The Lateral Ligament of the Rectum: A Myth Or a Reality?

Joel Leroy, MD FRCS, Federico Costantino, MD, James Wu, MD, Jacques Marescaux, MD FACS FRCS. IRCAD-EITS, Department of Digestive and Endocrine Surgery, University Hospital of Strasbourg, France

Introduction : The recent developments of 3-chip HD video laparoscopic cameras help the surgeon to have a better knowledge of the anatomy.

Materials and Methods: In this movie, we show what was formerly described as the lateral ligament of the rectum. The use of a sharp dissection of the lateral rectum in a male patient during a TME for a mid-rectal cancer demonstrates that the lateral densification of the mid-rectum is not a ligament but a network of vessels and branches of nerves coming from the inferior hypogastric plexus. Using a soft medial retraction of the mid-rectum and a lateral soft retraction of the pelvic fascia the different branches of the plexus are identified. These branches cross the space between the propria fascia of the rectum and the pelvic fascia. We can see how a strong medial retraction of the rectum causes an angulation of the plexus trunk with a risk of injury. The elective division of nerve branches away from the plexus trunk and the accessory mid-rectal vessels can now be performed thanks to a perfectly enhanced view of the pelvic anatomy.

Conclusion: In laparoscopic TME, the use of a HD video picture (Storz™ Image 1® HD camera) and atraumatic 4D retraction allows to better understand the anatomy, confirming that the lateral ligament does not exist.