title: Whole mount microscopic sections reveal that Denonvilliers' fascia is one entity and adherent to the mesorectal fascia; implications for the anterior plane in total mesorectal excision?
abstract: BACKGROUND
  Excellent anatomical knowledge of the rectum and surrounding structures is essential for total mesorectal excision (TME). Denonviliers' fascia (DVF) has been frequently studied, though the optimal anterior plane in TME is still disputed. The relationship of the lateral edges of DVF to the autonomic nerves and mesorectal fascia is unclear. We studied whole mout microscopic sections of en-bloc cadaveric pelvic exenteration and describe implications for TME.
  
  
  METHODS
  Four donated human adult cadaveric specimens (two males, two females) were obtained from the Leeds GIFT Research Tissue Programme. Paraffin-embedded mega blocks were produced and serially sectioned at 50 and 250 μm intervals. Sections were stained with haematoxylin & eosin, Masson's trichrome and Millers' elastin. Additionally, a series of eleven human fetal specimens (embryonic age of 9-20 weeks) were studied.
  
  
  RESULTS
  DVF consisted of multiple fascial condensations of collagen and smooth muscle fibres and was indistinguishable from the anterior mesorectal fascia and the prostatic fascia or posterior vaginal wall. The lateral edges of DVF appeared fan-shaped and the most posterior part was continuous with the mesorectal fascia. Fasciae were not identified in fetal specimens.
  
  
  CONCLUSIONS
  DVF is adherent to and continuous with the mesorectal fascia. Optimal surgical dissection during TME should be carried out anterior to DVF to ensure radical removal, particularly for anterior tumours. Autonomic nerves are at risk, but can be preserved by closely following the mesorectal fascia along the anterolateral mesorectum. The lack of evident fasciae in fetal specimens suggested that these might be formed in later developmental stages.
authors.affiliation: Department of Anatomy and Embryology, Leiden University Medical Center, P.O. Box 9600, 2300 ZC Leiden, The Netherlands; Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom.
authors.forename: A C
authors.initials: AC
authors.lastname: Kraima
authors.affiliation: Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom.
authors.forename: N P
authors.initials: NP
authors.lastname: West
authors.affiliation: Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom.
authors.forename: D
authors.initials: D
authors.lastname: Treanor
authors.affiliation: Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom.
authors.forename: D R
authors.initials: DR
authors.lastname: Magee
authors.affiliation: Department of Surgery, Catherina Hospital Eindhoven, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands.
authors.forename: H J
authors.initials: HJ
authors.lastname: Rutten
authors.affiliation: Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom.
authors.forename: P
authors.initials: P
authors.lastname: Quirke
authors.affiliation: Department of Anatomy and Embryology, Leiden University Medical Center, P.O. Box 9600, 2300 ZC Leiden, The Netherlands.
authors.forename: M C
authors.initials: MC
authors.lastname: DeRuiter
authors.affiliation: Department of Surgery, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands. Electronic address: c.j.h.van_de_velde@lumc.nl.
authors.forename: C J H
authors.initials: CJ
authors.lastname: van de Velde
mesh_terms: D037881:Aborted Fetus; D000328:Adult; D002102:Cadaver; D003094:Collagen; D005205:Fascia / Q000033:anatomy & histology* / Q000166:cytology / Q000196:embryology; D005260:Female; D016591:Histocytological Preparation Techniques; D006801:Humans; D008297:Male; D008853:Microscopy; D009130:Muscle, Smooth; D012004:Rectal Neoplasms / Q000601:surgery*; D012007:Rectum / Q000033:anatomy & histology* / Q000166:cytology / Q000196:embryology
chemical_list: D003094:Collagen
keywords: Autonomic nerves; Denonvilliers' fascia; Mesorectal fascia; Rectal cancer; Total mesorectal excision