sakchai Ruangsin
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Somkiat Sunpaweravong
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Tanan Bejrananda
- Urologic Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
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Li K, Zeng J, Pang P, Cheng H, He X, Cao F, Luo Q, Tong S, Zheng Y. Significance of Nerve Plane for Inferior Mesenteric Plexus Preservation in Laparoscopic Rectal Cancer Surgery. Front Oncol 2022; 12:853662. [PMID: 35530321 PMCID: PMC9072964 DOI: 10.3389/fonc.2022.853662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background Station 253 node dissection with high ligation of the inferior mesenteric artery (IMA) is difficult to perform without damage to the surrounding autonomic nerve plexuses. This study aimed to investigate the significance of the nerve plane for inferior mesenteric plexus (IMP) preservation in laparoscopic rectal cancer surgery. Methods A total of 56 consecutive rectal patients underwent laparoscopic en bloc station 253 node dissection with high ligation of the IMA. Station 253 nodes were divided into the extra- and intra-nerve plane station 253 nodes for further H&E staining and immunohistochemical analysis. Based on IMP nerve plane-based evidence and histopathological results, a novel nerve-sparing technique, IMP nerve plane orientation, was proposed and performed on 68 rectal cancer patients. Urinary and sexual functions in all patients were evaluated at 6 months postoperatively. Results Lymph node metastasis was not found, but abundant nerve bundles containing gangliocytes were observed in extra-nerve plane station 253 nodes. The nerve plane was identified intraoperatively and then confirmed by both postoperative gross specimen evaluation and histopathological analysis. The novel nerve-sparing technique (IMP nerve plane orientation) was successfully performed with no postoperative complications, and the operated patients had improved postoperative urinary and sexual functions. Conclusion The nerve plane is helpful for IMP preservation and station 253 node dissection. This novel nerve-sparing technique of nerve plane orientation is technically feasible and safe, which could result in faster recovery of urinary and sexual functions.
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Affiliation(s)
- Kai Li
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Junjie Zeng
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Pengcheng Pang
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hua Cheng
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaobo He
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Fengyu Cao
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qiang Luo
- Division of Nephrology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shilun Tong
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yongbin Zheng
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, China
- *Correspondence: Yongbin Zheng,
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Herzberg J, Khadem S, Begemann V, Strate T, Honarpisheh H, Guraya SY. Quality of Life in Patients With Rectal Resections and End-to-End Primary Anastomosis Using a Standardized Perioperative Pathway. Front Surg 2022; 8:789251. [PMID: 35071312 PMCID: PMC8776631 DOI: 10.3389/fsurg.2021.789251] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/07/2021] [Indexed: 12/22/2022] Open
Abstract
Objectives: Lower rectal resection is associated with a high rate of postoperative complications and, therefore, adversely impacts the postoperative health-related quality of life (QoL). Though sporadically practiced in different centers, there is no standard perioperative protocol for the management of patients with rectal growths. The aim of this analysis is to evaluate the patient-reported outcomes after low rectal resections followed by an end-to-end-reconstruction and temporary covering ileostomy using a multidisciplinary fail-safe-concept. Methods: Between 2015 and 2020, we evaluated patient reported outcomes after open and laparoscopic rectal resections with end-to-end reconstruction with a primary straight anastomosis using a standardized perioperative pathway All patients with stoma were excluded from the study. The data for the QoL of patients was collected using the established Low Anterior Resection Syndrome (LARS)-score and the EORTC-C30 and CR-29 questionnaires at a single postoperative timepoint. Results: We recruited 78 stoma-free patients for this analysis. Of 78 patients included in the study, 87.2% were operated laparoscopically and the mean global health status was 67.95 points, while a major LARS was detected in 48 (61.5%) patients. No anastomotic leakage (AL) occurred within the study cohort. There was no significant change in the LARS-score or the global health status depending on the follow-up-period. Conclusion: This study shows that good QoL and functional outcomes with no AL are achievable following end-to-end straight anastomosis using a standardized perioperative surgical fail-safe protocol procedure.
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Affiliation(s)
- Jonas Herzberg
- Department of Surgery—Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
- *Correspondence: Jonas Herzberg
| | - Shahram Khadem
- Department of Surgery—Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
| | - Valentin Begemann
- Department of Surgery—Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
| | - Tim Strate
- Department of Surgery—Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
| | - Human Honarpisheh
- Department of Surgery—Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
| | - Salman Yousuf Guraya
- Clinical Sciences Department, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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Ghareeb WM, Wang X, Chi P, Zheng Z, Zhao X. OUP accepted manuscript. Gastroenterol Rep (Oxf) 2022; 10:goac001. [PMID: 35154782 PMCID: PMC8827049 DOI: 10.1093/gastro/goac001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/10/2021] [Accepted: 11/10/2021] [Indexed: 12/05/2022] Open
Abstract
Background The relative anatomical understanding of the perirectal fasciae is of paramount importance for the proper performance of total mesorectal excision (TME). This study was to demonstrate the planes of TME and validates the intraoperative findings using cadaveric observations. Methods In this combined retrospective and prospective study, bilateral attachment of the rectosacral fascia (RSF) was observed in 28 cadaveric specimens (male, n = 14; female, n = 14). From January 2018 to December 2019, surgical videos of 67 patients who underwent laparoscopic TME at the Affiliated Union Hospital of Fujian Medical University (Fuzhou, China) were reviewed and interpreted with the cadaveric findings. Results The RSF (synonym: Waldeyer's fascia) is the end of the pre-hypogastric fascia at the level of S4 and comprises two layers (upper and lower). These two layers provide double fascial protection for the venous sacral plexus. It inserts into the fascia propria of the rectum along a broad horizontal arc that merges anterolaterally in an oblique downward direction until it meets the posterolateral merge of Denonvilliers' fascia at the lateral rectal ligament (LRL). This ligament does not look like a true ligament but is more likely to be a fascial combination that cushions the rectal innervation and middle rectal vessels. Conclusions Understanding the lateral attachment of RSF and its contribution to LRL provides invaluable surgical guidance to dissect this critical area. Therefore, lateral dissection is proposed from the anterior to the posterior direction to find the correct plane that guarantees an intact mesorectal envelope to protect the important nearby nerve structures.
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Affiliation(s)
- Waleed M Ghareeb
- Department of Colorectal Surgery, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, Fujian, P. R. China
- Department of General and Gastrointestinal Surgery, Suez Canal University, Ismailia, Egypt
| | - Xiaojie Wang
- Department of Colorectal Surgery, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, Fujian, P. R. China
| | - Pan Chi
- Department of Colorectal Surgery, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, Fujian, P. R. China
- Corresponding author. Department of Colorectal Surgery, The Affiliated Union Hospital of Fujian Medical University, 29 Xin-Quan Road, Fuzhou, Fujian 350001, P. R. China. Tel: +86-13675089677; Fax: +86-591-87113828;
| | - Zhifang Zheng
- Department of Colorectal Surgery, The Affiliated Union Hospital of Fujian Medical University, Fuzhou, Fujian, P. R. China
| | - Xiaozhen Zhao
- Laboratory of Clinical Applied Anatomy, Department of Human Anatomy, Histology, and Embryology, Fujian Medical University, Fuzhou, Fujian, P. R. China
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11
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Jansen-Winkeln B, Mehdorn M, Lange U, Köhler H, Chalopin C, Gockel I. Precision Surgery In Rectal Resection With Hyperspectral and Fluorescence Imaging And Pelvic Intraoperative Neuromonitoring (With Video). Surg Technol Int 2021; 38:154-158. [PMID: 34081769 DOI: 10.52198/21.sti.38.cr1383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Oncologic visceral surgery has recently been revolutionized by robotics, artificial intelligence (AI), sparing of functionally important structures and innovative intraoperative imaging tools. These techniques enable new dimensions of precision surgery and oncology. Currently, data-driven, cognitive operating rooms are standing at the forefront of the latest technical and didactic developments in abdominal surgery. Rectal low anterior resection with total mesorectal excision (TME) for lower- and middle-third rectal cancer is a challenging operation due to the narrow pelvis and the tender guiding structures. Thus, new approaches have been needed to simplify the procedure and to upgrade the results. The combination of robotics with pelvic intraoperative neuromonitoring (pIONM) and new possibilities of visualization, such as multi- and hyperspectral imaging (MSI / HSI) or fluorescence imaging (FI) with indocyanine green (ICG) is a forward-looking modality to enhance surgical precision and reduce postoperative complications while improving oncologic and functional outcomes with a better quality of life. The aim of our video-paper is to show how to achieve maximum precision by combining robotic surgery with pelvic intraoperative neuromonitoring and new imaging devices for rectal cancer.
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Affiliation(s)
- Boris Jansen-Winkeln
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Mathias Mehdorn
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Undine Lange
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Hannes Köhler
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Leipzig, Germany
| | - Claire Chalopin
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Leipzig, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
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12
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Risk factors for sexual dysfunction after rectal cancer surgery in 948 consecutive patients: A prospective cohort study. Eur J Surg Oncol 2021; 47:2087-2092. [PMID: 33832775 DOI: 10.1016/j.ejso.2021.03.251] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/23/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Sexual dysfunctions seriously affect the quality of life of patients. The aim of this study was to identify the risk factors for sexual dysfunction after rectal cancer surgery. METHODS A total of 948 consecutive patients undergoing rectal cancer radical resection were included between January 2012 and August 2019. The sexual functions were evaluated by the 5-item version of the International Index of Erectile Function (IIEF-5) in men and Index of Female Sexual Function (IFSF) in women at 12 months postoperatively. RESULTS Postoperative sexual dysfunction was observed in 228 patients with rectal cancer (24.05%), which included 150 cases in male patients (25.0%) and 78 cases in female patients (22.5%). A multivariate logistic regression analysis results showed that age ≥45 years old (OR = 1.72, p = 0.001), tumor below the peritoneal reflection (OR = 1.64, p = 0.005), receiving preoperative radiotherapy (OR = 4.12, p < 0.001) and undergoing abdominoperineal resection (APR), intersphincteric resection (ISR) and Hartmann surgery (OR = 2.43, p < 0.001) were the independent risk factors of sexual dysfunction for patients with rectal cancer. CONCLUSION Age ≥45 years old, tumors below the peritoneal reflection, receiving preoperative radiotherapy, and undergoing APR, ISR and Hartmann surgery were the independent risk factors of sexual dysfunction. Patients should be informed about the sexual dysfunctions in the pre-operative consultations. More attention should be paid to intraoperative pelvic autonomic nerve preservation on rectal cancer patients with these risk factors for clinic surgeons.
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13
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To what extent is the low anterior resection syndrome (LARS) associated with quality of life as measured using the EORTC C30 and CR38 quality of life questionnaires? Int J Colorectal Dis 2019; 34:747-762. [PMID: 30721417 DOI: 10.1007/s00384-019-03249-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Treatment of rectal cancer often results in disturbed anorectal function, which can be quantified by the Low Anterior Resection Syndrome (LARS) score. This study investigates the association of impaired anorectal function as measured with the LARS score with quality of life (QoL) as measured with the EORTC-QLQ-C30 and CR38 questionnaires. METHODS All stoma-free patients who had undergone sphincter-preserving surgery for rectal cancer from 2000 to 2014 in our institution were retrieved from a prospective database. They were contacted by mail and asked to return the questionnaires. QoL was evaluated in relation to LARS and further patient- and treatment factors using univariate and multivariate analysis. RESULTS Of the eligible patients (n = 331), 261 (78.8%) responded with a complete LARS score. Mean score for global QoL according to the EORTC-QLQ-C30 questionnaire was 63 ± 21 for all patients. If major LARS was present, mean score decreased to 56 ± 19 in contrast to 67 ± 20 in patients with no/minor LARS (p < 0.001). In regression analysis, major LARS was furthermore associated with reduced physical, role, emotional, cognitive and social functioning as well as impaired body image, more micturition problems and poorer future perspective. It was not related to sexual function. The variance explained by major LARS in the differences of QoL was approximately 10%. CONCLUSION The presence of major LARS after rectal resection for cancer is negatively associated with global health as well as many other aspects of QoL. Preserving anorectal function and treatment of LARS are potential measures to improve QoL in this patient group.
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14
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Liu J, Huang P, Liang Q, Yang X, Zheng Z, Wei H. Preservation of Denonvilliers' fascia for nerve-sparing laparoscopic total mesorectal excision: A neuro-histological study. Clin Anat 2019; 32:439-445. [PMID: 30664277 DOI: 10.1002/ca.23336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/10/2019] [Accepted: 01/12/2019] [Indexed: 11/06/2022]
Abstract
Urogenital complications due to pelvic autonomic nerve damage frequently occur following rectal surgery. We investigated whether total mesorectal excision (TME) with preservation of the Denonvilliers' fascia (DVF) can effectively prevent the removal of pelvic autonomic nerves through microscopy. Twenty consecutive male patients with mid-low rectal cancer who received TME with preservation or resection of the Denonvilliers' fascia (P and R groups, respectively) were included. Serial transverse sections from surgical specimens were studied histologically. Nerve fibers at the surfaces of the mesorectum were counted. Clinical correlation between the amount of nerve fibers removed and post-operative sexual function was analyzed. Nerve fibers closely localized to the DVF in the R group displaying rich erectile activity (positive anti-nNOS immunostaining). At the anterior surface of the mesorectum, the mean numbers of nNOS-positive nerve fibers per specimen in the P group were significantly lower than the R group (3.0 ± 1.8 vs. 5.0 ± 2.3, P < 0.05). Compared to the R group, patients in the P group had higher IIEF scores and better erectile function at 3 and 6 months post-operatively. The DVF is a key risk zone for pelvic denervation during laparoscopic TME. Preservation of the DVF can prevent the removal of autonomic nerves and protect post-operative erectile function. Clin. Anat. 32:439-445, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Jianpei Liu
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Pinjie Huang
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiong Liang
- Department of Pathology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaofeng Yang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zongheng Zheng
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hongbo Wei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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15
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Ishii M, Shimizu A, Lefor AK, Kokado Y, Nishigori H, Noda Y. Reappraisal of the lateral rectal ligament: an anatomical study of total mesorectal excision with autonomic nerve preservation. Int J Colorectal Dis 2018; 33:763-769. [PMID: 29556755 DOI: 10.1007/s00384-018-3010-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE The term "lateral rectal ligament" in surgery for rectal cancer has caused confusion regarding its true existence and contents. In previous studies, investigators claimed the existence of the ligament and described its topographical features as neurovascular structures and their surrounding connective tissues located at the anterolateral aspect of the distal rectum or the posterolateral aspect of the middle rectum. The purpose of this study is to evaluate the structure of the so-called "lateral rectal ligament" in cadaver dissections. METHODS Dissection was performed in nine cadavers (eight males and one female, aged 73 to 94 years) in accordance with typical total mesorectal excision techniques. During dissection, structures related to "the ligament" were examined and images recorded. RESULTS At the anterolateral aspect of the distal rectum, the middle rectal artery was noted to be crossing the fusion of Denonvilliers' fascia and the proper rectal fascia. At the posterolateral aspect of the middle rectum, there was a structure which consisted of the rectal nerves running through the fusion of the pelvic fasciae. Although called "ligaments," neither structure contained discrete strong connective tissue fixing the rectum to the pelvic wall. CONCLUSIONS The proper rectal fascia and surrounding pelvic fasciae fuse firmly anterolaterally and posterolaterally where neurovascular structures course toward the rectum. During a total mesorectal excision, the surgical dissection plane coincides with the fused part of the fasciae, which had long been considered the "lateral rectal ligament."
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Affiliation(s)
- Masayuki Ishii
- Department of Anatomy, Bio-imaging and Neuro-cell Science, Jichi Medical University, Tochigi, Japan.
- Colorectal and Pelvic Surgery Division, Shinko Hospital, 1-4-47, Wakinohamacho, Chuo-Ku, Kobe, Japan.
| | - Atsushi Shimizu
- Department of Surgery, Jichi Medical University, Tochigi, Japan
| | | | - Yujirou Kokado
- Colorectal and Pelvic Surgery Division, Shinko Hospital, 1-4-47, Wakinohamacho, Chuo-Ku, Kobe, Japan
| | - Hideaki Nishigori
- Colorectal and Pelvic Surgery Division, Shinko Hospital, 1-4-47, Wakinohamacho, Chuo-Ku, Kobe, Japan
| | - Yasuko Noda
- Department of Anatomy, Bio-imaging and Neuro-cell Science, Jichi Medical University, Tochigi, Japan
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Kupsch J, Jackisch T, Matzel KE, Zimmer J, Schreiber A, Sims A, Witzigmann H, Stelzner S. Outcome of bowel function following anterior resection for rectal cancer-an analysis using the low anterior resection syndrome (LARS) score. Int J Colorectal Dis 2018. [PMID: 29541896 DOI: 10.1007/s00384-018-3006-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Severity of anorectal dysfunction after low anterior resection is associated with various patient- and treatment-related factors. We aimed to quantify anorectal dysfunction after treatment for rectal cancer using the low anterior resection syndrome (LARS) score. METHODS We retrieved from a prospective database 331 eligible patients on whom anterior resection for rectal cancer had been performed from 2000 to 2014. All patients were sent a LARS score accompanied by a supplementary questionnaire. Response rate was 78.8% (261 patients). The main outcome measure was the relation of the LARS score to potentially associated patient and treatment factors. Secondary endpoints were further measures that reflect anorectal dysfunction, e.g., Vaizey score. RESULTS Overall, 144 (55.2%) patients exhibited scores > 20 reflecting minor (n = 51 (19.5%)) or major (n = 93 (35.6%)) LARS. A significant difference for scores > 20 was found for intersphincteric resection (IR, 73.2% affected patients) compared to total mesorectal excision (TME, 58.4%) and partial mesorectal excision (PME, 38.0%, p = 0.001). Radio(chemo)therapy resulted in LARS scores > 20 in 64.6% of patients compared to 43.1% in patients without irradiation (p = 0.001). Type of procedure (TME and IR as compared to PME), radio(chemo)therapy, and younger age were independently associated with LARS in logistic regression analysis. However, younger age remained the only independent factor for higher scores after exclusion of PME. CONCLUSIONS The LARS score identified a substantial proportion of patients after surgery for rectal cancer with anorectal dysfunction. The extent of surgical procedure is independently associated with the severity of symptoms whereas the role of radiotherapy needs further assessment.
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Affiliation(s)
- Juliane Kupsch
- Department of General, Visceral and Thoracic Surgery, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany
| | - Thomas Jackisch
- Department of General, Visceral and Thoracic Surgery, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany
| | - Klaus E Matzel
- Department of Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Joerg Zimmer
- Department of Radiation Therapy, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany
| | - Andreas Schreiber
- Department of Radiation Therapy, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany
| | - Anja Sims
- Department of General, Visceral and Thoracic Surgery, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany
| | - Helmut Witzigmann
- Department of General, Visceral and Thoracic Surgery, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany
| | - Sigmar Stelzner
- Department of General, Visceral and Thoracic Surgery, Teaching Hospital of the Technical University of Dresden, Friedrichstr. 41, 01067, Dresden, Germany.
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17
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Stelzner S, Böttner M, Kupsch J, Kneist W, Quirke P, West NP, Witzigmann H, Wedel T. Internal anal sphincter nerves - a macroanatomical and microscopic description of the extrinsic autonomic nerve supply of the internal anal sphincter. Colorectal Dis 2018; 20:O7-O16. [PMID: 29068554 DOI: 10.1111/codi.13942] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 10/03/2017] [Indexed: 12/13/2022]
Abstract
AIM The internal anal sphincter (IAS) contributes substantially to anorectal functions. While its autonomic nerve supply has been studied at the microscopic level, little information is available concerning the macroscopic topography of extrinsic nerve fibres. This study was designed to identify neural connections between the pelvic plexus and the IAS, provide a detailed topographical description, and give histological proof of autonomic nerve tissue. METHODS Macroscopic dissection of pelvic autonomic nerves was performed under magnification in seven (five male, two female) hemipelvises obtained from body donors (67-92 years). Candidate structures were investigated by histological and immunohistochemical staining protocols to visualize nerve tissue. RESULTS Nerve fibres could be traced from the anteroinferior edge of the pelvic plexus to the anorectal junction running along the neurovascular bundle anterolaterally to the rectum and posterolaterally to the prostate/vagina. Nerve fibres penetrated the longitudinal rectal muscle layer just above the fusion with the levator ani muscle (conjoint longitudinal muscle) and entered the intersphincteric space to reach the IAS. Histological and immunohistochemical findings confirmed the presence of nerve tissue. CONCLUSIONS Autonomic nerve fibres supplying the IAS emerge from the pelvic plexus and are distinct to nerves entering the rectum via the lateral pedicles. Thus, they should be classified as IAS nerves. The identification and precise topographical location described provides a basis for nerve-sparing rectal resection procedures and helps to prevent postoperative functional anorectal disorders.
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Affiliation(s)
- S Stelzner
- Department of General, Visceral and Thoracic Surgery, Dresden-Friedrichstadt General Hospital, Dresden, Germany
| | - M Böttner
- Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Kiel, Germany
| | - J Kupsch
- Department of General, Visceral and Thoracic Surgery, Dresden-Friedrichstadt General Hospital, Dresden, Germany
| | - W Kneist
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - P Quirke
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - N P West
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - H Witzigmann
- Department of General, Visceral and Thoracic Surgery, Dresden-Friedrichstadt General Hospital, Dresden, Germany
| | - T Wedel
- Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Kiel, Germany
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18
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Celentano V, Cohen R, Warusavitarne J, Faiz O, Chand M. Sexual dysfunction following rectal cancer surgery. Int J Colorectal Dis 2017; 32:1523-1530. [PMID: 28497404 DOI: 10.1007/s00384-017-2826-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Sexual and urological problems after surgery for rectal cancer are common, multifactorial, inadequately discussed, and untreated. The urogenital function is dependent on dual autonomic sympathetic and parasympathetic innervation, and four key danger zones exist that are at risk for nerve damage during colorectal surgery: one of these sites is in the abdomen and three are in the pelvis. The aim of this study is to systematically review the epidemiology of sexual dysfunction following rectal cancer surgery, to describe the anatomical basis of autonomic nerve-preserving techniques, and to explore the scientific evidence available to support the laparoscopic or robotic approach over open surgery. METHODS According to the PRISMA guidelines, a comprehensive literature search of studies evaluating sexual function in patients undergoing rectal surgery for cancer was performed in Medline, Scopus, Web of Science, Embase, and Cochrane Central Register of controlled trials. RESULTS An increasing number of studies assessing the incidence and prevalence of sexual dysfunction following multimodality treatment for rectal cancer has been published over the last 30 years. Significant heterogeneity in the prevalence of sexual dysfunction is reported in the literature, with rates between 5 and 90%. CONCLUSIONS There is no evidence to date in favor of any surgical approach (open vs laparoscopic vs robotic). Standardized diagnostic tools should be routinely used to prospectively assess sexual function in patients undergoing rectal surgery.
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Affiliation(s)
- V Celentano
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Southwick Hill Rd, Portsmouth, PO6 3LY, UK.
| | - R Cohen
- Department of Colorectal Surgery, University College London Hospitals, 235 Euston Rd, Bloomsbury, London, NW1 2BU, UK
| | | | - O Faiz
- Department of Surgery, St. Mark's Hospital, Harrow, UK
| | - M Chand
- Department of Colorectal Surgery, University College London Hospitals, 235 Euston Rd, Bloomsbury, London, NW1 2BU, UK
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19
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[Hybrid TAMIS total mesorectal excision. A new perspective in treatment of distal rectal cancer - Technique and results]. Chirurg 2017; 87:225-32. [PMID: 26187139 DOI: 10.1007/s00104-015-0043-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Transanal minimally invasive surgery (TAMIS) represents a promising technique for total mesorectal excision (TME) with respect to radicalness and preservation of function. There are only few publications in the literature describing results in patients with distal rectal cancer. METHODS Between May 2013 and March 2015, 24 selected patients with a rectal carcinoma < 6 cm from the anal verge underwent a laparoscopically assisted TAMIS TME (Hybrid-TAMIS TME) procedure. This prospective observational study was conducted to examine the safety of the technique and the quality of TME surgery in distal rectal cancer and to assess the short-term postoperative outcome. RESULTS The median age of patients (18 male and 6 female) at the time of surgery was 57 years (range 35-77 years) and 7 patients (29 %) had a body mass index (BMI) > 30 kg/m(2). Specimen excision was carried out transanally in 19 patients. Pathological grading of TME specimens was good in 22 (92 %) and moderate in 2 cases. After neoadjuvant radiochemotherapy a complete pathological remission was identified in five patients. The median distal resection margin was 7 mm (range 2-30 mm), the median circumferential resection margin was 6 mm (range <1 mm-30 mm) and in 2 patients the tumor was ≤ 1 mm from the positive circumferential margin. A colonic reservoir was created in 19 patients (79 %) and no 30-day mortalities occurred. Morbidity was 29 %, including 1 anastomotic leak, 2 hematomas and 1 neurogenic bladder. CONCLUSION Hybrid-TAMIS TME for distal rectal cancer is safe and can provide a sphincter-preserving high-quality TME in difficult cases. Studies with long-term follow-up assessing oncological and functional results are mandatory.
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20
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Buhr J, Hoffmann MW, Allemeyer EH. [Intraoperative pitfalls and complications in defecation disorders and rectal prolapse]. Chirurg 2017; 88:602-610. [PMID: 28083601 DOI: 10.1007/s00104-016-0366-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND No generally accepted gold standard exists for the operative therapy of rectal prolapse in its variety of manifestations. Existing evidence suggests that an individualized choice of procedure provides the best result for each single patient. Knowledge of possible pitfalls and intraoperative management of complications in frequently applied procedures are important prerequisites for reliable treatment of affected patients. MATERIAL AND METHODS A consecutive series of 233 patients (June 2011-May 2016) with individualized choice of operative procedure in patients with rectal prolapse and rectocele based on an algorithm for a clinical treatment pathway and stapled hemorrhoidopexy were included. Intraoperative pitfalls and complications and their management (iPCM) were prospectively documented and analyzed. RESULTS The iPCM could be classified into three different categories: group I: iPCM was immediately noted and intraoperatively treated with no impact on the further clinical course (n = 20), group II: iPCM was successfully treated conservatively within a short time after the procedure (n = 9) and group III: iPCM required surgical revision (n = 5). CONCLUSION Individualized treatment of rectal prolapse and rectocele requires a broad spectrum of methods in specialized coloproctology units. A clinical treatment pathway facilitates the optimal choice of procedure. Overall the complication rates during surgical treatment of transanal rectal prolapse are low; however, available operative procedures hold specific risks and knowledge of these risks helps to avoid them. Once complications occur, measures demonstrated in this study lead to normal clinical courses in the majority of cases.
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Affiliation(s)
- J Buhr
- Klinik für Allgemein- u. Viszeralchirurgie mit Sektion Proktologie, Raphaelsklinik Münster, Loerstraße 23, 48143, Münster, Deutschland
| | - M W Hoffmann
- Klinik für Allgemein- u. Viszeralchirurgie mit Sektion Proktologie, Raphaelsklinik Münster, Loerstraße 23, 48143, Münster, Deutschland
| | - E H Allemeyer
- Klinik für Allgemein- u. Viszeralchirurgie mit Sektion Proktologie, Raphaelsklinik Münster, Loerstraße 23, 48143, Münster, Deutschland.
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21
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Chew MH, Yeh YT, Lim E, Seow-Choen F. Pelvic autonomic nerve preservation in radical rectal cancer surgery: changes in the past 3 decades. Gastroenterol Rep (Oxf) 2016; 4:173-185. [PMID: 27478196 PMCID: PMC4976685 DOI: 10.1093/gastro/gow023] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 07/18/2016] [Accepted: 06/28/2016] [Indexed: 02/07/2023] Open
Abstract
The advent of total mesorectal excision (TME) together with minimally invasive techniques such as laparoscopic colorectal surgery and robotic surgery has improved surgical results. However, the incidence of bladder and sexual dysfunction remains high. This may be particularly distressing for the patient and troublesome to manage for the surgeon when it does occur. The increased use of neoadjuvant and adjuvant radiotherapy is also associated with poorer functional outcomes. In this review, we evaluate current understanding of the anatomy of pelvic nerves which are divided into the areas of the inferior mesenteric artery pedicle, the lateral pelvic wall and dissection around the urogenital organs. Surgical techniques in these areas are discussed. We also discuss the results in functional outcomes of the various techniques including open, laparoscopic and robotic over the last 30 years.
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Affiliation(s)
- Min-Hoe Chew
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Yu-Ting Yeh
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Evan Lim
- Singhealth Academy, Singapore General Hospital, Singapore
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Kneist W, Hanke L, Kauff DW, Lang H. Surgeons' assessment of internal anal sphincter nerve supply during TaTME - inbetween expectations and reality. MINIM INVASIV THER 2016; 25:241-6. [PMID: 27333465 PMCID: PMC5044775 DOI: 10.1080/13645706.2016.1197269] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background: Intraoperative identification of nerve fibers heading from the inferior rectal plexus (IRP) to the internal anal sphincter (IAS) is challenging. The transanal total mesorectal excision (TaTME) is said to better preserve pelvic autonomic nerves. The aim of this study was to investigate the nerve identification rates during TaTME by transanal visual and electrophysiological assessment. Material and methods: A total of 52 patients underwent TaTME for malignant conditions. The IRP with its posterior branches to the IAS and the pelvic splanchnic nerves (PSN) were visually assessed in 20 patients (v-TaTME). Electrophysiological nerve identification was performed in 32 patients using electric stimulation under processed electromyography of IAS (e-TaTME). Results: The indication profile for TaTME was comparable between the v-TaTME and the e-TaTME group. The identification of IRP was more meaningful under electrophysiological assessment than under visual assessment for the left pelvic side (81% vs. 45%, p = 0.008) as well as the right pelvic side (78% vs. 45%, p = 0.016). The identification rates for PSN did not significantly differ between both groups, respectively (81% vs. 75%, p = 0.420 and 84% vs. 70%, p = 0.187). Conclusions: The transanal approach facilitated visual identification of IAS nerve supply. In combination with electrophysiological nerve assessment the identification rate almost doubled. For further insights functional data are needed.
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Affiliation(s)
- Werner Kneist
- a Department of General, Visceral and Transplant Surgery , University Medical Center, Johannes Gutenberg-University Mainz , Mainz , Germany
| | - Laura Hanke
- a Department of General, Visceral and Transplant Surgery , University Medical Center, Johannes Gutenberg-University Mainz , Mainz , Germany
| | - Daniel W Kauff
- a Department of General, Visceral and Transplant Surgery , University Medical Center, Johannes Gutenberg-University Mainz , Mainz , Germany
| | - Hauke Lang
- a Department of General, Visceral and Transplant Surgery , University Medical Center, Johannes Gutenberg-University Mainz , Mainz , Germany
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Grama F, Van Geluwe B, Cristian D, Rullier E. Urogenital dysfunctions after treatment of rectal cancer. COLORECTAL CANCER 2015. [DOI: 10.2217/crc.15.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A significant part of rectal cancer survivors will experience urogenital dysfunction induced by the treatment. Significant progress has been made in order to improve the total mesorectal technique through different approaches (open, laparoscopic, robotic, transanal). Rectal cancer surgery is technically difficult notably deep in the pelvis, and therefore the most frequent cause of the postoperative dysfunction is the surgical nerve damage of the autonomic nerves at this level. The main objectives of these efforts were to obtain maximal oncological results and to achieve better functional outcomes including less postoperative urogenital dysfunctions. Our purpose was to build a comprehensive review of the existing literature data regarding this issue from past to present.
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Affiliation(s)
- Florin Grama
- Department of General Surgery, Colţea Clinical Hospital & Carol Davila University of Medicine & Pharmacy, Bucharest, Romania
| | - Bart Van Geluwe
- Department of Surgery, Colorectal Unit, CHU Bordeaux, Saint-André Hospital, Bordeaux, France
| | - Daniel Cristian
- Department of General Surgery, Colţea Clinical Hospital & Carol Davila University of Medicine & Pharmacy, Bucharest, Romania
| | - Eric Rullier
- Department of Surgery, Colorectal Unit, CHU Bordeaux, Saint-André Hospital, Bordeaux, France
- Segalen University, Bordeaux, France
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Stelzner S, Wedel T. Anatomische Grundlagen der nervenschonenden Rektumchirurgie. COLOPROCTOLOGY 2015. [DOI: 10.1007/s00053-015-0030-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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25
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Aigner F, Hörmann R, Fritsch H, Pratschke J, D'Hoore A, Brenner E, Williams N, Biebl M. Anatomical considerations for transanal minimal-invasive surgery: the caudal to cephalic approach. Colorectal Dis 2015; 17:O47-53. [PMID: 25418450 DOI: 10.1111/codi.12846] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 09/20/2014] [Indexed: 12/13/2022]
Abstract
AIM Nerve-sparing surgery during laparoscopic rectal mobilization is still limited by anatomical constraints such as obesity, the narrowness of the male pelvis, an ultra low rectal cancer or all of these. The transanal approach for total mesorectal excision has overcome the shortcomings of limited access to the rectal 'no-man's land' close to the pelvic floor. The aim of this anatomical study was to define a roadmap of anatomical landmarks for the caudal to cephalic approach so as to standardize nerve-sparing rectal mobilization procedures. METHOD Macroscopic dissections of the pelvis in a caudal to cephalic direction were performed in eight alcohol-glycerol embalmed cadavers. A roadmap of anatomical landmarks was created at different levels of section to demonstrate the sites of nerve injury. RESULTS Extrinsic autonomic nerves to the urogenital organs and the internal sphincter muscle are closely adjacent to the lowest portion of the rectum above the pelvic diaphragm. CONCLUSION This anatomical guide for the pelvic surgeon should facilitate a safe and nerve-sparing dissection of the mesorectal plane with a meticulous overview of the lowest autonomic nerve fibres. New anatomical insights by a 'caudal to cephalic' approach to the 'no-man's land' should help overcome anatomical constraints of a narrow, obese and male pelvis during rectal mobilization procedures.
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Affiliation(s)
- F Aigner
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria.,Department for General, Visceral and Transplantation Surgery, Charité Universitätsmedizin, Berlin, Germany
| | - R Hörmann
- Department of Anatomy, Histology and Embryology, Division for Clinical and Functional Anatomy, Innsbruck Medical University, Innsbruck, Austria
| | - H Fritsch
- Department of Anatomy, Histology and Embryology, Division for Clinical and Functional Anatomy, Innsbruck Medical University, Innsbruck, Austria
| | - J Pratschke
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria.,Department for General, Visceral and Transplantation Surgery, Charité Universitätsmedizin, Berlin, Germany
| | - A D'Hoore
- Department of Abdominal Surgery, University Hospitals Gasthuisberg, Leuven, Belgium
| | - E Brenner
- Department of Anatomy, Histology and Embryology, Division for Clinical and Functional Anatomy, Innsbruck Medical University, Innsbruck, Austria
| | - N Williams
- National Centre for Bowel Research and Surgical Innovation, Centre for Digestive Diseases, Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK
| | - M Biebl
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria.,Department for General, Visceral and Transplantation Surgery, Charité Universitätsmedizin, Berlin, Germany
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Yang XF, Luo GH, Ding ZH, Li GX, Chen XW, Zhong SZ. The urogenital-hypogastric sheath: an anatomical observation on the relationship between the inferomedial extension of renal fascia and the hypogastric nerves. Int J Colorectal Dis 2014; 29:1417-26. [PMID: 25060217 DOI: 10.1007/s00384-014-1973-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE The study aimed to perform an anatomical observation on the inferomedial extension of the renal fascia (RF) to the pelvis and explore its relationship with the hypogastric nerves (HGNs). METHODS Gross anatomy was performed on 12 formalin-fixed and 12 fresh cadavers. Sectional anatomy was performed on four formalin-fixed cadavers. RESULTS Different from the traditional concept, both the anterior and posterior RF included the outer and inner layer with different inferomedial extensions. The multiple layers of RF extended downward to form a sandwich-like and compound fascia sheath with potential and expandable spaces which was named as "the urogenital-hypogastric sheath." Below the level of the origin of the inferior mesenteric artery, the bilateral urogenital-hypogastric sheath communicated with the counterpart in front of the great vessels in the midline and the superior hypogastric plexus ran into the urogenital-hypogastric sheath which carried the HGNs, ureters, and genital vessels downward to their terminations in the pelvis. In the retrorectal space, the urogenital-hypogastric sheath surrounded the fascia propria of the rectum posterolaterally as a layer of coat containing HGNs. CONCLUSION The multiple layers of RF with different extensions are the anatomical basis of the formation of the urogenital-hypogastric sheath. As a special fascial structure in the retroperitoneal space and the pelvis, emphasis on its formation and morphology may be helpful for not only unifying the controversies about the relationship between the pelvic fascia and HGNs but also improving the intraoperative preservation of the HGNs by dissecting in the correct surgical plane.
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Affiliation(s)
- X F Yang
- Department of Gastrointestinal Surgery, Guizhou Provincial People's Hospital, Guiyang, China
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Zhou H, Ruan C, Sun Y, Zhang J, Wang Z, Hu Z. Nerve-guided laparoscopic total mesorectal excision for distal rectal cancer. Ann Surg Oncol 2014; 22:550-1. [PMID: 25331006 DOI: 10.1245/s10434-014-4161-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Urogenital dysfunctions are well-recognized problems after rectal cancer surgery and are often due to autonomic nerve damage. Although following holy planes during total mesorectal excision (TME) reduces the possibility of damage to the autonomic nerve fibers, these could still be affected in some critical areas.1 (,) 2 To improve the quality of surgery and prevent nerve damage, accurate intraoperative anatomical orientation of autonomic nerve is essential.3 Thanks to advancement of the high-definition laparoscopic technology, even the finest nerve fibers deep in the pelvic cavity can be identified through illumination and magnification.4 We aim to present a surgical technique of using the autonomic nerves as landmarks to guide laparoscopic TME for distal rectal cancer, with the purpose of preventing autonomic nerve damage to the largest extent. METHODS The video describes the technique of performing nerve-guided laparoscopic TME in a 50-year-old man with a rectal cancer (7 cm from anal verge). Preoperative staging by endorectal ultrasound and pelvic magnetic resonance imaging is stage I rectal cancer (cT2N0M0). Five trocars (two 12 mm and three 5 mm) are used. All procedures are performed with conventional laparoscopic instruments. The sigmoid colon is mobilized using a medial approach. The superior hypogastric plexus lies just posterior to the inferior mesenteric artery (IMA) are clearly identified and protected. Then the root of the IMA is ligated and cut. The left Toldt space is dissected, followed by complete mobilization of the sigmoid colon. The superior hypogastric plexus nerve fibers combine to a strong pair of hypogastric nerves as they enter the pelvic cavity, and can be clearly identified when the mesorectum is lifted. Then the mesorectum is separated from the hypogastric nerves by sliding down along the nerves. Dissection of the mesorectum is continued in the loose areolar plane along the midline down to the sacrococcygeal junction. Then the mesorectum is dissected laterally from posterior midline up to 9 o'clock on the left and to 3 o'clock on the right side. The splanchnic nerves can be identified as they swing from the sacrum and straight into the pelvic plexus. The peritoneum is dissected in an arc line about 0.5 cm above the line of rectovesical pouch. After the anterior side of the rectum is mobilized, the mesorectum is dissected along the seminal vesicles downward and sideward to the lateral margin. The neurovascular bundle of Walsh at the anterolateral side of the rectum is clearly identified and protected. The mobilization of the mesorectum ceases at the tendinous arch of levator ani. Then the rectum is only fixed to the pelvic side wall by its lateral ligaments, which are consisted by rectal branch of the inferior pelvic plexus and vessels. Thus care should be taken to cut only those rectal nerve fibers, leaving the inferior pelvic plexus intact. The mesorectum is divided 5 cm distal to the lesion with one firing of an endoscopic stapler. The specimen is extracted through a 3 cm transumbilical laparotomy. End-to-end anastomosis using a circular stapler is performed intra-abdominally. RESULTS There were no intraoperative complications. The operating time was 160 min. Blood loss was 20 mL. The patient underwent an uneventful recovery and was discharged home on postoperative day 6. Final pathology was pT2N0M0. At 6-month follow-up, the patient had no urogenital dysfunctions. CONCLUSIONS Nerve-guided laparoscopic total mesorectal excision for distal rectal cancer is safe and feasible. This technique should be considered whenever possible as a means to prevent autonomic nerve damage and subsequent loss of urogenital function.
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Affiliation(s)
- Haiyang Zhou
- Department of General Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
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