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For almost 100 years, the pelvic dissections for rectal cancers requiring a low anterior or an abdominoperineal resection have been accomplished with blunt dissection. As described by the English surgeon Miles, the surgeon's hands and fingers mobilized this section of rectum. Little sharp dissection is required except for division of the lateral suspensory ligaments, as shown in previous editions of the Atlas. Known complications from this blunt dissection include hemorrhage from torn presacral veins, perforation into the rectum, and injury to the pelvic autonomic nerves. An improved dissection, the total mesorectal excision (TME), has been shown to lessen these complications and to provide a better radial margin of tumor clearance. The TME requires meticulous sharp or electrocautery dissection under direct vision. The procedure takes significantly more time to perform, but it is associated with a lessened rate of local recurrence for rectal cancers. The TME technique is widely used both with sphincter preservation in very low rectal anastomoses and with abdominoperineal resection.

The peritoneum along the right side of the rectosigmoid junction is incised lateral to the inferior mesenteric and superior hemorrhoidal vessels (Figure 6). This incision extends down to the pouch of Douglas. The right ureter is identified beneath the residual peritoneum, and its course over the iliac vessels is exposed with blunt gauze dissection. The proximal bowel is retracted anteriorly and laterally. Alternatively, the proximal division of the bowel and vascular pedicles can be completed allowing the proximal end of the specimen to be moved around to aid visualization (Figure 11). If the tumor is very large, this should be avoided at this point, as it commits one to an excision prior to complete mobilization of the tumor. The superior hypogastric nerves are visualized just below the iliac vessels and the ureters. The dissection proceeds behind the superior hemorrhoidal vessels toward the entrance of the presacral space behind the sacral promontory. Division of the retrosacral fascia or ligament just below the sacral curvature at about S2 is done sharply in the midline with scissors or electrocautery, using a long, insulated tip (Figure 7). The rectum is retracted anteriorly with a fiberoptic lighted deep pelvic retractor, which may be straight or curved. Under direct vision, the posterior dissection continues down to the level of the coccyx. The sacral veins are clearly visualized beneath the parietal fascia, which is kept intact, thus minimizing bleeding.

The peritoneal reflection in the pouch of Douglas is incised about 1 cm up its anterior reflection over the bladder in men (shown in this illustration) or behind the uterus ...

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