Suprapubic versus transurethral catheterization for bladder drainage in male rectal cancer surgery (GRECCAR10), a randomized clinical trial.

BACKGROUND: Bladder drainage is systematically used in rectal cancer surgery; however, the optimal type of drainage, transurethral catheterization (TUC) or suprapubic catheterization (SPC), is still controversial. The aim was to compare the rates of urinary tract infection on the fourth postoperative day (POD4) between TUC and SPC, after rectal cancer surgery regardless of the day of removal of the urinary drain. METHODS: This randomized clinical trial in 19 expert colorectal surgery centers in France and Belgium was performed between October 2016 and October 2019 and included 240 men (with normal or subnormal voiding function) undergoing mesorectal excision with low anastomosis for rectal cancer. Patients were followed at postoperative days 4, 30, and 180. RESULTS: In 208 patients (median age 66 years [IQR 58-71]) randomized to TUC (n = 99) or SPC (n = 109), the rate of urinary infection at POD4 was not significantly different whatever the type of drainage (11/99 (11.1%) vs. 8/109 (7.3%), 95% CI, - 4.2% to 11.7%; p = 0.35). There was significantly more pyuria in the TUC group (79/99 (79.0%) vs. (60/109 (60.9%), 95% CI, 5.7-30.0%; p = 0.004). No difference in bacteriuria was observed between the groups. Patients in the TUC group had a shorter duration of catheterization (median 4 [2-5] vs. 4 [3-5] days; p = 0.002). Drainage complications were more frequent in the SPC group at all followup visits. CONCLUSIONS: TUC should be preferred over SPC in male patients undergoing surgery for mid and/or lower rectal cancers, owing to the lower rate of complications and shorter duration of catheterization. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02922647.

Minimally invasive approach for retrorectal tumors above and below S3: a multicentric tertiary center retrospective study (MiaRT study).

BACKGROUND: Retrorectal tumors are uncommon lesions developed in the retrorectal space. Data on their minimally invasive resection are scarce and the optimal surgical approach for tumors below S3 remains debated. METHODS: We performed a retrospective review of consecutive patients who underwent minimally invasive resection of retrorectal tumors between 2005 and 2022 at two tertiary university hospital centers, by comparing the results obtained for lesions located above or below S3. RESULTS: Of over 41 patients identified with retrorectal tumors, surgical approach was minimally invasive for 23 patients, with laparoscopy alone in 19, with transanal excision in 2, and with combined approach in 2. Retrorectal tumor was above S3 in 11 patients (> S3 group) and below S3 in 12 patients (< S3 group). Patient characteristics and median tumor size were not significantly different between the two groups (60 vs 67 mm; p = 0.975). Overall median operative time was 131.5 min and conversion rate was 13% without significant difference between the two groups (126 vs 197 min and 18% vs 8%, respectively; p > 0.05). Final pathology was tailgut cyst (48%), schwannoma (22%), neural origin tumor (17%), gastrointestinal stromal tumor (4%), and other (19%). The 90-day complication rates were 27% and 58% in the > S3 and < S3 groups, respectively, without severe morbidity or mortality. After a median follow-up of 3.3 years, no recurrence was observed in both groups. Three patients presented chronic pain, three anal dysfunction, and three urinary dysfunction. All were successfully managed without reintervention. CONCLUSIONS: Minimally invasive surgery for retrorectal tumors can be performed safely and effectively with low morbidity and no mortality. Laparoscopic and transanal techniques alone or in combination may be recommended as the treatment of choice of benign retrorectal tumors, even for lesions below S3, in centers experienced with minimally invasive surgery.

What management for patients with R1 resection after total mesorectal excision for rectal cancer? A review of the literature.

AIM OF THE STUDY: Treatment for rectal cancer is very standardized. However, for total mesorectal excision (TME) with positive margins at microscopic pathological examination (classified R1 ), there is no consensus regarding management. The objective of this update was, through a review of the literature, to identify the most suitable management to improve overall survival and/or recurrence-free survival after R1 TME for rectal cancer. PATIENTS AND METHODS: Published national quality guidelines and original studies were searched on Pubmed. Only studies and recommendations concerning the specific management of patients who had undergone R1 TME resection were selected. RESULTS: Five original non-randomized studies and seven published national quality guidelines were selected for review. For patients who have undergone R1 TME resection, the French and European published guidelines issued a Grade A recommendation in favor of post-operative radio-chemotherapy (RCT) for those in whom it had not already been performed pre-operatively. The French and European guidelines recommendation for adjuvant chemotherapy was based only on expert agreement. The original studies emphasized the survival benefit of adjuvant chemotherapy, as opposed to post-operative RCT, which did not seem to improve survival. Salvage surgery was not recommended in any of the studies. CONCLUSION: After R1 TME resection for rectal cancer, adjuvant chemotherapy seems to be indicated when feasible, whereas post-operative RCT and salvage surgery do not appear to improve patient survival.

Early and late morbidity of local excision after chemoradiotherapy for rectal cancer.

BACKGROUND: Local excision (LE) after chemoradiotherapy is a new option in low rectal cancer, but morbidity has never been compared prospectively with total mesorectal excision (TME). Early and late morbidity were compared in patients treated either by LE or TME after neoadjuvant chemoradiotherapy for rectal cancer. METHOD: This was a post-hoc analysis from a randomized trial. Patients with clinical T2/T3 low rectal cancer with good response to the chemoradiotherapy and having either LE, LE with eventual completion TME, or TME were considered. Early (1 month) and late (2 years) morbidities were compared between the three groups. RESULTS: There were no deaths following surgery in any of the three groups. Early surgical morbidity (20 per cent LE versus 36 per cent TME versus 43 per cent completion TME, P = 0.025) and late surgical morbidity (4 per cent versus 33 per cent versus 57 per cent, P < 0.001) were significantly lower in the LE group than in the TME or the completion TME group. of LE, was associated with the lowest rate of early (10 versus 18 versus 21 per cent, P = 0.217) and late medical morbidities (0 versus 7 versus 7 per cent, P = 0.154), although this did not represent a significant difference between the groups. The severity of overall morbidity was significantly lower at 2 years after LE compared with TME or completion TME (4 versus 28 versus 43 per cent grade 3-5, P < 0.001). CONCLUSION: The rate of surgical complications after neoadjuvant chemoradiotherapy in the LE group was half that of TME group at 1 month and 10 times lower at 2 years. LE is a safe approach for organ preservation and should be considered as an alternative to watch-and-wait in complete clinical responders and to TME in subcomplete responders.

Quality of life in colostomy patients practicing colonic irrigation: An observational study.

AIMS OF THE STUDY: The presence of colostomy has a major impact on quality of life that could potentially be improved by performing colonic irrigation (CI), yet few studies have assessed the impact of this technique on quality of life. The aim of this study was to assess the quality of life between two groups of patients having a colostomy; those practicing CI vs those not practicing CI. PATIENTS AND METHODS: The French Federation of Ostomy (FFO) members were evaluated by a self-questionnaire assessing their experience of CI. Quality of life as assessed by the Stoma-QOL questionnaire was compared between patients practicing CI or not. RESULTS: In total 752 patients were eligible for the study. The median age was 75 years, and 47.26% were men. The median duration between stoma surgery and questionnaire completion was 12.3 years. Forty-one percent of the patients practiced CI. The median quality of life score was significantly higher for the patients practicing the CI: (69.26 vs 58.33, P<0.001). In multivariable analysis, the risk factors for not performing CI were age, obesity, the presence of colostomy for less than six years, and a non-oncologic indication for operation. CONCLUSIONS: CI appeared to improve the quality of life of patients with colostomy. This care is a therapeutic education issue and should be proposed to all patients. Supervision by the enterostomal therapy nurse is recommended especially for patients with a high risk of failure.

Thoracoscopy in prone position with two-lung ventilation compared to conventional thoracotomy during Ivor Lewis procedure: a multicenter case-control study.

BACKGROUND: Intraoperative management based on thoracoscopy, prone position and two-lung ventilation could decrease the rate of postoperative pulmonary complications after esophagectomy. The aim of this study was to compare this multifaceted approach (MIE-PP) and conventional thoracotomy for Ivor Lewis procedure after a systematic laparoscopic dissection. METHODS: Data from 137 consecutive patients undergoing Ivor Lewis procedures between 2010 and 2017 at two tertiary centers was analyzed retrospectively. The outcomes of patients who underwent MIE-PP (n = 58; surgeons group 1) were compared with those of patients undergoing conventional approach (n = 79; surgeons group 2). Our primary outcome was major postoperative pulmonary complications. Our main secondary outcomes were anastomotic leak, quality of resection and mortality. RESULTS: Female patients were more prevalent in the MIE-PP group (p = 0.002). Other patient characteristics, cTNM staging and neoadjuvant treatment rate were not different between groups. Major postoperative pulmonary complications were significantly lower in the MIE-PP group compared to Conventional group (24 vs. 44%; p = 0.014). Anastomotic leak occurred in 31 versus 18% in MIE-PP group and Conventional groups, respectively (p = 0.103). Complete resection rate (98 vs. 95%; p = 0.303) and mean number of harvested lymph nodes (16 (4-40) vs. 18 (3-37); p = 0.072) were similar between the two groups. Postoperative mortality rates were 0 versus 2% at day 30 (p = 0.508) and 0 versus 7.6% at day 90 (p = 0.038). CONCLUSION: Short-term outcomes of minimally invasive Ivor Lewis using thoracoscopy, prone position and two-lung ventilation are at least equivalent to the hybrid approach. Anastomotic leak after MIE-PP remains a major concern.

Management of neuropathic pain induced by surgery: Review of the literature by a group of experts specialized in pain management, anesthesia and surgery.

Chronic postsurgical neuropathic pain (CPSNP) is frequent. While prevalence varies considerably according to type of operation and means of evaluation, it can reach 37% following breast surgery. Identification of risk factors related to the procedure and to the patient and taking into account the development of new, minimally invasive surgical techniques is increasingly nerve-sparing and reduces the likelihood of injury. CPSNP diagnosis in daily practice is facilitated by simple and quickly usable tools such as the NP4 4-question test. Management is based on pharmacological (analgesics, antiepileptics, antidepressants, local anesthetics) and non-pharmacological (kinesitherapy, neurostimulation, psychotherapy) approaches. In light of the present review of the literature, the authors, who constitute an expert group specialized in pain management, anesthesia and surgery, express their support for topical treatments (lidocaine, capsaicin) in treatment of localized postsurgical neuropathic pain in adults.

Perioperative FOLFOX 4 Versus FOLFOX 4 Plus Cetuximab Versus Immediate Surgery for High-Risk Stage II and III Colon Cancers: A Phase II Multicenter Randomized Controlled Trial (PRODIGE 22).

BACKGROUND: Perioperative chemotherapy has proven valuable in several tumors, but not in colon cancer (CC). OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of perioperative chemotherapy in patients with locally advanced nonmetastatic CC. METHODS: This is a French multicenter randomized phase II trial in patients with resectable high-risk T3, T4, and/or N2 CC on baseline computed tomography (CT) scan. Patients were randomized to receive either 6 months of adjuvant FOLFOX after colectomy (control) or perioperative FOLFOX for 4 cycles before surgery and 8 cycles after (FOLFOX peri-op). In RAS wild-type patients, a third arm testing perioperative FOLFOX-cetuximab was added. Tumor Regression Grade (TRG1) of Ryan et al was the primary endpoint. Secondary endpoints were toxicity, perioperative morbidity, and quality of surgery. RESULTS: A total of 120 patients were enrolled. At interim analysis, the FOLFOX-cetuximab arm was stopped (lack of efficacy). The remaining 104 patients (control, n = 52; FOLFOX preop n = 52) represented our intention-to-treat population. In the FOLFOX perioperative group, 96% received the scheduled 4 cycles before surgery. R0 resection and complete mesocolic excision rate were 94% and 93%, respectively. Overall mortality and morbidity rates were similar in both groups. Perioperative FOLFOX chemotherapy did not improve major pathological response rate (TRG1 = 8%) but was associated with a significant pathological regression (TRG1-2 = 44% vs 8%, P < 0.001) and a trend to tumor downstaging as compared to the control group. CT scan criteria were associated with a 33% rate of overstaging in control group. CONCLUSIONS: Perioperative FOLFOX for locally advanced resectable CC is feasible with an acceptable tolerability but is not associated with an increased major pathological response rate as expected. However, perioperative FOLFOX induces pathological regression and downstaging. Better preoperative staging tools are needed to decrease the risk of overtreating patients.

Three-dimensional computer-assisted dissection of pancreatic lymphatic anatomy on human fetuses: a step toward automatic image alignment.

PURPOSE: Pancreatic cancer is the fourth cause of death by cancer worldwide. Lymph node (LN) involvement is known to be the main prognostic factor. However, lymphatic anatomy is complex and only partially characterized. The aim of the study was to study the pancreatic lymphatic system using computer-assisted anatomic dissection (CAAD) technique and also to update CAAD technique by automatizing slice alignment. METHODS: We dissected three human fetuses aged from 18 to 34 WA. 5-µm serial sections of duodeno-pancreas and spleen blocks were stained (hematoxylin-eosin, hematoxylin of Mayer and Masson trichrome), scanned, aligned and modeled in three dimensions. RESULTS: We observed a rich, diffuse but not systematized lymphatic network in the peri-pancreatic region. There was an equal distribution of LNs between the cephalic and body-tail portions. The lymphatic vascularization appeared in continuity from the celiac trunk to the distal ends of its hepatic and splenic arterial branches parallel to the nerve ramifications of the celiac plexus. We also observed a continuity between the drainage of the pancreatic head and the para-aortic region posteriorly. CONCLUSION: In view of the wealth of peri-pancreatic LNs, the number of LNs to harvest could be increased to improve nodal staging and prognostic evaluation. Pancreatic anatomy as described does not seem to be compatible with the sentinel LN procedure in pancreatic surgery. Finally, we are now able to offer an alternative to manual alignment with a semi-automated alignment.

Assessing the costs of disposable and reusable supplies wasted during surgeries.

BACKGROUND: The management of disposable and reusable supplies might have an impact on the cost efficiency of the Operating Room (OR). This study aimed to evaluate the cost and reasons for wasted supplies in the OR during surgical procedures. METHODS: We conducted an observational and prospective study in a French university hospital. We assessed the cost of wasted supplies in the OR (defined by opened unused devices), the reasons for the wastage, and the circulator retrievals. At the end, we assessed the perception of surgeons and nurses relative to the supply wastage. RESULTS: Fifty routine procedures and five non-scheduled procedures were observed in digestive (n = 20), urologic (n = 20) and gynecologic surgery (n = 15). The median cost [IQR] of open unused devices was €4.1 [0.5; 10.5] per procedure. Wasted supplies represented up to 20.1% of the total cost allocated to surgical supplies. Considering the 8000 surgical procedures performed in these three surgery departments, the potential annual cost savings were 100 000€. The most common reason of wastage was an anticipation of the surgeon's needs. The circulating nurse spent up to 26.3% of operative time outside of the OR, mainly attending to an additional demand from the surgeon (30%). Most of the survey respondents (68%) agreed that knowing supply prices would change their behavior. CONCLUSIONS: This study showed the OR is a major source of wasted hospital expenditure and an area wherein an intervention would have a significant impact. Reducing wasted supplies could improve the cost efficiency of the OR and also decrease its ecological impact.

European Hernia Society guidelines on prevention and treatment of parastomal hernias

Background International guidelines on the prevention and treatment of parastomal hernias are lacking. The European Hernia Society therefore implemented a Clinical Practice Guideline development project. Methods The guidelines development group consisted of general, hernia and colorectal surgeons, a biostatistician and a biologist, from 14 European countries. These guidelines conformed to the AGREE II standards and the GRADE methodology. The databases of MEDLINE, CINAHL, CENTRAL and the gray literature through OpenGrey were searched. Quality assessment was performed using Scottish Intercollegiate Guidelines Network checklists. The guidelines were presented at the 38th European Hernia Society Congress and each key question was evaluated in a consensus voting of congress participants. Results End colostomy is associated with a higher incidence of parastomal hernia, compared to other types of stomas. Clinical examination is necessary for the diagnosis of parastomal hernia, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. Currently available classifications are not validated; however, we suggest the use of the European Hernia Society classification for uniform research reporting. There is insufficient evidence on the policy of watchful waiting, the route and location of stoma construction, and the size of the aperture. The use of a prophylactic synthetic non-absorbable mesh upon construction of an end colostomy is strongly recommended. No such recommendation can be made for other types of stomas at present. It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. So far, there is no sufficient comparative evidence on specific techniques, open or laparoscopic surgery and specific mesh types. However, a mesh without a hole is suggested in preference to a keyhole mesh when laparoscopic repair is performed. Conclusion An evidence-based approach to the diagnosis and management of parastomal hernias reveals the lack of evidence on several topics, which need to be addressed by multicenter trials. Parastomal hernia prevention using a prophylactic mesh for end colostomies reduces parastomal herniation. Clinical outcomes should be audited and adverse events must be reported.

European Hernia Society guidelines on prevention and treatment of parastomal hernias.

BACKGROUND: International guidelines on the prevention and treatment of parastomal hernias are lacking. The European Hernia Society therefore implemented a Clinical Practice Guideline development project. METHODS: The guidelines development group consisted of general, hernia and colorectal surgeons, a biostatistician and a biologist, from 14 European countries. These guidelines conformed to the AGREE II standards and the GRADE methodology. The databases of MEDLINE, CINAHL, CENTRAL and the gray literature through OpenGrey were searched. Quality assessment was performed using Scottish Intercollegiate Guidelines Network checklists. The guidelines were presented at the 38th European Hernia Society Congress and each key question was evaluated in a consensus voting of congress participants. RESULTS: End colostomy is associated with a higher incidence of parastomal hernia, compared to other types of stomas. Clinical examination is necessary for the diagnosis of parastomal hernia, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. Currently available classifications are not validated; however, we suggest the use of the European Hernia Society classification for uniform research reporting. There is insufficient evidence on the policy of watchful waiting, the route and location of stoma construction, and the size of the aperture. The use of a prophylactic synthetic non-absorbable mesh upon construction of an end colostomy is strongly recommended. No such recommendation can be made for other types of stomas at present. It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. So far, there is no sufficient comparative evidence on specific techniques, open or laparoscopic surgery and specific mesh types. However, a mesh without a hole is suggested in preference to a keyhole mesh when laparoscopic repair is performed. CONCLUSION: An evidence-based approach to the diagnosis and management of parastomal hernias reveals the lack of evidence on several topics, which need to be addressed by multicenter trials. Parastomal hernia prevention using a prophylactic mesh for end colostomies reduces parastomal herniation. Clinical outcomes should be audited and adverse events must be reported.

Anatomical basis of the coordination between smooth and striated urethral and anal sphincters: loops of regulation between inferior hypogastric plexus and pudendal nerve. Immuno-histological study with 3D reconstruction.

PURPOSE: (1) Describe both nervous pathways to the sphincters, and highlight the anatomical support of their coordination. (2) Obtain a 3D representation of this complex innervation system. METHODS: A computer-assisted anatomical dissection technique was used. Serial histological sections were cut in the pelvis of four female human foetuses (aged 19-32 weeks of gestation). The sections were treated with conventional staining, and with seven different immunostainings. The sections were digitalized and, finally, a 3D representation was built from the corresponding images. RESULTS: Myelinated and sensory fibres were detected at the inferior hypogastric plexus (IHP) level. Our analysis showed that most of the afferent sensory fibres come from the urinary and anal sphincters through the anterior and posterior branches of the IHP respectively. A highly positive nitrergic (anti-NOS1) and sensitive (anti-CGRP) labelling was found in the external layer of the urethral sphincter. The 3D representation allowed describing the two components of the innervation system. A sensory-motor regulation loop was found for both sphincters. CONCLUSION: A 3D description of the components of both nervous pathways to the sphincters has been established. Our findings on the innervation of the sphincters tend to question the classical infra/supra levatorian muscle description. The coordinated work of the internal and external layers of the anal and urethral sphincter is probably mediated by multiple roles regulation.

Is non-operative management of severe blunt splenic injury safer than embolization or surgery? Results from a French prospective multicenter study.

PURPOSE OF THE STUDY: The management of the severe blunt splenic injuries remains debated. The aim of this study is to evaluate the morbidity and mortality of splenic injury according to severity and management (surgery, embolization, non-operative management [NOM]). METHODS: A prospective multicenter study was conducted including patients aged 16 years and older with diagnosed splenic injury. We evaluated severity according to the AAST classification, the presence of hemoperitoneum or a contrast blush on initial CT scan. The initial hemodynamic status, patients co-morbidities, the ISS (injury severity score), management and morbidity were also noted. RESULTS: Between May 2010 and May 2012, 91 patients were included. Thirty-seven patients (41%) had mild splenic injury (AAST I or II and a small hemoperitoneum) while 54 patients (59%) had severe splenic injury (AAST III or greater). The management included 18 splenectomies (20%), 15 embolizations (16%). Among 67 patients undergoing NOM without initial embolization, five (7%) developed secondary bleeding, five required surgery and nine underwent secondary embolization. No patient died and morbidity was 44% (n=40), 13% for mild injuries vs. 65% for severe injuries (P<0.01). For severe injuries, total morbidity was 58% after NOM, 73% after embolization and 70% after surgery. Specific morbidity related to the management was 10% after NOM vs. 47% after embolization (P=0.02). Specific morbidity after surgery was 15%. CONCLUSION: Embolization, because of its important specific morbidity, should not be performed as a prophylactic measure, but only in presence of clinical or laboratory signs of bleeding.

Evaluation of a laparoscopic training program with or without robotic assistance.

The aim of the present study was to evaluate the value of a box trainer simulator in laparoscopy training. A further aim was to determine if robotic-assisted approaches further improved the young residents' skills in laparoscopic surgery. The study was a prospective randomized study. Twelve residents in obstetrics & gynecology completed four laparoscopy-related procedures of varying complexity using a box trainer simulator. Participants were randomized into two groups; robotic-assisted laparoscopy (LRA) and traditional laparoscopy (TL). All subjects were assessed with a time and technical score, which are quantitative and qualitative approaches (respectively). All residents completed the training and a satisfaction questionnaire, which confirmed that the training was well regarded. Regardless of the workshop type, there was a clear time and technical improvement for the difficult tasks. The improvement of time score was most apparent for simple tasks in LRA and for more complex tasks in TL. After training, we did not find a significant difference for the technical score between Novices and Experts in TL and LRA. These findings suggest that training in laparoscopy surgery is useful, reproducible and well accepted by both novice and more advanced trainees. Furthermore, gynecological endoscopy center consider including robotic-assisted approaches in their surgical training program.

Transanal endoscopic proctectomy and nerve injury risk: bottom to top surgical anatomy, key points.

The transanal approach for rectal resection is a promising approach, because it increases the circumferential radial margin, especially for difficult cases. Meanwhile, functional sequelae are frequent after rectal cancer surgery and are often due to neurological lesions. There is little literature describing surgical anatomy from bottom to top. We combined our surgical experience with our fetal and adult anatomical research to provide a bottom-up surgical description focusing on neurological anatomy (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A148).

MRI-based 3D pelvic autonomous innervation: a first step towards image-guided pelvic surgery.

OBJECTIVE: To analyse pelvic autonomous innervation with magnetic resonance imaging (MRI) in comparison with anatomical macroscopic dissection on cadavers. MATERIAL AND METHODS: Pelvic MRI was performed in eight adult human cadavers (five men and three women) using a total of four sequences each: T1, T1 fat saturation, T2, diffusion weighed. Images were analysed with segmentation software in order to extract nervous tissue. Key height points of the pelvis autonomous innervation were located in every specimen. Standardised pelvis dissections were then performed. Distances between the same key points and the three anatomical references forming a coordinate system were measured on MRIs and dissections. Concordance (Lin's concordance correlation coefficient) between MRI and dissection was calculated. RESULTS: MRI acquisition allowed an adequate visualization of the autonomous innervation. Comparison between 3D MRI images and dissection showed concordant pictures. The statistical analysis showed a mean difference of less than 1 cm between MRI and dissection measures and a correct concordance correlation coefficient on at least two coordinates for each point. CONCLUSION: Our acquisition and post-processing method demonstrated that MRI is suitable for detection of autonomous pelvic innervations and can offer a preoperative nerve cartography. KEY POINTS: • Nerve preservation is a hot topic in pelvic surgery • High resolution MRI can show distal peripheral nerves • Anatomo-radiological comparison shows good correlation between MRI and dissection • 3D reconstructions of pelvic innervation were obtained with an original method • This is a first step towards image-guided pelvic surgery.

Is low tie ligation truly reproducible in colorectal cancer surgery? Anatomical study of the inferior mesenteric artery division branches.

AIM: Curative surgery is the standard treatment for colorectal cancer. The ligation level of the inferior mesenteric artery (IMA) is still debated, as neither low tie (LT) nor high tie ligation (HT) has shown any benefit on the patients' overall survival. We examined whether LT is standardizable and easily reproducible from an anatomical point of view. METHOD: One hundred CT angiographies of healthy patients were analysed for the anatomy of the IMA and its division branches: left colic artery (LCA), sigmoid arteries trunk and superior rectal artery. Data analysed comprised angles between the IMA and the aorta, diameters of the IMA and its branches, repartition of the branches and distances between the origin of the branches and the origin of the IMA. RESULTS: IMA anatomy showed no variation. In contrast, its division branches showed important variability in terms of distance to the origin and repartition: in 19.9% of the patients, the IMA directly splits into three branches, and in 17.6% of the patients, the LCA originated at more than 5 cm from the origin of the IMA. These frequent variations led us to assume that the standardization of LT is very difficult in a context of neoplasm, where the quality of the lymphadenectomy is fundamental. CONCLUSION: The division branches of the IMA are extremely subject to interindividual variations, making it difficult if not impossible to reproduce identically a surgical procedure based on their anatomy. HT appears to us as the only relevant procedure for colorectal cancer.

Biomechanical origin of the Denonvilliers' fascia.

INTRODUCTION: Since 1836 and the first description of the recto-genital fascia by Charles Denonvilliers, many anatomists have shown interest in this subject. Recently, pelvic surgeons have in turn shown similar interest, for they consider that perfect knowledge of this anatomical domain is crucial for optimal nerve conservation during surgery. Thanks to new anatomical description techniques, fascia location and relationships with pelvic nerves now appear clearer. OBJECTIVES: To describe and represent Denonvilliers' fascia and its relationships in the female foetus at different stages of gestation and in three-dimensional space (3D). MATERIEL/PATIENTS AND METHODS: Computer-assisted anatomical dissection technique was used. Serial histological sections were made from four human female foetuses. Sections were treated with conventional staining, as well as with nerve and smooth muscle immunostaining. Finally, the sections were digitalized and reconstructed in 3D. RESULTS: Denonvilliers' fascia was clearly located and visualized in three dimensions. It was present in the female foetus, being distinct from the fascia propria of the rectum. It appeared to be composed of multiple parallel layers situated between the vagina and the rectum. From a lateral view, it had an asymmetrical "Y-shaped" aspect that seemed to play the role of a protective sheet for the neurovascular bundles. CONCLUSION: This study betters our comprehension of the Denonvilliers' fascia in the female foetus and of its connections with pelvic nerves. It also provides a better understanding of safe planes during pelvic dissection. These findings also suggest a biomechanical theory for embryological origin of the Denonvilliers' fascia.

Optimal plane for nerve sparing total mesorectal excision, immunohistological study and 3D reconstruction: an embryological study.

AIM: Genito-urinary complications are frequent after rectal surgery and are often due to nerve damage. The relationship between the pelvic nerves and surgical planes are unclear. The aim of the study was to determine the relationship between the inferior hypogastric plexus and the fascia of the lateral pelvic wall and between Denonvilliers' fascia and the efferent branches of the inferior hypogastric plexus. METHOD: Computer-assisted anatomical dissection was used. Serial histological sections were made from six human foetuses and a male adult. Sections were stained with haematoxylin and eosin, Masson's trichrome and immunostainings. The sections were then digitalized and reconstructed in three dimensions. RESULTS: The inferior hypogastric plexus was situated in a virtual space between the fascia propria of the rectum and the fascia on the upper surface of the levator ani. During the lateral dissection, the optimal surgical plane is the plane of the fascia propria of the rectum. We located Denonvilliers' fascia in three dimensions. It plays the role of a protective sheet for the neurovascular bundle. The optimal plane for nerve preservation is situated behind Denonvilliers' fascia. CONCLUSION: This study has enabled a clear visualization of the optimal planes to perform total mesorectal excision while ensuring nerve preservation. Three-dimensional visualization clearly helps to bridge the gap between histological examination and the findings of surgery.