Isolation of the Rectum and Mesorectum

Following the avascular plane identified after dividing the IMA, the plane between the mesorectum and the presacral fascia is entered. It has a typical cotton candy appearance that indicates the proper plane of dissection (Fig. 19). The dissection is continued down to the plane of the levator ani, sparing the hypogastric nerves, and the typical bilobated appear-

Fig. 16. To take down the splenic flexure, first a hole is made in the mesentery of the distal part of the transverse colon, just above the pancreatic tail (arrow 1); then the omentum is separated from the transverse colon (arrow 2)

ance of the mesorectum comes into view (Fig. 20). The rectum is isolated by sharp dissection, pushing anteriorly on the rectum. Once the rectum has been isolated posteriorly, the anterior peritoneal reflection is opened and the anterior aspect of the rectum is isolated from the vagina or seminal vesicles and prostate. If the cancer is located in the upper third of the rectum, the mesorectum is divided with the harmonic scalpel below the cancer, and the rectum is stapled with a green endo-GIA (Fig. 21). If the tumour is in the lower two thirds of the rectum, a total mesorectal excision is performed and the rectum is divided just above the dentate line.

Fig. 17. Hole in the mesentery of the transverse colon
Fig. 18. Take-down of the omentum from the transverse colon. Om, omentum; Co, colon, Sp, spleen
Fig. 19. The cotton candy avascular plane between the rectum and mesorectum and the presacral fascia are identified. AP, avascular plane; R, rectum; Hyp, left hypogastric nerve
Fig. 20. MR, mesorectum; Hyp, right hypogastric nerve

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