disfunzioni sessuali ed urinarie: come evitarle? D. Mascagni Cattedra di Chirurgia Generale Direttore: Prof. A. Filippini Verona, 2010
CHIRURGIA RADICALE PER CANCRO DEL RETTO SOTTOPERITONEALE 5cm 2 cm DISTAL CLEARENCE LATERAL CLEARENCE TME 1cm SSP CONVENTIONAL SURGERY (local recurrence >20%) RADICAL SURGERY + ADJUVANT THERAPY (local recurrence <10%) Sexual & Bladder DYSFUNCTION
The surgical approach of rectal cancer with TME was finally standardized becoming an accurate and precise procedure. This improvement is mainly due to a better knowledge of the anatomy of the pelvis
NERVE SPARING TECHNIQUE 1st STEP exposure and preservation of the SUPERIOR HYPOGASTRIC PLEXUS (sympathetic fibers) at the pelvic promontory, in corrispondence of the aortic bifurcation, posteriorly to the superior rectal artery
NERVE SPARING TECHNIQUE 2nd STEP proximally, the sympathetic fibers of the Para-aortic Trunks, and of the Inferior Mesenteric Plexus, deriving from T10-L2, are isolated and preserved by sparing the pre-aortic connective tissue and leaving in situ a 1-2cm-long stump of the IMA
Sites of risk of NERVE DAMAGE INFERIOR MESENTERIC ARTERY The risk in the abdomen occurs during ligation of the pedicle of the inferior mesenteric artery, particularly if this is done flush at the aorta. sympathetic damage
NERVE SPARING TECHNIQUE 3rd STEP distally, from the Superior Hypogastric Plexus, the surgical procedure continues into the pelvis following the right and left hypogastric nerves accurately dissected in their posterior and lateral course to reach the Inferior Hypogastric Plexus in proximity of the lateral lygament
Dissezione mesorettale posteriore
Sites of risk of NERVE DAMAGE POSTERIOR DISSECTION Anatomical dissection is carried out in the loose areolar connective tissue immediately outside the fascia propria, and the nerves lie just outside this plane. If blunt dissection is used and bleeding not rigorously controlled direct vision is lost sympathetic damage
Dissezione mesorettale laterale
NERVE SPARING TECHNIQUE 4th STEP the lygaments are divided immediately at the endopelvic fascia. Here is at risk the IHP (or Pelvic Plexus) in which the sympathetic fibers deriving from the Hypogastric Nerves join the parasympathetic fibers arising from S2-S4
Lateral ligaments do not originate from the endopelvic fascia, but they are an extension of the mesorectum, anchoring it to the endopelvic fascia. Here they must be cut for TME to take place Nano, 2000
Insertion of all ligaments at the endopelvic fascia is placed under the urogenital bundle The middle rectal artery courses anteriorly and inferiorly in respect to the lateral ligament
Lateral traction may tent the endopelvic fascia with its enclosed pelvic nerves toward the knife, scissors, or, most dangerously, the electrocautery scalpel.
Sites of risk of NERVE DAMAGE LATERAL DISSECTION Straying laterally, out of the mesorectal plane, may injure the pelvic plexus, particularly if excess traction is placed, tenting the plexus superiorly and medially Both, hooking of the lateral tissue with the finger and clamping of the middle rectal pedicle can cause nerve injury sympathetic/parasympathetic damage
aponeurosi di Denonvilliers: teoria della fusione peritoneale Denonvilliers fascia arises from the fusion of the two walls of the embriological peritoneal cul de sac and extends from the deepest point of the rectovescical pouch to the pelvic floor
There is no so-called posterior layer of Denonvilliers fascia. This terminology has unfortunately persisted and caused both anatomical and surgical misconceptions Lindsey,2000
The posterior layer is the fascia propria of the rectum. Dissection between the two layers of Denonvilliers fascia is really a dissection between the fascia propria of the rectum, containing the mesorectum, and the true Denonvilliers fascia covering the prostate and seminal vescicles
INTRAMESORECTAL plane It is not an anatomical plane and dissection may be slightly more difficult and bloody than in the mesorectal plane. Bleeding is usually quite easy to control using diathermy oncologically uncorrect nerve damage avoided
correct MESORECTAL plane Dissection in this plane will separate the fascia propria of the rectum, with its enclosed anterior mesorectum, from Denonvilliers fascia, which is left intact on the prostate and seminal vescicles oncologically correct nerve damage minimized
EXTRAMESORECTAL plane Resection of the Denonvilliers fascia anteriorly, staying immediately on and exposing the prostate and seminal vescicles. The risk of damage to the cavernous nerves is theoretically high oncologically overtreatment if not required high risk of nerve damage
NERVE SPARING TECHNIQUE 5th STEP finally, anteriorly and laterally, great care was taken to dissect the lateral border of Denonvillier s fascia where the IHP join the neurovascular bundle described by Walsh
P B N DVF R The cavernous nerves run in neurovascular bundles at the lateral borders of Denonvilliers fascia, anterior to it, at the posterolateral border of the apex of the prostate, but are closely related to the anterior wall of the rectum
Sites of risk of NERVE DAMAGE ANTERIOR DISSECTION There is a very narrow space between the rectum and the prostate/seminal vescicles. During deep dissection or heamostasis the cavernous nerves are at risk, mainly at the antero-lateral sites and if an uncorrect plane is followed. Nerve damage is more common the deeper the pelvic dissection goes parasympathetic damage
Extraelevator APR ( CRM+ / IOP) peritoneal dissection in prone Jack- Knife position has the advantage of revealing and preserving delicate nerves and blood vessels, reducing bleeding and postoperative sexual/urinary dysfunction N.P. West, Br J Surg 2010
Sympathetic Fibers DAMAGE IMP,PT,SHP,HN Minor Incontinence Retrograde Ejaculation Parasympathetic Fibers DAMAGE SN,IHP,NVB,CN Neurological Bladder Impotentia erigendi
l anatomia è altrettanto indispensabile per la medicina quanto la geografia per la storia Jean Fernel, 1542