Surgeons' assessment of internal anal sphincter nerve supply during TaTME - inbetween expectations and reality

Werner Kneist, Laura Hanke, Daniel W Kauff, Hauke Lang, Werner Kneist, Laura Hanke, Daniel W Kauff, Hauke Lang

Abstract

Background: Intraoperative identification of nerve fibers heading from the inferior rectal plexus (IRP) to the internal anal sphincter (IAS) is challenging. The transanal total mesorectal excision (TaTME) is said to better preserve pelvic autonomic nerves. The aim of this study was to investigate the nerve identification rates during TaTME by transanal visual and electrophysiological assessment.

Material and methods: A total of 52 patients underwent TaTME for malignant conditions. The IRP with its posterior branches to the IAS and the pelvic splanchnic nerves (PSN) were visually assessed in 20 patients (v-TaTME). Electrophysiological nerve identification was performed in 32 patients using electric stimulation under processed electromyography of IAS (e-TaTME).

Results: The indication profile for TaTME was comparable between the v-TaTME and the e-TaTME group. The identification of IRP was more meaningful under electrophysiological assessment than under visual assessment for the left pelvic side (81% vs. 45%, p = 0.008) as well as the right pelvic side (78% vs. 45%, p = 0.016). The identification rates for PSN did not significantly differ between both groups, respectively (81% vs. 75%, p = 0.420 and 84% vs. 70%, p = 0.187).

Conclusions: The transanal approach facilitated visual identification of IAS nerve supply. In combination with electrophysiological nerve assessment the identification rate almost doubled. For further insights functional data are needed.

Keywords: Rectal cancer; TaTME; autonomic nerves; total mesorectal excision; transanal surgery.

Figures

Figure 1.
Figure 1.
Vertical organized inferior hypogastric plexus (star) with superior, central and inferior branches and its sympathetic/parasympathetic sources. Hypogastric nerve marked with arrow. Cadaver dissection via abdominal surgical approach with Prof. Dr. med. M. Herrmann (Institute of Anatomy, University of Ulm)
Figure 2.
Figure 2.
Visually assessed tiny nerve fibers heading to the internal anal sphincter (arrows)
Figure 3.
Figure 3.
Pelvic splanchnic nerves located posterolaterally running along the right pelvic side wall to intermingle with the inferior hypogastric plexus.
Figure 4.
Figure 4.
Electrophysiologically assessed posterior branches of the inferior rectal plexus (arrows). Former exidental opening of levators fascia (star)

References

    1. Baader B, Herrmann M. Topography of the pelvic autonomic nervous system and its potential impact on surgical intervention in the pelvis. Clin Anat. 2003;16:119–30.
    1. He JH, Wang Q, Cai QP, Dang RS, Jiang EP, Huang HL, et al. Quantitative anatomical study of male pelvic autonomic plexus and its clinical potential in rectal resection. Surg Radiol Anat. 2010;32:783–90.
    1. Hieda K, Cho KH, Arakawa T, Fujimiya M, Murakami G, Matsubara A. Nerves in the intersphincteric space of the human anal canal with special reference to their continuation to the enteric nerve plexus of the rectum. Clin Anat. 2013;26:843–54.
    1. Kinugasa Y, Arakawa T, Murakami G, Fujimiya M, Sugihara K. Nerve supply to the internal anal sphincter differs from that to the distal rectum: An immunohistochemical study of cadavers. Int J Colorectal Dis. 2014;29:429–36.
    1. Ishiyama G, Hinata N, Kinugasa Y, Murakami G, Fujimiya M. Nerves supplying the internal anal sphincter: an immunohistochemical study using donated elderly cadavers. Surg Radiol Anat. 2014;36:1033–42.
    1. Moszkowicz D, Peschaud F, Bessede T, Benoit G, Alsaid B. Internal anal sphincter parasympathetic-nitrergic and sympathetic-adrenergic innervation: A 3-dimensional morphological and functional analysis. Dis Colon Rectum. 2012;55:473–81.
    1. Runkel N, Reiser H. Nerve-oriented mesorectal excision (NOME): Autonomic nerves as landmarks for laparoscopic rectal resection. Int J Colorectal Dis. 2013;28:1367–75.
    1. Kneist W, Kauff DW, Lang H. Laparoscopic neuromapping in pelvic surgery: Scopes of application. Surg Innov. 2014;21:213–20.
    1. Fang JF, Wei B, Zheng ZH, Chen TF, Huang Y, Huang JL, et al. Effect of intra-operative autonomic nerve stimulation on pelvic nerve preservation during radical laparoscopic proctectomy. Colorectal Dis. 2015;17:O268–76.
    1. Grade M, Beham AW, Schüler P, Kneist W, Ghadimi BM. Pelvic intraoperative neuromonitoring during robotic-assisted low anterior resection for rectal cancer. J Robot Surg. 2016;10:157–60.
    1. de Lacy AM, Rattner DW, Adelsdorfer C, Tasende MM, Fernández M, Delgado S, et al. Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: “down-to-up” total mesorectal excision (TME)–short-term outcomes in the first 20 cases. Surg Endosc. 2013;27:3165–72.
    1. Kauff DW, Wachter N, Bettzieche R, Lang H, Kneist W. Electrophysiology-based quality assurance of nerve-sparing in laparoscopic rectal cancer surgery: Is it worth the effort? Surg Endosc. 2016 doi: 10.1007/s00464-016-4787-z.
    1. Motson RW, Whiteford MH, Hompes R, Albert M, Miles WF, Expert Group. Current status of trans-anal total mesorectal excision (TaTME) following the Second International Consensus Conference. Colorectal Dis. 2016;18:13–18.
    1. Kneist W, Rink AD, Kauff DW, Konerding MA, Lang H. Topography of the extrinsic internal anal sphincter nerve supply during laparoscopic-assisted TAMIS TME: Five key zones of risk from the surgeons' view. Int J Colorectal Dis. 2015;30:71–8.
    1. Aigner F, Hörmann R, Fritsch H, Pratschke J, D'Hoore A, Brenner E, et al. Anatomical considerations for transanal minimal-invasive surgery: The caudal to cephalic approach. Colorectal Dis. 2015;17:O47–53.
    1. Bertrand MM, Colombo PE, Alsaid B, Prudhomme M, Rouanet P. Transanal endoscopic proctectomy and nerve injury risk: Bottom to top surgical anatomy, key points. Dis Colon Rectum. 2014;57:1145–8.
    1. Lacy AM, Tasende MM, Delgado S, Fernandez-Hevia M, Jimenez M, De Lacy B, et al. Transanal total mesorectal excision for rectal cancer: Outcomes after 140 patients. J Am Coll Surg. 2015;221:415–23.
    1. Chouillard E, Regnier A, Vitte RL, Bonnet BV, Greco V, Chahine E, et al. Transanal NOTES total mesorectal excision (TME) in patients with rectal cancer: Is anatomy better preserved? Tech Coloproctol. 2016 doi: 10.1007/s10151-016-1449-z.
    1. Kneist W, Wachter N, Paschold M, Kauff DW, Rink AD, Lang H. Midterm functional results of taTME with neuromapping for low rectal cancer. Tech Coloproctol. 2016;20:41–9.
    1. McLemore EC, Harnsberger CR, Broderick RC, Leland H, Sylla P, Coker AM, et al. Transanal total mesorectal excision (taTME) for rectal cancer: a training pathway. Surg Endosc. 2015 doi: 10.1007/s00464-015-4680-1.
    1. Penna M, Hompes R, Mackenzie H, Carter F, Francis NK. First international training and assessment consensus workshop on transanal total mesorectal excision (taTME). Tech Coloproctol. 2016;20:343–52.
    1. Atallah S, Albert M, Monson JR. Critical concepts and important anatomic landmarks encountered during transanal total mesorectal excision (taTME): toward the mastery of a new operation for rectal cancer surgery. Tech Coloproctol. 2016 doi: 10.1007/s10151-016-1475-x.

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