Intraoperative Protection of Pharyngeal Autonomic Nerves: Preventing Dysphagia After Anterior Cervical Decompression and Fusion Surgery.

OBJECTIVE: The study aims to investigate whether intraoperative protection of the pharyngeal autonomic nerve can effectively reduce the incidence of postoperative dysphagia following anterior cervical decompression and fusion surgery (ACDF). METHODS: A retrospective analysis was conducted on 130 cases that underwent ACDF from January 2018 to June 2022 at our hospital. Divided into nonautonomic neuroprotection (NANP) group and autonomic neuroprotection group based on whether receive protective measures for the pharyngeal autonomic nerve during surgery. General data were recorded and compared between the 2 groups. Postoperative outcomes were evaluated using Neck Disability Index, Japanese Orthopaedics Association (JOA) score, and JOA improvement rate. The incidence and severity of postoperative dysphagia were assessed using Bazaz dysphagia assessment criteria and swallowing-quality of life questionnaire. RESULTS: There were no significant differences in general data (P > 0.05). The average operation time and intraoperative blood loss also showed no significant differences (P > 0.05). Both groups showed significant improvements in Neck Disability Index and JOA scores at all follow-up time points compared to preoperative scores (P < 0.01). The incidence of postoperative dysphagia in the autonomic neuroprotection group was significantly lower than that in the NANP group at all follow-up time points (P < 0.05). Both group showed a significant reduction in scores 3 days postoperatively compared to preoperative scores (P < 0.01), and the NANP group also showed significant reductions in scores at 3 month and 1 year postoperative follow-up time points compared to preoperative scores (P < 0.01). CONCLUSIONS: The adoption of pharyngeal autonomic nerve protective measures during ACDF can effectively lower the probability of postoperative dysphagia.

[Application status and progress of intraoperative nerve monitoring in pelvic autonomic nerve preserving radical resection of rectal cancer].

The current treatment strategy for rectal cancer is a comprehensive treatment centered on surgery. The application of total mesorectal excision (TME) has significantly reduced the local recurrence rate and improved the survival prognosis, but a series of pelvic organ dysfunction caused by pelvic autonomic nerve injury during the operation will reduce the postoperative quality of life of patients. Pelvic autonomic nerve preserving (PANP) radical proctectomy has emerged, but the biggest challenge in the implementation process of this technology is the accurate identification of nerves. A series of studies have shown that pelvic intraoperative autonomic monitoring (pIONM) can effectively assist surgeons to identify nerves, The purpose of this article is to introduce the function of pelvic autonomic nerve, the clinical manifestation of postoperative pelvic dysfunction and its relationship with nerve injury, the key points of implementing PANP, and the current situation and research progress of pIONM technology application.

Deep-learning-based semantic segmentation of autonomic nerves from laparoscopic images of colorectal surgery: an experimental pilot study.

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.

[Pelvic autonomic nerve preservation in rectal cancer: anatomical concept and clinical significance].

Colorectal cancer is one of the most common cancers in the world, and surgery is the mainstage treatment. Urogenital and sexual dysfunction after radical resection of rectal cancer has become an important problem for patients, which seriously affects the quality of life. Some patients give up radical surgery for rectal cancer because of the concerns about sexual and urinary dysfunction. The cause of this problem is intraoperative of injury pelvic autonomic nerve. The preservation of the hypogastric nerve during the surgery is important for the male ejaculation. Pelvic splanchnic nerves are mainly responsible for the male erection. The anatomical origin, distribution, and urogenital function of these two nerves are detailed described in this article. At the same time, this article introduces the classification, key points of the operation and the evaluation of autonomic nerve preservation surgery. With the rapid development of minimally invasive surgery, performing radical surgery for rectal cancer is important, we also need to fully understand the anatomical concept of pelvic autonomic nerves, and apply modern minimally invasive surgical techniques to preserve the patient's pelvic autonomic nerves as well. It is an compulsory course and an important manifestation for the standardization of rectal cancer surgery.

Pelvic autonomic nerve preservation in rectal cancer: anatomical concept and clinical significance / 中华胃肠外科杂志

Colorectal cancer is one of the most common cancers in the world, and surgery is the mainstage treatment. Urogenital and sexual dysfunction after radical resection of rectal cancer has become an important problem for patients, which seriously affects the quality of life. Some patients give up radical surgery for rectal cancer because of the concerns about sexual and urinary dysfunction. The cause of this problem is intraoperative of injury pelvic autonomic nerve. The preservation of the hypogastric nerve during the surgery is important for the male ejaculation. Pelvic splanchnic nerves are mainly responsible for the male erection. The anatomical origin, distribution, and urogenital function of these two nerves are detailed described in this article. At the same time, this article introduces the classification, key points of the operation and the evaluation of autonomic nerve preservation surgery. With the rapid development of minimally invasive surgery, performing radical surgery for rectal cancer is important, we also need to fully understand the anatomical concept of pelvic autonomic nerves, and apply modern minimally invasive surgical techniques to preserve the patient's pelvic autonomic nerves as well. It is an compulsory course and an important manifestation for the standardization of rectal cancer surgery.

Topography of the pelvic autonomic nerves - an anatomical study to facilitate nerve-preserving total mesorectal excision.

INTRODUCTION: Urogenital dysfunction caused by iatrogenic injury to the autonomic nerves persists as a common complication of rectal cancer surgery. This study aims to investigate the relationship between autonomic nerves and the 'holy plane' with the intention of identifying hazardous sites at which urogenital dysfunction may occur. PATIENTS AND METHODS: Dissection of the 'holy plane' and preparation of the autonomic nerves were performed on Thiel-embalmed bodies. The morphology of the inferior hypogastric plexus and its distance to nearby reference points was recorded. RESULTS: In all 28 bodies (13 females, 15 males), we observed that the autonomic nerves were enveloped in parietal pelvic fascia and thereby absent from the 'holy plane' of total mesorectal excision. The midpoint of the inferior hypogastric plexus resided 85 mm from the sacral promontory, and 47 mm from the coccygeal apex. Both distances were significantly longer in men than in women (p < 0.01, p < 0.01). The ureter coursed 11 mm superiorly to the inferior hypogastric plexus. Distal to the ischial spine, it ran 13 mm laterally to the mesorectal fascia. Differences between females and males were not statistically significant (p = 0.32, p = 0.85). CONCLUSIONS: Pursuit of the 'holy plane' spares the autonomic nerves. Restricted visibility may complicate the identification and sparing of the autonomic nerves, and, thus, requires the meticulous planning and execution of surgery. Contextual, the ureter may act as another landmark for the localisation of the inferior hypogastric plexus, additionally to the already established lateral ligaments of the rectum.

Clinician needs and perceptions about cardioneuroablation for recurrent vasovagal syncope: An international clinician survey.

BACKGROUND: Cardioneuroablation (CNA) targets the intrinsic cardiac autonomic nervous system ganglionated plexi located in the peri-atrial epicardial fat. There is increasing interest in CNA as a treatment of vasovagal syncope (VVS), despite no randomized clinical trial (RCT) data. OBJECTIVE: The purpose of this study was to poll the opinion on CNA) for VVS. METHODS: A REDCap (Research Electronic Data Capture) survey was administered to international physicians treating patients with VVS on their opinion about patient selection criteria, ablation approach, RCT design, and most appropriate end points for CNA procedures. RESULTS: The survey was completed by 118 physicians; 86% were cardiac electrophysiologists. The majority of respondents (79%) would consider referring a patient with refractory VVS for CNA, and 27% have performed CNA for VVS themselves. Most felt patient selection should require a head-up tilt test with a cardioinhibitory response (67%) and suggest a minimum age of 18 years with a median of 3 (interquartile range 2-5) episodes in the past year. There were differences in patient selection between physicians who have performed CNA themselves and those who have not. The majority felt that the ablation strategy should include both atria (70%) with an anatomical approach in combination with autonomic stimulation (85%). Performing a sham procedure in the control arm was supported by 56% of respondents, providing equipoise in RCT design. The preferred primary outcome was freedom from syncope within 1 year of follow-up. CONCLUSION: There is widespread support for well-designed RCTs to confirm the hypothesized clinical benefit of CNA, provide data to guide the risk-benefit equations during patient selection, and appropriately estimate the placebo effect.

[Perirectal fascial anatomy and pelvic autonomic nerve preservation during the transanal total mesorectal excision].

The difficulty of transanal total mesorectal excision (TME) is to find the correct dissection plane of perirectal space. As a complex new surgical procedure, the fascial anatomic landmarks of transanal approach operation are more likely to be ignored. It is often found that dissection plane is false after the secondary injury occurs during the operation, which results in the damage of pelvic autonomic nerves. Meanwhile, the mesorectum is easily damaged if the dissection plane is too close to the rectum. Thus, the safety of oncologic outcomes could be limited by difficulty achieving adequate TME quality. The promotion and development of the theory of perirectal fascial anatomy provides a new thought for researchers to design a precise approach for transanal endoscopic surgery. Transanal total mesorectal excision based on fascial anatomy offers a solution to identify the transanal anatomic landmarks precisely and achieves pelvic autonomic nerve preservation. In this paper, the authors focus on the surgical experience of transanal total mesorectal excision based on the theory of perirectal fascial anatomy, and discuss the feature of perirectal fascial anatomy dissection and technique of pelvic autonomic nerve preservation during transanal approach operation.

Association between urinary function and resected pattern of the autonomic nerve system after transanal total mesorectal excision for rectal cancer.

AIM: Transanal total mesorectal excision (TaTME) is expected to improve the quality of total mesorectal excision as well as preserve urinary function. We aimed to study the frequency and risk factors of urinary dysfunction in rectal cancer patients after TaTME. Moreover, we analysed the association between urinary function and resected pattern of the autonomic nerve system (ANS) in TaTME. METHOD: We retrospectively analysed 231 patients who underwent TaTME at our hospital from 2013 to 2018. Independent risk factors for urinary dysfunction were assessed by multivariate analysis. Urinary dysfunction was defined as a condition that requires urethral catheterisation. We intraoperatively judged and classified the preserved or resected pattern of ANS into four categories. RESULTS: The rate of urinary dysfunction after TaTME was 12.1% at discharge. Multivariate analysis revealed that beyond TME and ANS resection were the two major independent risk factors for urinary dysfunction. Total ANS preservation had reduced rates of urinary dysfunction, and all patients were free from catheterisation 6 months post-surgery. There was a higher rate of urinary dysfunction in total ANS resection than in partial ANS resection at 6 months post-surgery. CONCLUSION: This study showed that urinary function after TaTME was associated with resection of the ANS. Furthermore, the rate of urinary dysfunction and recovery time were closely related to the pattern of ANS resection.

Perirectal fascial anatomy and pelvic autonomic nerve preservation during the transanal total mesorectal excision / 中华胃肠外科杂志

The difficulty of transanal total mesorectal excision (TME) is to find the correct dissection plane of perirectal space. As a complex new surgical procedure, the fascial anatomic landmarks of transanal approach operation are more likely to be ignored. It is often found that dissection plane is false after the secondary injury occurs during the operation, which results in the damage of pelvic autonomic nerves. Meanwhile, the mesorectum is easily damaged if the dissection plane is too close to the rectum. Thus, the safety of oncologic outcomes could be limited by difficulty achieving adequate TME quality. The promotion and development of the theory of perirectal fascial anatomy provides a new thought for researchers to design a precise approach for transanal endoscopic surgery. Transanal total mesorectal excision based on fascial anatomy offers a solution to identify the transanal anatomic landmarks precisely and achieves pelvic autonomic nerve preservation. In this paper, the authors focus on the surgical experience of transanal total mesorectal excision based on the theory of perirectal fascial anatomy, and discuss the feature of perirectal fascial anatomy dissection and technique of pelvic autonomic nerve preservation during transanal approach operation.

The risk factors for urinary dysfunction after autonomic nerve-preserving rectal cancer surgery: a multicenter retrospective study at Yokohama Clinical Oncology Group (YCOG1307).

AIM: The aim of this retrospective study was to evaluate the frequency and risk factors of urinary dysfunction after autonomic nerve-preserving surgery for rectal cancer. METHODS: This was a retrospective multiinstitution study of 1002 rectal cancer patients conducted between January 2008 and December 2012 in Yokohama Clinical Oncology Group. Patients who had preoperative urinary dysfunction or had not undergone autonomic nerve preservation surgery were excluded. Urinary dysfunction was defined as that with a Clavien-Dindo classification grade ≥ 2. Patient-, tumor-, and surgery-related variables were examined by univariate and multivariate analyses. RESULTS: A total of 887 patients were analyzed. Postoperative urinary dysfunction was observed in 77 patients (8.8%). A multivariate logistic analysis showed that a tumor location in lower rectum (odds ratio [OR] 2.16; 95% confidence interval [CI] 1.15-3.71; p = 0.02), tumor diameter ≥ 40 mm (OR 2.07; 95% CI 1.19-4.44; p < 0.01), operation time ≥ 240 min (OR 2.07; 95% CI 1.19-4.44; p < 0.01), blood loss ≥ 300 ml (OR 2.35; 95% CI 1.12-3.84; p = 0.02), and diabetes (OR 3.26; 95% CI 1.80-5.89; p < 0.01) were independent risk factors of urinary dysfunction. The incidence of urinary dysfunction exceeded 20% in patients with 3 preoperative predictors (tumor location, tumor diameter, diabetes). CONCLUSIONS: This result demonstrated that high-risk patients with more than two risk factors should be informed of the risk of urinary dysfunction. TRIAL REGISTRATION: UMIN000033688.

End-to-side Somatic-to-autonomic Nerve Grafting to Restore Erectile Function and Improve Quality of Life After Radical Prostatectomy.

BACKGROUND: Radical prostatectomy (RP) is recommended for the treatment of men with clinically localised prostate cancer. However, RP is associated with a high incidence of erectile dysfunction (ED), which can impact the quality of life (QoL) significantly. OBJECTIVE: To evaluate the effectiveness of end-to-side nerve grafting surgery to restore erectile function and improve sexual QoL in men with ED after RP. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of a single-centre experience of nerve grafting in men with ED following RP was performed. Seventeen men had surgery between March 2015 and October 2017 in Melbourne, Australia, which fulfilled study inclusion and exclusion criteria. INTERVENTION: Microsurgical bilateral end-to-side nerve grafts from a selective fascicular neurotomy of the femoral nerve to the penile corpora cavernosa. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Results were serially measured utilising the International Index of Erectile Function (IIEF-5) and the sexual domain of Expanded Prostate Cancer Index Composite (EPIC-26). The proportion and 95% confidence interval (CI) of men recovering sexual function following nerve grafting were determined. RESULTS AND LIMITATIONS: All patients had ED following their RP. Median age at nerve grafting was 64yr (interquartile range [IQR] 60-66yr). Median time between nerve- and non-nerve-sparing RP, and nerve grafting was 2.4 (IQR 2.1-3.1) and 2.2 (IQR 1.7-5.1)yr, respectively. Median follow-up was 18 (IQR 15-24) mo. At 12mo after nerve grafting, 71% (95% CI 44-90%) of patients had erectile function recovery sufficient for satisfactory sexual intercourse, and 94% (95% CI 71-99%) and 82% (95% CI 57-96%) had clinically significant improvements in sexual function and reduced bother, respectively. There were two minor wound infections. Limitations include the retrospective study design. CONCLUSIONS: End-to-side nerve grafting restored erectile function in 71% of men with ED following RP, supporting previous findings. Of the men, 94% had clinically relevant improvements in sexual QoL. We recommend multicentre implementation of post-RP nerve grafting into clinical practice with appropriate data collection to confirm its efficacy and feasibility. PATIENT SUMMARY: We provide confirmatory evidence that end-to-side nerve grafting surgery restored erectile function and improved sexual quality of life in, respectively, 71% and 94% of men with erectile dysfunction following radical prostatectomy.

Preservation of Denonvilliers' fascia for nerve-sparing laparoscopic total mesorectal excision: A neuro-histological study.

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.

[Feasibility and application value of autonomic nerve-preserving D3 radical resection for right-sided colon cancer under laparoscope].

OBJECTIVE: To explore the feasibility and application value of the preservation of vegetative nervous functions in radical resection for right-sided colon cancer. METHODS: Clinical data of 55 cases with right-sided colon cancer undergoing laparoscopic D3+ complete mesocolic excision (CME) radical resection from January 2016 to July 2017 at Department of Gastrointestinal Surgery of Guangdong Province Hospital of Traditional Chinese Medicine were retrospectively analyzed. Exclusion criteria included emergency surgery for various reasons, intestinal obstruction or perforation, distant metastasis or locally advanced cancer, previous history of abdominal surgery and preoperative neoadjuvant chemoradiotherapy. Twenty-nine cases underwent lymphadenectomy with intrathecal dissection of superior mesenteric artery (SMA) and part of superior mesenteric plexus was resected (nerve partial resection group, NPR group). Twenty-six cases received lymphadenectomy with the clearance of lymphatic adipose tissue on the right side of SMA by sharp or obtuse method outside the sheath; the sheath of superior mesenteric vein (SMV) was entered at the junction of SMA and SMV; the SMV was naked in the sheath; the third station lymph node dissection was completed with preservation of superior mesenteric plexus (nerve preserved group, NP group). Intra-operative and postoperative complications were compared between two groups. RESULTS: The baseline data were not significantly different between two groups (all P>0.05). The operation time in NP group was significantly shorter than that in NPR group [(164.0±19.8) minutes vs. (176.0±19.7) minutes, t=2.249, P=0.029]. No significant differences in operative blood loss, operative vessel damage, postoperative time to flatus, postoperative hospital stay and abdominal pain were observed between two groups(all P>0.05). The number of harvested lymph node in two groups was 28.5±7.8 and 27.6±6.5 respectively without significant difference(P>0.05). As compared to NPR group, NP group had lower incidence of chylous leakage[3.8%(1/26) vs. 37.9%(11/29), χ²=9.337, P=0.002] and postoperative diarrhea [15.4%(4/26) vs. 41.4%(12/29), χ²=4.491, P=0.034]. CONCLUSION: Autonomic nerve-preserving D3+ CME radical resection for right-sided colon cancer is safe and feasible, and can prevent the postoperative gastrointestinal dysfunction caused by nerve injury and decrease the risk of chylous leakage.

Effect of 28-mm Cryoballoon Ablation on Major Atrial Ganglionated Plexi.

OBJECTIVES: The authors intended to investigate if 28-mm cryoballoon (CB) ablation also modifies the 4 major atrial ganglionaated plexi (GP). BACKGROUND: The major atrial GP facilitate the initiation and maintenance of atrial fibrillation (AF). The 28-mm CB covers a large surface area of the left atrium and probably the GP areas. METHODS: High-frequency stimulation (20 Hz) was delivered to the area of anterior right GP (ARGP), inferior right GP, superior left (SLGP), and inferior left GP (ILGP). Positive GP sites were defined as a prolongation of R-wave to R-wave (RR) interval during AF by >50%. The area of each GP before and after CB ablation was compared. RESULTS: A total of 18 patients with paroxysmal AF who underwent CB and radiofrequency ablation and had positive GP sites were reviewed. The Wilcoxon signed-rank test was used to assess the effects of CB ablation on each GP. There was a statistically significant difference in the area of all 4 GP after CB ablation: 1) ARGP area: 2.9 cm2 (interquartile range [IQR]: 2.1 to 3.5 cm2) pre-CB, 0.1 cm2 (IQR: 0 to 0.6 cm2) post-CB, p = 0.0002; 2) inferior right GP area: 2.1 cm2 (IQR: 0.9 to 2.9 cm2) pre-CB, 0.5 cm2 (IQR: 0 to 1.7 cm2) post-CB, p = 0.001; 3) SLGP area: 1.4 cm2 (IQR: 0.6 to 2.4 cm2) pre-CB, 0 cm2 (IQR: 0 to 0 cm2) post-CB, p = 0.0002; and 4) ILGP area: 1.3 cm2 (IQR: 0.3 to 2.2 cm2) pre-CB, 0.3 cm2 (IQR: 0 to 1.6 cm2) post-CB, p = 0.008. CONCLUSIONS: The surface area of all 4 of the major atrial GP was substantially reduced by CB ablation. The SLGP and ARGP had the largest, whereas the ILGP had the least percent of reduction following CB ablation. Part of the therapeutic effects of CB ablation may result from modifying the 4 major atrial GP.

Imanaga's First Method for Reconstruction with Preservation of Mesojejunal Autonomic Nerves During Pylorus-Preserving Pancreatoduodenectomy.

BACKGROUND Pancreatic surgeries have undergone substantial development. Pancreaticoduodenectomy and pylorus-preserving pancreatoduodenectomy inherently require reconstruction. In 1960, Professor Imanaga introduced a reconstructive technique performed in the order of the gastric remnant, pancreatic duct, and biliary tree from the viewpoint of physiologic function after pancreaticoduodenectomy. We herein report our experience with Imanaga's first method during pylorus-preserving pancreatoduodenectomy and retrospectively evaluate the short- and long-term outcomes. Technicalities and pitfalls are also discussed. CASE REPORT Eight patients were evaluated (mean follow-up period, 16.7 ± 1.0 years). Mesojejunal autonomic nerves were preserved without tension to the greatest extent possible for reconstruction. Intentional dissection of regional lymph nodes and nerves was performed in five and two patients, respectively. During the short-term postoperative period, one patient developed pancreatic leakage resulting in an intraperitoneal abscess, and endoscopic transgastric drainage was required. Two patients developed delayed gastric emptying. In three patients, passage from the duodenojejunostomy to pancreaticojejunostomy was mechanically disturbed, and endoscopic dilations with a balloon bougie were repeated. Repeated cholangitis was observed in three patients. During the long-term postoperative period, neither cachexia nor sarcopenia was observed, although two patients had diabetes. Two patients were free from all medications. Three patients who did not undergo intentional dissection of lymph nodes and nerves showed acceptable short- and long-term outcomes, although one each developed repeated cholangitis and adhesive ileus during the short-term period. CONCLUSIONS Imanaga's first reconstruction may have potential benefits, especially for diseases that do not require intentional dissection. Adequate mobilization of the pancreatic remnant is important for successful reconstruction.

Reappraisal of the lateral rectal ligament: an anatomical study of total mesorectal excision with autonomic nerve preservation.

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."