Rectal resection is associated with a risk of sexual dysfunction even when performed for benign disease, with the most frequent type resulting in retrograde ejaculation due to injury to the hypogastric nerves.
A simple technique to identify and protect these nerves during rectal mobilization.
Exposure of the hypogastric plexus during rectal resection.
Careful identification of the hypogastric nerves during rectal mobilization using the described technique may reduce injury to these nerves and related sexual dysfunction.
Sympathetic fibers originate from the thoracolumbar section of the spinal cord and form the hypogastric plexus that runs just anterior to the distal part of the aorta, beginning at the origin of the inferior mesenteric artery. Below the aortic bifurcation, the hypogastric plexus forms 2 trunks, the hypogastric nerves that run laterally and caudally to reach the lateral pelvic walls. Lateral to the rectum and along the lateral pelvic walls, the hypogastric nerves merge with parasympathetic fibers that originate from S2-S4 to form the pelvic plexus (modified with permission from Takashi et al8). IMA indicates inferior mesenteric artery; B, hypogastric plexus; H, hypogastric nerves; R, rectum; U, urinary bladder.
Exposure. The small bowel is packed upward toward the patient's right upper quadrant, covered with a moist towel, and is kept in place by a malleable retractor that has been bent into a Ushape. The rectum is retracted anteriorly with the surgeon's left hand. The black arrow shows the ligated inferior mesenteric artery and the white arrow indicates the shadow of the superior hemorrhoidal vessels as they course downward along the rectal mesentery.
Developing the correct posterior plane. The St Mark retractor is positioned between the lateral peritoneum that still surrounds the upper rectum. The retractor held by the first assistant is positioned in an almost vertical or oblique fashion with the handle pointed toward the surgeon so that it fits in the space posterior to the fascia propria of the rectum.
Nerve identification. The retractor is rotated clockwise and positioned horizontally behind the rectum while anterior traction is applied to both the rectum and the retractor. This maneuver allows for separation of the rectum, mesorectum, and fascia propria from the posterior presacral fascia (arrow).
Posterior dissection. The retractor is pulled anteriorly and caudally, and the dissection of this "cotton-candy" avascular plane is performed using electrocautery. The nerves are visible and are left intact posteriolaterally. The arrow indicates the position of the sacral promontory.
The hypogastric trunks have the appearance of a wishbone.
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