2025/03/01 by Hongjie Yang, Yuanda Zhou, Peishi Jiang +7 · 1 voice
Medicine · #Anorectal Disease Treatments and Outcomes #Colorectal Cancer Surgical Treatments #Stoma care and complications
paper · doi:10.1093/bjs/znae316
openalex publication_date 2025/03/01 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/30
Total pelvic exenteration (TPE) offers the possibility of long-term survival for select patients with locally advanced and recurrent pelvic malignancies and is a technically challenging procedure1,2, particularly for patients with bulky tumours stuck in a narrow pelvis or with tumour-related adhesions. Laparoscopic TPE is now performed in experienced centres worldwide, using innovative surgical strategies combined with modern instruments to improve surgical outcomes3. The major challenge in TPE is dissection of the vascular branches originating from the internal iliac vessels, incorporating the superior and inferior vesical vessels and their branches, the vessels of the reproductive organs, and the middle artery of the rectum (Fig. 1). These vessels are normally isolated and transected individually4,5; however, this is time-consuming, with a high risk of bleeding. Theoretically, the procedure would be simplified if the lateral vascular branches could be transected together without further dissection. This approach could be fulfilled through a fascial space priority approach based on fasciae-oriented dissection for patients with centrally located tumours. Diagram of the pelvic anatomy, transection of the vesicohypogastric vascia and ureterohypogastric nerve fascia, and the surgical field of laparoscopic total pelvic exenteration with supra-levator resection a The paravesical space was fully separated till the ATFP (asterisks). b The two spaces could communicate with each other at the surface of the coccygeus (the double arrow line) and the VHGF and UHGNF are transected together with a stapler. c The final surgical field. The stumps of VHGF and UHGNF (the white arrow), the stump of the urethra (yellow arrow), and the stump of the rectum (black arrow) were marked. ATFP, arcus tendineus of the pelvic fascia; CIA, common iliac artery; CIV, common iliac vein; EIA, external iliac artery; EIV, external iliac vein; HN, hypogastric nerve; IIA, internal iliac artery; IVVs, inferior vesical vessels; ON, obturator nerve; SHP, superior hypogastric plexus; SN, sciatic nerve; SVVs, superior vesical vessels; TPE, total pelvic exenteration; UHGNF, ureterohypogastric nerve fascia; Ur, ueter; VHGF, vesicohypogastric fascia Two fasciae of the lateral pelvis are important in TPE, the vesicohypogastric fascia and the ureterohypogastric nerve fascia, also referred to as the urogenital fascia. The lateral vascular branches leading to the pelvic organs are enveloped within the vesicohypogastric fascia, whereas the pelvic autonomic nerves are encapsulated within the ureterohypogastric nerve fascia. The vesicohypogastric fascia can be separated by dissection of the paravesical space, and the ureterohypogastric nerve fascia can be separated by lateral extension of the retrorectal space. With thorough dissection of these two anatomical spaces, the vessels and hypogastric nerves can be transected simultaneously with a disposable linear stapler (Sinolinks, Changzhou, China), thus, en-bloc resection of the pelvic organs can be achieved without disturbing the tumour (see Supplementary material, Video). On examination of the specimen, it is clear that the pelvic organs are encased within the envelope composed of the visceral and pelvic fasciae, providing adequate surgical margins and preventing tumour spillage (Fig. 2). The en-bloc specimen following total pelvic exenteration of a 52-year-old male diagnosed with locally advanced rectal cancer with tumour perforation, pelvic abscess, and rectovesical fistula The pelvic organs were enveloped with the visceral fascia of the rectum and the bladder, the resected pelvic fascia, peritoneum, and the involved small intestine (asterisks). a The posterior view; b the lateral view; c the anterior view. B, bladder; R, rectum During this approach, care should be taken to prevent iatrogenic injury, with the avoidance of blind spots in the field of view and appropriate adjustment of the stapler critical to this. The authors devised a method of creating suitable space by incising the arcus tendineus of the pelvic fascia at the surface of the coccygeus, allowing adequate space for safe application of the stapler. Meticulously checking the surrounding tissues before stapling should also be routine. The staplers used in this video have been used in numerous procedures including pulmonary and hepatic lobectomy and nephrectomy, with proven safety and effectiveness6–8. For selected patients with a centrally located advanced pelvic malignancy, laparoscopic TPE can be performed simply and safely with a fascial space priority approach. This research was funded by the Tianjin Key Medical Discipline(Specialty) Construction Project (No. TJYXZDXK-044A) and the hospital level scientific research fund of Tianjin Union Medical Center (No. 2022GCXK004). The authors declare no conflict of interest. Supplementary material is available at BJS online. The data that support the findings of this study are available from the corresponding author upon reasonable request. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Hongjie Yang (Writing—original draft, Writing—review & editing), Yuanda Zhou (Writing—original draft, Writing—review & editing), Peishi Jiang (Conceptualization, Writing—review & editing), Jiafei Liu (Writing—review & editing), Zhichun Zhang (Data curation, Writing—review & editing), Qingsheng Zeng (Data curation, Writing—review & editing), Peng Li (Writing—review & editing), Yu Long (Writing—review & editing), Xipeng Zhang (Investigation, Writing—review & editing), and Yi Sun (Project administration, Writing—review & editing)