Regarding the anatomy of total mesorectal excision (TME), the 'holy plane' of sharp dissection lies between which two fascial layers?

• A Between Denonvilliers' fascia anteriorly and Waldeyer's fascia posteriorly
• B Between the posterior peritoneum and the pre-sacral venous plexus
• C Between the longitudinal muscle of the rectum and the levator ani fascia
• D Between the visceral mesorectal fascia (fascia propria of the rectum) and the parietal endopelvic fascia, within the areolar tissue of the presacral space ✓

Explanation

The 'holy plane' of TME, described by Heald, is an avascular areolar tissue plane between the visceral mesorectal fascia (fascia propria of the rectum, enclosing the mesorectum) medially and the parietal endopelvic fascia laterally/posteriorly. Dissecting in this plane ensures complete mesorectal excision with an intact envelope and avoids injury to the hypogastric and pelvic autonomic nerves that lie on the parietal side. Denonvilliers' fascia is the anterior barrier between rectum and seminal vesicles/prostate.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.