Anatomical Basis of Rectal Cancer Surgery Focused on Pelvic Fascia

Abstract

Fascial structures are the natural embryonic dissection plane for the precise surgery of rectal cancer. This chapter characterized the fascial structures implicated in the rectal cancer surgery, which include Toldt fascia, Denonvilliers’ fascia, proper fascia of the rectum, endopelvic fascia (parietal layer of pelvic fascia), presacral fascia, rectosacral fascia, and Waldeyer’s fascia. Toldt fascia is the extension of Gerota fascia and constitutes the natural dissection plane for the mobilization of left colon. The whole mesorectum was enclosed circumferentially by the thin layer of proper fascia of the rectum; the pelvic sacral bone was covered with the endopelvic fascia (parietal layer of pelvic fascia). Endopelvic fascia and proper fascia of the rectum fused at the level of sacral promontory, and the presacral space is entered after the fascial junction is incised.

Rectosacral fascia usually originated in the S4 level, and the retrorectal space is entered when this fascia is sharply incised. Waldeyer’s fascia constitutes the fascia layer covering levator ani muscle. Denonvilliers’ fascia is situated in front of proper fascia of the rectum. Usually, the anterior dissection for mobilization of the rectum is in front of Denonvilliers’ fascia to ensure oncological efficacy; however, to enhance the preservation of sexual function, some surgeons suggest the dissection plane be back to the Denonvilliers’ fascia. Full respect of the fascia structures is the basic principle for the precise implementation of total mesorectal excision for rectal cancer.