Dissection of the Rectum

After division of the vessels, placement of the patient into a deeper Trendelenburg position assists in retracting the small intestine out of the pelvic cavity. Placement of the left side up may also assist in keeping the small intestine well retracted. Next, we attempt to identify the right side of the rectum. The assistant should gently draw the sigmoid colon cephalad and slightly to the ventral side using the grasping forceps, drawing the mesentery near the stump of the pedicle to the left ventral side using the grasping forceps from the left upper quadrant cannula. We then bluntly separate the mesorectum (fascia propria of the rectum) from the fascia propria of the sacrum by pushing it anteriorly and identifying the retrorectal space. We adopt a dissection of the presacral space from the right to left side, recognizing the boundary between the mesorectal fascia and presacral fascia. In this manner, one may identify the hypogastric nerves and more distally the pelvic nerve plexus, and minimize potential for injury (Figure 8.5.8). In addition, meticulous dissection of fine vessels by electrosurgery minimizes bleeding into the presacral space, making the proper plane of dissection between the fascia propria of the rectum and the presacral fascia easier to identify. Once dissection proceeds distally into the pelvis to about the third

Presacral Fascia Surgery

Figure 8.5.8. The rectal dissection starts from the right side, carefully identifying and sweeping down the hypogastric nerves, which can be tented upward with traction.

Figure 8.5.8. The rectal dissection starts from the right side, carefully identifying and sweeping down the hypogastric nerves, which can be tented upward with traction.

sacral vertebrae level, Waldeyer's fascia becomes visible as a thickening of the presacral plane. At this point, the surgeon should dissect the right side of the rectum down to the peritoneal reflection in the cul-de-sac by the assistant drawing the rectum to the left of the pelvis and by cutting the peritoneum on the right side laterally using laparoscopic mini-shears (US Surgical Corp., Norwalk, CT). Again, we take our time in this dissection, because meticulous attention to hemostasis permits better identification of the small nerve roots and branches of the pelvic nerves, and helps avoid injury to sacral venous plexus.

The next step is dissection of the left side of the rectum. The recto-sigmoid is drawn to the right side of the pelvis using grasping forceps from the right upper quadrant cannula. The left side of rectum is identified and placed under tension. Because of the previous posterior and right-sided dissection, the nerves, ureter, and lateral pelvic structures are largely cleared from the dissection site. The assistant should place the mesorectum under tension by use of grasping forceps from the left upper quadrant, drawing it to the right side. Simultaneously the surgeon should hold and draw the left-sided peritoneum using grasping forceps, apply countertraction in the horizontal direction, and dissecting the boundary between the peritoneum and mesentery of the left side of the rectum using electrosurgery (Figure 8.5.9).

Once this is completed, the peritoneum is incised at the peritoneal reflection, from right to left, and gentle blunt dissection is used to define the correct plane on the anterior side of the rectum. Denonvil-liers' fascia can then be exposed with identification of the vaginal wall or seminal vesicles (Figure 8.5.10). The rectum is drawn to the right upper side of the pelvis, placing the left lateral ligaments under tension, making them easier to be identified. The anterior side of this ligament is bluntly dissected with a lateral motion to define a plane between them and the lateral mesorectum, and the ligament can be divided by LCS (Figure 8.5.11). After division of the ligament, further dissection distally for several centimeters will expose the levator ani muscle and often the convex bulge of the ischiorectal fossa beneath the pelvic floor muscles. The same maneuver is repeated on the right side of the rectum, and posterior and anterior levels of dissection are checked to complete the dissection circumferentially to the pelvic floor.

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Responses

  • ISAIAS
    What is rectal dissection?
    8 years ago
  • Dirk
    What is disecting the rectum?
    3 years ago

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