The rectum is the final straight portion of the large intestine in humans and some other The rectum is a part of the lower gastrointestinal tract. The rectum is a continuation of the sigmoid colon, and connects to the anus. The rectum follows the shape. In regards to the upper rectum, Benzoni et al found that the relation . for that we add a levator ani insertion as a parameter for lower rectal classification. Rectal washouts are performed to decompress the lower intestine and deflate the gastrointestinal contrast study; Upper gastrointestinal contrast study; Rectal biopsy Orders should include specific size, and length of catheter to be inserted.
and Insertion Upper Lower Rectum
The retrorectal space is located between the fascia propria of the rectum anteriorly, presacral fascia posteriorly, rectosacral ligament inferiorly, and lateral rectal ligaments laterally.
The retrorectal space is continuous with the retroperitoneum superiorly. Treatment of rectal cancer depends on its location in the rectum and extent of involvement of rectal wall and regional lymph nodes LN by primary tumor. The level of the tumor in the rectum can be determined clinically in relation to the anorectal ring and endoscopically in relation to the rectal valves.
The anorectal ring is felt on rectal examination as a muscular band that corresponds to the proximal shelf of the anal canal[ 5 ]. Cancers of the intraperitoneal rectum upper third behave like cancers of the colon with regards to recurrence patterns and prognosis but cancers of the extraperitoneal rectum constitute the rectum from the oncologic standpoint. Cancers of the upper and proximal part of the middle rectum are treated with an anterior resection and a straight colorectal anastomosis.
Cancers of the distal middle and lower rectum are treated with abdominoperineal resection APR and end colostomy, sphincter sparing procedure or intersphincteric resection.
For distal rectal cancer, sphincter sparing is possible if the lower edge of the tumor is at least 3 cm from the anorectal ring so as to allow a 2 cm distal magin. A 2 cm is considered adequate since any distal intramural spread is almost always within 1. The coloanal anastomosis may be performed hand sewn transanally at the dendate line after excision of the mucosa from the dentate line to the anorectal junction or stapled at the anorectal junction.
With intersphincteric resection, dissection is performed in the intersphincteric plane starting at the intersphincteric groove with partial or complete removal of the internal sphincter and a hand-sewn anastomosis performed transanally. The posterior approach is an established procedure but not frequently practiced because of associated morbidity and the advent of newer, less invasive and refined transanal procedures, i.
The pelvic fascia is associated with the pelvic wall and viscera and fills spaces between pelvic viscera and is continuous at the pelvic brim with the extraperitoneal abdominal fascia. In the abdomen, the visceral fascia runs under the peritoneum anterior to the aorta and cava, extends into the pelvis and envelops the rectum and mesorectum as the visceral endopelvic fascia.
The parietal fascia runs posterior to the aorta and cava and extends into the pelvis along the entire pelvic wall as the parietal endopelvic fascia. In the true pelvis posteriorly, there is a potenial space between the two fasciae filled with loose areolar tissue and devoid of vessels and nerves[ 14 ].
Below the peritoneal reflection the circular continuity of the visceral endopelvic fascia is interrupted laterally by the presence of the lateral rectal ligaments and pelvic nerve fibers that arise from S3 and S4 foramina. At the distal side of the lateral ligaments is a free space that extends between the endopelvic fasciae to the levator ani muscles[ 14 ].
Others divide the pelvic fascial arrangement into thin connective tissue layers covering surfaces of organs and connective tissue condensations of varying thickness that separate compartments.
The parietal endopelvic fascia is described as a multilayered fascial tissue condensation that contain the hypogastric nerves together with the pelvic splanchnic nerves PSN [ 15 - 17 ].
Posteriorly, the fascia and embedded nerves can be easily separated as a compact structure from the anterior surface of the sacrum to uncover another thin fascia in front of the sacrum[ 16 ]. The fascia fuses with mesorectal fascia in the mid line posteriorly at the level of S4 creating a connective tissue bridge that can be quite dense and corresponds to the rectosacral ligament[ 17 , 18 ]. The parietal endopelvic fascia exhibits an inner and outer lamella[ 15 , 19 ].
The continuity of the 2 lamellae varies, as does the thickness of tissue between them. The inner lamella envelops the mesorectal fascia posteriorly and laterally, thus confining the retrorectal space. Laterally the inner lamella and mesorectal fascia fuse thus the retrorectal space does not extend anterolateral[ 14 , 16 ].
The outer lamella extends between the iliac vessels on both sides and borders the presacral fascia posteriorly creating another plane that could be mistaken for the retrorectal space[ 19 ]. Laterally, the outer lamella cannot be delineated as distinctly as posteriorly since it is pierced by the PSN and blood vessels.
The PSN emerging from the sacral roots and the hypogastric nerves originating from the superior hypogastric plexus, join the inferior pelvic plexus within the parietal pelvic fascia from and send several fine branches that diverge in a fan-like pattern towards the distal ureter, vas deferens, seminal vesicles, urinary bladder, prostate and the rectum[ 16 ].
The autonomic nerve fibers innervating the rectum pierce the lateral aspect of the fascia and enter the rectal wall T-junction [ 16 , 20 ]. On the posterior abdominal wall, a connective tissue sheath associated with the kidneys, ureters and genital vessels urogenital fascia descends into the pelvis below the promontory of the sacrum for few cm in front of S1, rarely S2, where it ends anterior to presacral fascia sometimes as a conspicuous border arched between the hypogastric nerves[ 21 , 22 ].
The urogenital fascia invests the ureters always lateral to the hypogastric nerves on the pelvic wall under the peritoneum of the pararectal fossa[ 21 , 22 ]. In the mid line posteriorly it descends in front of the sacrum, coccyx, the middle sacral artery and presacral veins, fuses with the periosteum of the sacrum and coccyx and covers the piriformis muscle.
At the sacral foramina it ensheathes the nervi erigentes. The presacral fascia and the interface with the backside of the parietal pelvic fascia mimic the retrorectal space and the posterior aspect of the mesorectum[ 16 ]. The lateral margin of the fascia is connected with loose tissue to the sheath around the PSN[ 25 ]. At the level of S3-S4, the fascia sends extensions, the rectosacral ligament posterior rectal ligament , in an anterior inferior direction or may become adherent to the fascia propria of the rectum cm above the anorectal ring[ 16 , 18 , 21 , 25 - 27 ].
It separates the retrorectal space from the subfascial space[ 21 ]. The composition of the rectosacral ligament is not well studied. Although few vessels and nerves are identified in cadavers, the rectosacral fascia does not contain any significant vessels.
Distal to the rectosacral ligament between the fascia propria of the rectum and presacral fascia, lays the horizontal last cm of the rectum[ 21 ].
The presacral fascia in that area becomes thinner and fascia propria thicker and may be composed of two layers. Fascia propria is an extension of the abdominal retroperitoneal visceral fascia or represents an upward capsular extension from the superior fascia of the pelvic floor that reflects off the pelvic sidewalls to become continuous with the subperitoneal loose connective tissues of the pelvis covering the pelvic floor musculature[ 14 , 28 ].
Thomas Jonnesco[ 29 ] was the first to describe the perirectal fascia as a strong, nonyielding, no more than mm thick serofibrous sheath that encapsulated the rectum, fat, and the superior hemorrhoidal vessels and its branches and tributaries. The sheath extended cranially around the rectum as far as the upper limit of the ampulla and continued into the retroperitoneum in a plane posterior to the inferior mesenteric vessels.
Caudally it adhered to the presacral fascia opposite the S4 as the rectosacral ligament. Most distally as the mesorectum thinned out to the point where the fascia propria adhered intimately to the longitudinal muscle layer of the rectum at the anorectal junction. Anteriorly the fascia did not extend as high but rather merged with the peritoneum reflection rectovesical or rectovaginal pouch.
It appeared thicker posteriorly than anteriorly. Anteriorly the fascia could not be demonstrated as a separate layer. The mesentery of the rectum, i. The mesorectum encases the rectum as a thick cushion mainly posteriorly and laterally. Posteriorly it has a characteristic bilobed appearance[ 21 , 27 , 28 , 30 ]. Inferiorly it thins out and tapers down to the anorectal junction. The mesorectum is enclosed with the perirectal fascia[ 27 ].
The SHA is a direct continuation of the inferior mesenteric artery IMA that arises from the anterior surface of the aorta at the undersurface of the third part of the duodenum. It descends in the mesosigmoid colon to the level of S3 where it bifurcates into right and left branches then further divides into anterior and posterior branches.
These branches penetrate rectal wall into the submucosa and descend in that plane to the level of columns of Morgagni. The MHA shows great variability in its origin, presence, size and number. The artery may arise from the anterior division of the internal iliac artery IIA or have an anomalous origin from the inferior vesicle, inferior gluteal, or internal pudendal artery[ 26 , 31 , 32 ]. When present bilaterally the origin is not always identical on both sides[ 32 ].
The artery is long and tortuous, passes down and medially below the peritoneal reflection on top the levator muscle, pierces the pelvic plexus during its course, enters the anterolateral aspect of the rectum between the superior and inferior rectal branches of the pelvic plexus, and gives several branches to the muscular coat of the lower rectum and submucosal plexus[ 25 , 32 , 33 ]. The size of the artery is variable and the point of insertion in rectum is cm from the anus[ 25 , 32 , 33 ].
Immediately at the insertion, it is anterolateral to the rectum related anteriorly to the prostate and seminal vesicle or upper vagina. The branching PSN arise posterior to the origin of the MHA and run in an anteromedial direction and reach the rectum at a similar height above the pelvic floor as the MHA.
The MHA is closer to the pelvic floor and crosses the mesorectum independent of any structure. Since the presence of the MHA is variable and mostly is absent and its blood goes mainly to the muscle of the rectum and mostly to the prostate, its contribution to the viability of the rectum is considered insignificant[ 32 ].
The IHA is a branch of the anterior division of the internal pudendal artery that is a branch of the IIA and is mainly extrapelvic. The endopelvic fascia invests it as it passes out of the pelvis below the piriformis muscle through the greater sciatic foramina. The vessel crosses the ischioanal fossa, traverses the EAS to reach the submucosa of the anal canal and ascends in that plane.
Its main significance is to supply the sphincter complex[ 31 ]. The venous drainage of the rectum is partly hepatic and partly systemic: Information on the middle rectal vein is sparse but its rate of appearance is similar to that of the artery and drains into the internal iliac vein[ 26 ]. The lymphatic drainage of the rectum follows the vascular supply. The mesenteric LN stations include central intermediate LN from origin of last sigmoid artery to the origin of the left colic artery and central LN from the left colic artery to origin of IMA.
Drainage into paracolic LN is unusual. The lower rectum however has a cloacal origin and its lymphatic channels are part of the pedicles draining to lateral LN[ 38 ].
From the middle and lower rectum lymphatic drainage is mainly up wards along SHA and lateral to pelvic LN; downward spread is uncommon. The number of LN found in the mesorectum ranges from depending on the method of preparation of specimens[ 39 , 40 ]. The majority of the mesorectal LN are located posteriorly with few on each side. There are relatively few LN in the mesorectum of the lower rectum. Rectal cancer can spread outside the rectal wall in a continuous fashion or as discontinuous tumor extensions or deposits into the mesorectum up to 5 cm distal to the tumor margin[ 30 , 41 - 46 ].
Discrete nodules found in the extramural adipose tissue may represent LN replaced by tumor. Involvement of circumferential margin by tumor is the main cause of local recurrence after rectal cancer surgery[ 46 , 48 ]. Circumferential margin is the nonperitonealized surface of the rectal specimen created by mesorectal dissection at surgery.
Circumferential margin is considered positive if the distance between the deepest extent of the tumor and closest surgical clearance around the tumor, i. CRM is an independent predictor of outcome in patients with rectal cancer[ 49 - 51 ]. However, other investigators have considered 2 mm as the cutoff point.
Although the ideal CRM has not been universally accepted, resection with as wide of a CRM margin as possible must be accomplished. Circumferential margin for distal tumors is problematic since the mesorectum encases the rectum as a thick cushion mainly posteriorly and laterally proximally and inferiorly it thins out and tapers down to the anorectal junction making it impossible to obtain a 2 cm cuff of marginal tissue circumferentially.
Lymph node involvement is the most important prognostic factor and a major determining factor whether a patient is candidate for adjuvant therapy. The overall survival is determined by number of LN involved. Violation of the perirectal fascia and transmesorectal dissection is associated with high local recurrence rate[ 24 ]. Local recurrence after rectal cancer surgery is associated with incomplete excision of circumferential margin, presence of isolated deposits in the mesorectum and tumor in regional LN and incomplete LN clearance[ 43 , 53 , 54 ].
To eradicate the primary rectal tumor and control regional disease, the rectum, first area of LN drainage mesorectal LN and surrounding tissue must be completely excised while maintaining an intact fascial envelope around the rectum and protecting and preserving surrounding structures, including the ureters, gonado iliac vessels, sacral venous plexus and pelvic autonomic nerves.
To achieve such a radical resection, thorough knowledge of the pelvic structures and fascial planes is paramount. Total mesorectal excision TME , originally described by Abel[ 55 ] in and later adopted by other surgeon, implies removal of the entire mesorectum including portion distal to the tumor within its enveloping fascia as an intact unit[ 27 , 30 , 45 , 53 , 56 , 57 ]. For mid- to low-rectal cancer, LAR with TME has been demonstrated to minimize locoregional recurrences[ 30 , 56 - 61 ].
With, APR, the operative plane follows the mesorectum to the muscular tube of the rectal wall stopping at the puborectalis sling. The anus is removed by perineal approach and dissection is performed outside the edge of the EAS and leaving the ischioanal fat.
With ELAPR, abdominal dissection stops at the rectosacral ligament and the anus, coccyx and most of the levator muscle are removed by perineal approach[ 19 ].
Lateral LN dissection may be performed with TME as part of an extraregional dissection lateral clearance for lower rectal cancer but the reported outcome is no different than that with TME[ 40 , 57 , 65 ]. Sharp dissection facilitates identification and preservation of the autonomic nerves, allows adequate hemostasis and avoids tearing of the fascial envelope around the mesorectum.
The inferior mesenteric vessels are divided and retracted with the rectosigmoid junction anteriorly, and extrafascial dissection is commenced. Identification and preservation of the hypogastric nerves is discussed later. Dissection is performed between the fascia propria of the rectum and the presacral fascia posteriorly in the retrorectal space that contains loose areolar tissue and is devoid of vessels and nerves and pelvic wall laterally.
Sharp dissection is performed under vision down to the rectosacral ligament posteriorly and lateral rectal ligaments laterally. The rectosacral ligament is divided so as to gain access and mobilize the last cm of the rectum and the anorectal junction[ 21 ]. The mesorectal fascia is not detached from the parietal pelvic fascia and the levator muscle is not separated from the sacrococcygeal junction[ 19 ]. The sacrococcygeal junction is disconnected through the perineal phase to detach the coccyx that is the insertion of the midline raphe of the levator muscle.
The parietal pelvic fascia is divided in the midline through the disconnected sacrococcygeal junction and the levator is divided laterally at both sides[ 19 ]. The anterior plane of dissection to separate the rectum from the prostate gland and vagina is controversial and is discussed later. However, dissection is performed inside the pelvic autonomic nerves down to the top of the anorectal junction where the rectum has little mesorectal fat and appears as a bare tube[ 25 , 31 , 32 ].
Laterally the lateral rectal ligaments are divided detailed discussion to follow. Damage to the accessory branches rather than the main of the MHA may occur MHA during division of the lateral ligaments. The point of insertion of the MHA into the rectum is cm from the anus. Damage to the main MHA occurs during dissection of the rectum anteriorly and anterolaterally on the pelvic floor, when it is being dissected off the seminal vesicle and prostate gland or vagina vide infra.
Down ward spread is uncommon. Lateral spread to lateral pelvic LN is more clinically important in tumors with lower margin below 5 cm from the dendate line and the incidence becomes significantly higher with lower margin below 3 cm above the dendate line[ 14 , 36 , 40 ].
With extended resection, i. The number of LN removed with extrafascial mesorectal excision depends on level of the tumor. Canessa et al[ 39 ] in a study in formalin-fixed cadavers noted that the mean number of LN was 8.
The LN ranged in size from 2 to 10 mm. It is shown that LN must be examined to accurately determine node negativity and any less limits the predictive value of the pathologic examination[ 68 , 69 ]. The role of extended resections is controversial since randomized studies on survival benefits from the procedure are still missing.
Opponents of lateral pelvic lymphadenectomy question the benefit of the procedure since only small percentage of patients have lateral LN involvement. The operative time with extended resections is prolonged and morbidity is high. In addition some studies have shown lateral pelvic lymphadenectomy is not necessary in terms of curability for patients with advanced lower rectal cancer who undergo preoperative radiotherapy[ 70 ]. Several other studies reported the outcome with TME to be no different from the data on extended lymphadenectomy.
Hence many surgeons in the Western World, Europe, to some extent in Japan favored the mesorectal excision only. The number of regional LN removed varies with location of the tumor and surgical technique. Considerable anatomical, surgical and physiological importance has been attached to the lateral ligaments of the rectum. Anatomists consider the ligaments as fascial bridge that act as a pathway for nerve fibers, small vessels and lymphatics from and to the rectum[ 28 , 50 ].
Surgeons recognize the ligaments as extraperitoneal thick bundle of dense connective tissue that provide pathway to lymphatic channels and contribute to the support of the rectum and in which the MHA and plexuses are embedded[ 71 , 72 ].
Proper handling of the ligaments during surgery has an important bearing on colonic, anorectal, sexual and urinary function as well as the prevention of local recurrence of the cancer[ 56 , 61 , 73 - 75 ]. To gain access to the depths of the lateral pelvis, full mobilization of the mid-lower rectum requires identification of the lateral rectal ligaments that are then clamped, divided and ligated to avoid intra- and post-operative hemorrhage since the MHA are large and do not respond to electro cautery[ 61 ].
Despite this clear-cut description and straightforward handling of the ligaments, there are many variations and contradictory accounts reported in the literature as to the nature, anatomy, and contents of the lateral rectal ligaments. Thomas Jonnesco[ 29 ] was the first to describe the lateral rectal ligaments as a continuation of the parietal fascia predominantly surrounding the origin of MHA from the IIA.
Goligher et al[ 61 ] described the ligaments, as seen from above, as having a triangular shape with the base on the pelvic sidewall and the apex joining the side of the rectum. Hojo[ 77 ] considered the ligaments as rectal structures that should be removed completely. Heald in original and subsequent articles s [ 30 , 45 ] and Reynolds et al[ 78 ] did not mention the lateral ligaments in their description of TME.
Enker[ 75 ] recognized the ligament as an important landmark during autonomic nerve sparing sidewall dissection for rectal cancer. Takahashi et al[ 14 ] described the ligament as a bundle of dense connective tissue in the pararectal space with variable thickness and length that extends from the peripheral part of the IIA to the sidewall of the midrectum between the peritoneum and levator muscle.
The hypogastric nerve fibers reach the center of the ligament where they unite with the PSN as they emerge from the sacral roots and form the inferior hypogastric nerve plexus inside the ligament[ 14 ].
Use only Sodium Chloride 0. Notify the surgical team if two successive washouts fail to achieve abdominal decompression.
Lubricant Use only water based lubricant. Procedure may be repeated twice if return is not clear If there is 0. Contact medical staff if unsure Do not pull back on syringe to aspirate, allow the saline to run out naturally. Sometimes manipulating the catheter in and out a few centimetres gently and massaging the abdomen may encourage fluid returns to be expelled.
Washout result Volume, colour, consistency and type of substance; e. In the case of retention of instilled solution a. The control unit allows the younger children to participate in their own care and the older children to carry their washout independently. The washout is usually performed with the child sitting on the toilet. Increased volumes of washout are occasionally required for neonates that are unable to be adequately decompressed.
Members of the treating surgical team registrar, fellow, consultant may use their clinical discretion to increase the washout volume used and the size of the catheters. Diagnosing Neonatal Intestinal Obstruction. Rapid Diagnosis of Intestinal Obstruction. Retrieved March 30, from Emedicine: Building Knowledge to Advance Practice. Silva N, Young J. Retrieved May 4, from University of Michigan section of Pediatric surgery. You will be observed closely until most of the effects of the medication have worn off.
Your throat might be a little sore, and you might feel temporarily bloated due to the air introduced into your stomach during the test. You will be able to eat after you leave unless your doctor instructs you otherwise. Your doctor generally can tell you your test results on the day of the procedure; however, the results of some tests might take several days.
You should arrange for someone to accompany you home because the sedatives may affect your judgment and reflexes for the rest of the day. Colonoscopy is well-tolerated and rarely causes much pain. You might feel pressure, bloating or cramping during the procedure. You will likely receive a sedative to help you relax and better tolerate any discomfort. You will lie on your side or back while your doctor slowly advances a flexible tube colonoscope through your large intestine to examine the lining.
The whole procedure itself usually takes 45 to 60 minutes, although you should plan on two to three hours for waiting, preparation and recovery. If you were given sedatives during the procedure, someone must drive you home and stay with you. Even if you feel alert after the procedure, your judgment and reflexes could be slow for the rest of the day. You may have some cramping or bloating because of the air introduced into the colon during the examination.
This should disappear quickly when you pass gas.
Rectal prolapse occurs when the rectum turns itself inside out and comes out through the anus. Pain and discomfort felt deep within the lower abdomen; Blood and mucus from the anus; The feeling of Back to top This involves inserting slender instruments through a number of small incisions in the abdomen. 7 Lie on your side with your lower leg straightened out and your upper leg bent forward toward (If not inserted past this sphincter, the suppository may pop out.) . Surgery is usually the main treatment for rectal cancer, although radiation Some stage I rectal cancers and most stage II or III cancers in the upper part of the with the colon) can be removed by low anterior resection (LAR).