Topology of the Fascial Structures in Rectal Surgery: Complete Cancer Resection and the Importance of Avoiding Autonomic Nerve Injury

To decrease local recurrence and avoid autonomic nerve injury, mobilization of the rectum is performed by anatomical dissection along the fascial planes. Anterior to the rectum, Denonvilliers' fascia divides into several laminae at both sides and separates the mesorectum from the autonomic nerves. This fascia is better preserved when the tumor is not located on the anterior wall of the rectum. Posterior to the rectum, the prehypogastric nerve fascia covering the hypogastric nerves is evident between the fascia propria of the rectum and the parietal pelvic fascia. The prehypogastric nerve fascia connects to 1 of the lateral laminae of Denonvilliers' fascia. The dissection plane posterior to the rectum is between the fascia propria of the rectum and the prehypogastric nerve fascia. After dissection both anterior and posterior to the rectum, the medial part of the lateral ligament becomes clearly identifiable. The parietal pelvic fascia is located dorsal to the hypogastric nerves and ventral to the pelvic splanchnic nerves. Appropriate selection of dissection planes ensures the complete capture of the mesorectal package and simultaneously reduces the risk of nerve injury.