The female pelvic floor features a complex anatomical structure involving the urinary, reproductive, and digestive systems. The evolution of anatomical understanding has profoundly influenced the development of colorectal surgery. With advances in the three-level vaginal support theory, refined anatomical studies, and innovations in surgical techniques, significant progress has been made in the treatment strategies for female pelvic floor disorders, particularly those related to pelvic floor dysfunction in colorectal surgery. The key anatomical structures of the female pelvic floor include the female pelvic floor, focusing on key structures such as the levator ani muscle complex, hiatus of the pelvic diaphragm, arcus tendineus fasciae pelvis, and neurovascular bundles. Pelvic floor reconstruction surgery aims to restore both anatomy and function, and the choice of surgical methods emphasizes individualization. Current surgical techniques are developing towards minimally invasive directions, with laparoscopy, robot-assisted, and transvaginal natural orifice surgery becoming increasingly popular. At the same time, it emphasizes maximizing the protection of colorectal function through a multidisciplinary collaboration model.
The treatment paradigm for rectal cancer is undergoing a fundamental change from radical resection to functional preservation. While traditional total mesorectal excision reduces local recurrence rates, it often comes at the cost of compromised anal and functional quality of life. In the molecular subtype-guided precision therapy, particularly with the application of neoadjuvant chemoradiotherapy combined with immunotherapy, the pathological complete response rate has significantly improved.This offers the possibility for patients to avoid surgery after achieving a complete response. Clinical practice of the watch-and-wait strategy has shown that patients achieving a clinical complete response have comparable long-term survival outcomes to those undergoing radical surgery, while maximally preserving organ function and quality of life. However, challenges including insufficient accuracy in response assessment, ambiguous patient selection criteria, and the need for optimization of long-term follow-up systems still remain. Looking ahead, rectal cancer management must integrate multiple objectives including tumor control, organ preservation, and quality of life. This evolution represents not only technological advancement but also a vital embodiment of patient-centered medical humanism.
Surgical treatment of colon cancer has evolved in parallel with the progress of modern surgery. From the early practices of staged resection, through the dissection of regional lymph nodes and considerable length of colon, to the introduction of complete mesocolic excision and histologic recognition of the visceral fascia, and onward to the current emphasis on organ-function preservation, history shows that the “standard” operation for colon cancer has differed in every era of surgical innovation. In recent years, regional lymph node dissection, surgical procedures, and even methods of specimen extraction have undergone significant evolution. Relying on a unified surgical technique as the standardized procedure for colon cancer is no longer sufficient to meet the demands of precision medicine. With the development of the study of colon cancer, the standardized procedures of different eras have gradually been distilled into the fundamental surgical standards for colon cancer, such as regional lymph node dissection, the 10-cm rule, and mesocolic excision, which require long-term adherence.
Based on a series of research findings on the meticulous anatomy related to fascia, mesentery and interstitial spaces in recent years, combined with clinical practice experience, an anatomical framework for “function-sparing total mesorectal excision (TME)” is proposed: (1) The left primitive retroperitoneum is the anatomical substrate of the “wrong-plane” phenomenon during left mesocolic mobilization; an initial lateral approach that exposes the left ureter followed by a central dissection minimizes the convergence distance. (2) Metastasis to No.253 lymph nodes is relatively rare, but the prognosis is extremely poor in patients with such metastasis; selective intrasheath dissection of the inferior mesenteric artery in patients with locally advanced disease can achieve both adequate lymph node dissection and preservation of the inferior mesenteric plexus. (3) Revisiting the classical “two-concentric-rings” model, the rectosacral fascia was found to split laterally and fuse densely with the pelvic plexus. The optimal circumferential dissection sequence is therefore posterior-anterior-lateral: posteriorly, the rectosacral fascia is arcuately incised; anteriorly, a “partial Denonvilliers fascia preservation” technique safeguards the neurovascular bundle while ensuring complete anterior mesorectal excision; finally, residual lateral tethering bands are divided to reach the “terminal line” while preserving the pelvic plexus. This stepwise anatomy-driven strategy secures oncologic radicality while maximizing genito-urinary function, providing a reproducible and standardized plane for laparoscopic/robotic rectal cancer surgery.
In radical surgery for rectal cancer, the completeness of regional lymph node dissection is closely associated with the accuracy of tumor staging and long-term oncological outcomes. The No.253 lymph node, located at the root of the inferior mesenteric artery, represent a critical pathway for the upward spread of rectal cancer from regional to central lymphatic drainage. However, due to the complex anatomical structures and marked individual variations in this region, the dissection of No.253 lymph node has long been regarded as one of the most technically demanding and high-risk aspects of rectal cancer surgery. In recent years, with the increasing application of the concept of precise anatomy in colorectal surgery, a deeper understanding of the anatomical planes and tissue composition in this area has been achieved, providing a solid theoretical basis for the safe and effective dissection of No.253 lymph node. The key to No.253 lymph node dissection lies in precise recognition of the retroperitoneal anatomy. The No.253 lymph node area should be regarded as an independent three-dimensional anatomical unit, and regional en bloc dissection should be performed along the inferior mesenteric artery within the pre-aortic fascial plane. A standardized surgical approach facilitates complete lymph node dissection while minimizing bleeding and nerve injury, thereby balancing oncological radicality with postoperative functional preservation.
Conformal Intersphincteric Resection (ISR) represents an evolution in the surgical philosophy for ultralow rectal cancer, shifting from the paradigm of "maximal sphincter preservation" to that of "functional sphincter preservation." At its core, the procedure involves a precise, tumor-conformal excision and reconstruction based on the individualized pattern of tumor invasion into the anal sphincter complex, aiming to balance radical oncological clearance with functional preservation. The surgery achieves this through a conformal incision, three-dimensional dissection within the intersphincteric plane, and a precise "rendezvous" between the abdominal and perineal approaches. This ensures complete tumor removal while maximally protecting the external sphincter-puborectalis complex, which is critical for active continence. The successful implementation of conformal ISR integrates three principal objectives: oncological radicality, anatomical precision, and functional preservation. It relies on meticulous preoperative planning, millimeter-accurate intraoperative technique, and function-oriented perioperative management. With advances in minimally invasive and navigation technologies, conformal ISR is progressing toward greater precision, offering more patients the potential to achieve the dual goals of cancer cure and functional preservation.
Left hemicolectomy is a surgical procedure for splenic flexure colon carcinoma and descending colon carcinoma. Due to the unique embryonic origin and complex anatomical location of the splenic flexure of the colon, this surgery is often associated with high technical difficulty and a relatively high incidence of complications. The concept of mesenteric anatomy essentially involves understanding the anatomical location and adjacent relationships of mature human organs from the perspective of embryonic development. Its core viewpoint is that each organ in the abdominal cavity has its own mesentery and is encapsulated by its specific membrane. With the development of organs and their mesenteries, the membranes between different organs approach, fuse, and stabilize, forming distinct planes that ultimately constitute the different anatomical structures. Thus, surgery is no longer centered on a single organ or guided by its blood vessels, but rather regards the organ, its mesentery, blood vessels, and lymph nodes as an integrated whole encapsulated by “envelopes” to achieve en bloc resection. Understanding the fascia (Toldt fascia) and spaces (left retrocolic space, transverse retrocolic space, and omental bursa) surrounding the left colon based on the concept of mesenteric anatomy form the theoretical basis for left hemicolectomy. The “three-step method” for splenic flexure mobilization based on this concept enables surgeons to safely and effectively perform high-quality operations.
The low rectum is characterized by complex anatomical layers and intimate adjacent relationships. The pelvic floor region, in particular, converges fascial, muscular, neural, and vascular networks. Anatomical misidentification during surgery can compromise oncological radicality or lead to functional impairment. A significant challenge in transanal endoscopic rectal cancer surgery lies in the intraoperative difficulty of identifying clear anatomical planes and landmarks. Transanal Endoscopic Intersphincteric Resection (taE-ISR) offers a unique surgical perspective, aiding surgeons in more precisely determining the distal resection margin. Furthermore, the magnifying effect of the endoscope allows for clearer visualization of fine anatomical structures, thereby enabling accurate intersphincteric plane dissection and total mesorectal excision. However, its success heavily relies on the surgeon’s ability to identify key pelvic floor anatomical landmarks. For novices, misjudging the dissection plane due to insufficient anatomical knowledge can not only obscure the surgical field but also lead to serious complications such as incomplete mesorectal excision and pelvic nerve injury, directly impacting tumor radicality and postoperative functional recovery. Consequently, there is an urgent need for colorectal surgeons to deepen their understanding of the anatomical planes and key landmarks relevant to this procedure in clinical practice. The key anatomical landmark identification points and operative strategies in taE-ISR are of crucial significance for improving surgical safety, achieving radical tumor resection, and preserving the function of the anus.
Pelvic exenteration (PE) is a crucial surgical approach for locally advanced/recurrent rectal cancer, which can be categorized into four types: pelvic clearance, total pelvic exenteration, extended pelvic clearance, and extended total pelvic exenteration. The holistic fascial anatomy of the pelvic cavity exhibits a fundamental "ring-within-a-ring" architecture, continuous with the abdominal cavity, dividing the pelvic wall into five zones: left/right lateral pelvis, pelvic floor, posterior pelvis, and anterior pelvis. The lateral pelvic region represents the key surgical challenge, with management of internal iliac vessels being the critical priority. Based on tumor size and depth of invasion, the internal iliac vessels can be transected at three distinct levels, with the root level of the internal iliac artery and vein constituting the most hazardous zone in lateral pelvic surgery. Individualized management of the lateral pelvis and internal iliac vessels, guided by precise pelvic anatomy, is essential to reduce hemorrhagic risk, minimize nerve injury, and enhance the feasibility of en bloc resection. Refined pelvic anatomical understanding contributes to the standardization of PE procedures, providing surgeons with a reproducible surgical pathway, thereby improving overall R0 resection rates. Future integration with three-dimensional reconstruction and intraoperative navigation may further enhance the precision of pelvic anatomical identification and enable personalized surgical planning.
In recent years, the incidence of right colon cancer has been gradually increasing, placing higher demands on laparoscopic right hemicolectomy and related fine anatomical dissection. As a key vascular landmark in right hemicolectomy, the gastrocolic trunk of Henle, with its complex anatomical variations and classifications, poses significant challenges to laparoscopic radical surgery for right colon cancer. It not only affects intraoperative vascular identification and procedural difficulty, but also directly influences surgical safety, bleeding risk, and the completeness of lymph node dissection. How to accurately identify and properly manage the Henle’s trunk remains a critical issue in right hemicolectomy.In view of the anatomical complexity of Henle's trunk, it is essential to establish a surgical strategy oriented by key anatomical planes. In the cranial approach with pre-transection technique, surgeons have better visualization and safer management of Henle's trunk and its tributaries under direct vision. This optimized strategy combines meticulous dissection with standardized operation, significantly improving the safety and surgical quality of laparoscopic radical right hemicolectomy.
The radicality and functional preservation of low anterior resection for rectal cancer are closely intertwined with the degree of understanding of pelvic fine anatomy. With the widespread adoption of the total mesorectal excision (TME) concept and the iterative advancements in minimally invasive techniques, surgery has progressed from the “gross anatomical level” to the “submicroscopic membranous anatomical level”. Performance of low anterior resection for rectal cancer requires clear identification of the three key anatomical spaces posterior, anterior, and lateral to the rectal mesorectum, as well as critical anatomical structures including Denonvilliers’ fascia, the rectal lateral ligaments, and the localization landmarks of the pelvic autonomic nerve plexuses. In low and ultra-low rectal surgeries, it is necessary to identify anatomical pitfalls and coping strategies for complex scenarios such as narrow pelvis, obese body types, and anterior wall tumor invasion. Leveraging the high-definition magnification advantages of high-definition laparoscopy and robotic surgical platforms, promotes the development of TME toward greater precision and minimal invasiveness, aiming to achieve R0 tumor resection while maximally reducing local recurrence rates and preserving urogenital function.
Rectal prolapse is a type of pelvic floor dysfunction, and surgical intervention serves as the core treatment for this condition. Among the surgical options, ventral rectopexy has become one of the primary procedures due to its proven efficacy and manageable complications. In 2013,the first edition of "International Expert Consensus on Abdominal Rectal Fixation Surgery" was questioned by the academic community due to methodological flaws and potential conflicts of interest. To address these issues, the International Ventral Rectopexy Working Group initiated a consensus revision project based on evidence-based methodology. The aim was to overcome previous methodological limitations and develop 17 statements across ten core areas, thereby systematically reconstructing the clinical protocols and technical standards for the procedure. The updated consensus establishes a clear hierarchical framework, detailing key surgical steps, complication management pathways, and individualized strategies for specific populations.
Objective To analyze the nationwide prospective registry data included in the China Colorectal Cancer Surgery Database (CCCD) after its upgrade in January 2020, with a particular focus on key indicators such as the MRI examination rate for rectal cancer and the proportion of neoadjuvant therapy, aiming to provide evidence-based medicine support for formulating domestic colorectal surgery treatment strategies and clinical practice. Methods The clinical and pathological data of colorectal cancer surgery patients collected in the CCCD database from January 2020 to September 2025 were included. After standardized collation, a comprehensive analysis of their clinical characteristics, surgical treatment plans, and short-term outcomes was conducted. Results The latest database update included 19,806 colorectal cancer cases from 86 centers, with a participation rate of 36.0% for municipal hospitals. Among colorectal cancer patients, the proportion of rectal cancer (50.2%) was higher than that of colon cancer (49.8%), Nearly 70.9% of rectal cancers were mid-low rectal cancers. The preoperative MRI examination of rectal cancer patients had a “DISTANCE” formatted reporting rate of 73.9%. Of all the colorectal cancer patients, 10.5% received neoadjuvant therapy preoperatively, with specific rates of 6.7% for colon cancer and 16.0% for rectal cancer. Notably, approximately 16.6% of patients with mid-low rectal cancer underwent neoadjuvant treatment. Additionally, the utilization rate of laparoscopic surgery reached 88.7%, among which total laparoscopic colorectal surgeries accounted for 48.5%. In terms of radical surgery, the R0 resection rate was 96.2%, while the R2 resection rate was 2.9%. The overall postoperative complication rate was 8.40%. Anastomotic leakage was identified as the most common major complication, with an incidence of 2.0%. Specifically, the leakage rate following mid-low rectal cancer surgery was 2.9%, whereas the rate for other sites (upper rectal cancer and colon cancer) was 1.7%. Conclusion The latest results from the CCCD database analysis indicate dynamic changes in the baseline situation and surgical treatment patterns of colorectal cancer in China in recent years, with an ongoing improvement in the level of standardized diagnosis and treatment. In the future, attention should be focused on the construction of multi-center standardized treatment protocols and the improvement of diagnostic and treatment capabilities in municipal hospitals, as well as further optimizing the follow-up data collection mechanism.
Objective To evaluate the clinical application value of a systematic exposure and dissection strategy based on mainmast-style traction in robot-assisted radical resection of right colon cancer. Methods A retrospective analysis was performed on 79 patients undergoing robot-assisted right hemicolectomy between January 2021 and August 2025 at the Department of Gastrointestinal Surgery, the Affiliated Hospital of Xuzhou Medical University. All patients underwent systematic dissection under mainmast-style traction, including caudal “three-step climbing” and cephalad “double-layered curtain” dissection. Operative time, blood loss, conversion to open surgery rate, intraoperative organ injury rate, postoperative complications (Clavien-Dindo), recovery indicators, lymph node yield, and mesenteric integrity were recorded as outcome measures. Results All procedures were completed without conversion. Operative time was (168.1±18.5) min, and blood loss was (18.1±8.5) mL. One case (1.3%) of major vascular injury occurred, with no duodenal or pancreatic injuries. The overall postoperative complication rate was 17.7%, all Clavien-Dindo grades Ⅰ-Ⅱ. The time for first flatus was (36.5±8.2) h, and postoperative hospital stay was (7.5±1.5) d. Mean lymph node harvest was (35.4±6.8), and mesenteric integrity was “complete” in 94.9%. Conclusion The mainmast-style traction combined with programmed dissection constitutes a controllable, teachable, and reproducible robotic surgical workflow, which may help promote the standardization of surgical exposure and dissection, shorten the learning curve, and facilitate high-quality right hemicolectomy.
Objective To explore the applicable population and optimized protocol of two-stage pull-through delayed coloanal anastomosis (TCA) for low rectal cancer. Methods A retrospective analysis was conducted on the clinical data of 106 patients with low rectal cancer who underwent TCA at the Department of Gastrointestinal Surgery, General Surgery Center, the First Hospital of Jilin University, from December 2023 to November 2025. The primary outcome measures included complications related to bowel resection (including ischemia, necrosis, hemorrhage, and retraction of resected bowel) and complications related to anastomosis (including anastomotic leakage, stenosis, atresia, and rectovaginal fistula). The study analyzed the influencing factors of these major outcomes in the patients. Results Among 106 patients, 31 cases developed surgical-related complications (29.3%). Rescue stoma procedures were performed in 10 cases due to complications, including 6 cases caused by bowel prolapse and 4 cases due to anastomotic complications. Patients with bowel prolapse had a significantly higher risk of subsequent anastomotic complications (P=0.005). The BMI ≥24 was an independent risk factor for postoperative bowel prolapse (OR=4.15, 95%CI 1.14-15.11, P=0.031). The surgical duration ≥240 minutes was an independent risk factor for postoperative anastomotic complications (OR=6.86, 95%CI 1.58-29.72, P=0.010). For female patients, a surgical interval ≤6 days was an independent risk factor for rectovaginal fistula (OR=0.04, 95%CI <0.001-0.61, P=0.021). Conclusion Before performing TCA surgery, comprehensive consideration should be given to factors such as the patient’s BMI and operation duration to avoid potential complications. For female patients, the interval between two surgeries should be appropriately prolonged.
Objective To evaluate the application value of worrisome features (WF) from the 2023 Kyoto Guidelines in diagnosing malignancy for mucin-producing pancreatic cystic neoplasms (mPCNs) without main pancreatic duct dilation. Methods A retrospective analysis was conducted on the clinical data of 374 patients who underwent pancreatic surgery at the Department of Hepatobiliary Pancreatic Surgery, First Hospital Affiliated to Naval Medical University, between January 2012 and December 2023, with postoperative pathological confirmation of branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) or pancreatic mucinous cystic neoplasm (MCN). The diagnostic performance of malignancy for MCN, BD-IPMN and <30 mm mPCN was evaluated by sensitivity, specificity, area under the receiver operating characteristic curve (AUC), Youden index, and F1-score. Results Among all patients, there were 164 cases of MCN and 210 cases of BD-IPMN. Results of multivariable logistic analysis showed that CA19-9≥37 kU/L (OR=8.35, 95%CI 2.23-31.25, P=0.002), enhancing mural nodule (OR=7.60, 95%CI 1.33-43.27, P=0.022), calcification (OR=13.49, 95%CI 2.77-65.75, P=0.001), and abdominal pain (OR=8.89, 95%CI 2.30-34.34, P=0.002) were independent risk factors for malignancy of MCN. CA19-9≥37 kU/L (OR=3.25, 95%CI 1.61-6.59, P=0.001) and distal pancreatic atrophy (OR=2.99, 95%CI 1.31-6.85, P=0.009) were independent risk factors for malignancy of BD-IPMN. CA19-9≥37 kU/L (OR=5.21, 95%CI 2.13-12.73, P<0.001), thickened or enhanced cyst wall (OR=3.57, 95%CI 1.43-8.92, P=0.007), distal pancreatic atrophy (OR=7.42, 95%CI 2.53-21.74, P<0.001), and growth rate of diameter ≥2.5 mm/year (OR=2.85, 95%CI 1.23-6.59, P=0.014) were independent risk factors for malignancy in <30 mm mPCN. The presence of ≥3 WFs demonstrated the best diagnostic performance for malignancy of MCN, with an AUC of 0.859. The presence of ≥2 WFs showed the best diagnostic performance for malignancy of BD-IPMN and <30 mm mPCN with AUCs of 0.734 and 0.791, respectively. Conclusion The number of WFs from the 2023 Kyoto Guidelines can be used for diagnosing malignancy in mPCN without main pancreatic duct dilation, with the highest diagnostic performance observed for MCN malignancy.
Transanal total mesorectal excision (taTME) is a reverse anatomical approach developed to overcome the limitations of the traditional transabdominal approach, such as difficult surgical exposure and challenges in controlling the distal resection margin in patients with a narrow pelvis, obesity, or low rectal cancer. The core of taTME lies in the accurate identification and maintenance of the "holy plane" between the rectal visceral fascia and the prehypogastric nerve fascia from a transanal perspective. Key anatomical points include the recognition and management of structures such as the rectosacral fascia in the posterior plane, the pelvic plexus neurovascular bundle in the lateral plane, and Denonvilliers' fascia along with the rectourethralis muscle in the anterior plane. TaTME also demonstrates unique anatomical advantages in complex procedures such as lateral lymph node dissection and multivisceral resection, enhancing the precision and safety of deep pelvic surgery. However, the technique is associated with a steep learning curve and requires further standardization and individualized research to optimize surgical outcomes and functional preservation.
