Pelvic nerves preservation during rectal surgery

Surgery for rectal prolapse or enterocele usually by a laparoscopicapproach comprises Douglas pouch removal and rectopexy to thepromontory. The pelvic autonomic nerves are rarely injured duringthe procedure because no posterior nor lateral dissection has to bedone.In the same way, surgery for Inflammatory Bowel Diseases, ieCrohn’s disease and ulcerative colitis, is not at risk for the pelvicnerves because the rectum is resected without the mesorectum.Electrocautery or thermofusion is directly applied against the rectalmuscular wall, quite far from the superior hypogastric sympatheticplexus, the hypogastric nerves and the inferior hypogastric plexus.For rectal cancer and particularly lower rectal cancer, the mesorectumshould be excised to insure adequate nodes clearance. Thegood plane emphasized by Heald and already mentioned by Gerota,is situated between the pelvic fascia and the rectal sheet. The planeis easily entered by laparoscopy, so that the superior hypogastricplexus and the hypogastric nerves are not threatened duringmesorectal excision of the upper and middle third of the rectum.The risk of pelvic nerves lesions is maximal in the lower pelvis,particularly in males, when the efferent branches coming from theinferior hypogastric plexus run toward the seminal vesicles andprostate (so called Walsh plexus).Anatomic knowledge, surgeon’s experience, new tools designs andlaparoscopic approach supposing magnification of the good planes,participate in reducing the risk of pelvic nerves lesions during rectalsurgery.