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1 Department of Radiology, Cardiff and the Vale NHS Trust, University of Wales
College of Medicine, Heath Park, Cardiff CF14 4XW, Wales.
2 Present address: Department of Radiology, The Royal Marsden NHS Trust, Downs
Rd., Sutton, Surrey SM2 5PT, England.
3 Department of Imaging, The Middlesex Hospital, Mortimer St., London W1T 3AA,
England.
4 Cardiff School of Biosciences, Biomedical Bldg., Cardiff University, Cardiff
CF10 3US, Wales.
5 Department of Anatomy, The Royal College of Surgeons of England, 35/43
Lincoln's Inn Fields, London WC2A 3PE, England.
6 Department of Colorectal Surgery, The Pelican Centre, North Hampshire
Hospital, Aldermaston Rd., Basingstoke, Hampshire RG24 9NA, England.
OBJECTIVE. The surgical removal of a rectal carcinoma and the adjacent lymph nodes in an en bloc package lessens the risk of local recurrence due to residual tumor. Heightened awareness of good surgical techniques has created much interest in the anatomy involved in total mesorectal excision surgery, with particular focus on the fascial planes and nerve plexuses and their relationship to the surgical planes of excision. Clear preoperative depiction of these relationships is of value in determining tumor resectability. The aim of this study was to describe the radiologic appearance of these anatomic structures.
SUBJECTS AND METHODS. High-spatial-resolution T2-weighted MRI was performed using a 1.5-T system in cadaveric sections and in patients before they underwent total mesorectal excision surgery. Anatomic dissections of sagitally sectioned hemipelves were compared with MRIs obtained in vivo to establish criteria for visualization of the structures relevant to anterior resection of the rectum.
RESULTS. High-spatial-resolution MRI depicted a number of structures of importance in total mesorectal excision surgery. The mesorectal fascia, which forms the boundary of the surgical excision plane in total mesorectal excision, was identified, and the presacral fascia, peritoneal reflection, and Denonvilliers' fascia were also shown. Structures 1–2 mm in diameter were visualized because the contrast resolution afforded by T2-weighted fast spin-echo imaging permitted depiction of the inferior hypogastric nerve plexus and the fascial planes within the posterior pelvis.
CONCLUSION. Anatomic landmarks important to the performance of rectal cancer surgery, in particular the mesorectal fascia, may be defined on MRI and are of potential importance in the staging of tumors, assessing resectability, planning surgery, and selecting patients for preoperative neoadjuvant therapy.
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