Vittoria Bellato interviews Thilo Wedel, Director of the Institute of Anatomy and Head of the Center of Clinical Anatomy at the Medical Faculty of the Christian-Albrechts-University Kiel/Germany, in the run-up to ESCP Virtually Vilnius 2020.
After his medical studies in Asunción/Paraguay and Lübeck/Germany Thilo Wedel received his postgraduate training both in visceral surgery and anatomy. His scientific and educational interest has long been focused on clinical anatomy and its relevance for surgical procedures in the field of visceral surgery, urology and gynecology. His institute is offering a broad spectrum of surgical workshops comprising open, laparoscopic and robotic techniques. In the field of colorectal surgery, 'hot topics' such as transanal total mesorectal excision and complete mesocolic excision are addressed by means of scientific contributions and hands-on workshops.
Vittoria Bellato: Dear Thilo, thank you for agreeing to speak at the ESCP 15th Annual & Scientific Conference about the anatomy of the pelvic nerves - can you give us some anticipation on your topic?
Thilo Wedel: When it comes to surgery for rectal carcinoma, the challenge is at least two-fold: on the one hand an oncologically safe resection should be achieved; on the other hand anorectal and urogenital dysfunctions should be as minimal as possible. For the latter goal preservation of pelvic autonomic nerves is mandatory, as they govern fecal and urinary continence, micturition and defecation, and sexual functions in both males and females.
VB: Which are the anatomical pecularities of those pelvic autonomic nerves?
TW: Unlike somatic nerves, they form abundant meshworks with variable shapes and courses which are feeded from preaortic sympathetic and sacral parasympathetic nerve fibers. The networks extend from the presacral area along the pelvic sidewall and supply virtually every intrapelvic organ - which makes nerve-sparing procedures mandatory not only for colorectal surgeons but also for urologists and gynecologists.
VB: Are there any landmarks which help to protect these nerve meshes?
TW: Before the nerve fibres reach their destinations they travel within the parietal pelvic fascia - thus, the best protection is to dissect along the 'holy plane of TME' advocated by Bill Heald and to only transect those nerve fibres diverging into the rectum. During mobilisation of the distal rectum the pelvic splanchnic and levator ani nerves (dorsolaterally) as well as the internal anal sphincter nerves (anterolaterally) have to be respected.
VB: How will your talk differ from normal textbook anatomy?
TW: By means of stepwise dissections of pelvic specimens we will have a chance to appreciate the three-dimensional topography and exact course of these nerves otherwise hidden within their fascial envelopes. We will try to 'look behind the intraoperative scenes'.
VB: Are there any gender-specific differences?
TW: Good point! Anatomically, both genders exhibit quite similar conditions. Unfortunately, the biggest gender-specific difference is seen in clinical practice: urogenital dysfunctions after injury of pelvic autonomic nerves are underestimated or even neglected in female patients.
VB: What are some important future developments in the field?
TW: As outlined above, pelvic autonomic nerves are hidden within fascial envelopes and often show unpredictable courses and functions. Therefore, surgeons would benefit from better identification, visualisation and functional mapping of these nervous meshworks. In this context, pelvic intraoperative neuromonitoring (pIONM, introduced by Werner Kneist) appears to be a promising tool.
Hear more from Thilo on the ‘Anatomy of Pelvic Nerves’ at ESCP Virtually Vilnius 2020 at 14.20-14.30 on Monday 21 September 2020.
