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Rectal Anatomy: Clinical Perspective

Chapter · January 2018

DOI: 10.1007/978-3-319-16384-0_1

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 Rectal Anatomy: Clinical
Perspective 1
Slawomir Marecik, John Park, and Leela M. Prasad

“freeze” and appreciate the operating field, as

Introduction well as improved precision of dissection and
more hemostatic techniques [2]. At the same
This chapter will discuss the anatomy of the rec- time, new methods of processing and handling
tum and pelvis as it relates to the diagnosis and the cadaveric material allowed for more effec-
surgical management of rectal cancer. tive study of pelvic anatomy in the lab [3, 4].
Over the last 30 years, a significant amount of Finally, the last 15 years have seen the role of
progress has been made to more fully understand magnetic resonance imaging (MRI) rapidly
rectal and pelvic anatomy. Professor Bill Heald evolve. Today, it is one of the main diagnostic
stressed the importance of proper anatomical tools in rectal cancer [5]. With improved resolu-
technique during rectal dissection based on tion and quality of images obtained, MRI tech-
embryological development and led efforts for its nology has improved our understanding of both
ultimate widespread utilization [1]. Subsequently, pelvic anatomy, as well as rectal cancer overall
the advent of minimally invasive techniques in [6, 7]. In fact, MRI has helped to validate previ-
the last decade of the twentieth century made it ous observational anatomical studies in repro-
possible to appreciate the pelvis from a different ducible and objective ways.
perspective. Laparoscopy now provided a magni-
fied view and allowed for surgical procedures to
be recorded for further analysis and widespread Rectum
teaching. As a result, it became easier to under-
stand the nuances of rectal surgery. Anatomically, the rectum is the last segment of
Advances in technology including robotic the large intestine that occupies the posterior pel-
surgery have further advanced our ability to vis along the concavity of the sacral bone. This
visualize surgical pelvic anatomy. Several fac- organ can be 12–18 cm long, with the proximal
tors have played an important role in this end located at or just below the level of the sacral
advancement, including improved ability to promontory and the distal end at the junction
with the anal canal (Figs. 1.1, 1.2, and 1.3). The
S. Marecik (*) • J. Park • L.M. Prasad length of the rectum can vary and is dependent on
Division of Colorectal Surgery, Advocate Lutheran its distention, body habitus, and amount of meso-
General Hospital & University of Illinois at Chicago, rectal fixation. It is an organ with an increased
1550 N. Northwest Hwy S.107, Park Ridge,
IL 60068, USA ability for accommodation and ability to change
e-mail: [email protected] its size. The rectum differs from the colon as it

© Springer International Publishing AG 2018 1

G.J. Chang (ed.), Rectal Cancer, DOI 10.1007/978-3-319-16384-0_1
2 S. Marecik et al.

contains a complete outside layer of longitudinal mesorectal fat (Fig. 1.4). The rectum lacks the
muscle within its wall. This feature results in the free-floating appendices epiploicae. Because the
lack of haustra and taenia strips. The wall of the transition between the colon and the rectum is not
rectum consists of several layers, which can be abrupt, another distinct segment, the rectosig-
fully appreciated during endorectal sonography. moid, can be appreciated. This 4–8 cm segment
These are mucosa with muscularis mucosae, sub- is usually the narrowest part of the large intestine,
mucosa, muscularis propria, and surrounding when not counting the appendix.
Endoscopically, the rectum is wider than the
rest of the left colon. The rectum’s most distal
part, the ampulla, is the widest, allowing for safe
retroflexion of the flexible endoscope. In linear
measurements, this part, when distended, is at
least two to three times wider than the width at the
anorectal junction. Additionally, the change in
size between these two segments takes place in a
very short distance, an important fact to consider
during bowel stapling. The high accommodation
properties of the rectum result in increased thick-
ness of the non-stretched rectal wall. On average,
three internal folds can protrude into the lumen of
the rectum (valves of Houston) when the bowel is
moderately distended; however, anatomical varia-
Fig. 1.1  MRI of pelvis (sagittal, T2 sequence), male, tions exist [8] (Fig. 1.3). These folds involve
ulcerated tumor in the posterior, lower rectum (arrow) approximately 25–75% of the circumference and

S1
S2
Tenia coli S3

S4
Sigmoid Rectum
colon S5 Levator ani m.
Peritoneum
Coccyx

Bladder Puborectalis sling

Anococcygeal
ligament
Seminal
vesicles Level of anorectal
ring

External sphincter
Pecten
Anal verge

Internal sphincter

Fig. 1.2  Rectal anatomy, lateral view

1  Rectal Anatomy: Clinical Perspective 3

Rectosigmoid

Superior
rectal valve

Rectal column
Morgagni
Middle rectal
valve Inferior rectal valve

Levator ani m.

Conjoined
longitudinal m.

External Internal
sphincter (deep) hemorrhoidal plexus
Pectinate (dentate)
Internal sphincter line
Musculus
(Superficial)
submucosae ani
(Subcutaneous) Intersphincteric
line
Rectal sinus

Fig. 1.3  Rectal anatomy, AP view

Perirectal fat, hyperechoic

Muscularis propria, hypoechoic

Submucosa, hyperechoic

Mucosa/muscularis
mucosa, hypoechoic

Interface, hyperechoic

Fig. 1.4  Endorectal ultrasound, layers of the rectal wall and the mesorectum
4 S. Marecik et al.

are the result of increased muscular fiber concen-

tration in the circular layer of the bowel wall. The
lowest valve is located approximately 3–5 cm
above the anorectal junction. The second valve
(Kohlrausch’s plica) is on the opposite side and
often corresponds with the level of the anterior
peritoneal reflection in an individual of average
weight and height. The third valve is located on
the left side. Together, all three valves create sev-
eral mild curvatures that need to be negotiated
during endoscopic exam or transanal insertion of
the stapler. Inadvertent incorporation of the folded
valve into the staple line during transanal stapling
may result in anastomotic leak.
Still more important curves to consider, how- Fig. 1.5  Rectum after total mesorectal excision (perito-
neal reflection marked with arrow)
ever, are those seen on lateral projection, includ-
ing a 90-degree (anorectal) angle between the
ampulla and the anal canal, and a gentler anterior the site of locoregional tumor spread and should
curve along the concavity of the sacrum. The be resected en bloc along with the involved seg-
sharp anorectal angle forms the “posterior rectal ment of the rectal tube [1]. Clinically, the average
shelf” and contributes to fecal continence. It can number of lymph nodes within the entire meso-
be easily appreciated upon digital exam (Fig. 1.2). rectal specimen can vary anywhere between 5
Unfortunately, it can also make it difficult to prop- and 20 (up to 40 in some anatomical studies) and
erly evaluate the posterior cancers of the very dis- can be reduced after preoperative radiation ther-
tal rectum during transanal sonography. In this apy [10–13]. In its distal part, the mesorectum
case, it is difficult to orient the ultrasound beam tapers out and frequently disappears in thin indi-
perpendicularly to the posterior wall of the most viduals (Fig. 1.6). This allows the rectal tube to
distal rectum. Both angles may need to be negoti- be in direct apposition to the convexity of the
ated safely during transanal stapler insertion. pubococcygeus and iliococcygeus (levator ani)
muscles and the concavity (groove) of the ano-
coccygeal raphe (Fig. 1.7).
Mesorectum

In the majority of individuals, the circumference Fascial Layers of the Pelvis

of the rectal tube, excluding significant portion of
the anterior aspect, is surrounded by adipose tissue Fascia Propria of the Rectum
called mesorectum (Fig. 1.5). Initially, the term
mesorectum was considered a misnomer [9]. The fascia propria of the rectum (FPR) is also
Today, it is accepted as a proper term describing a referred to as mesorectal fascia, investing fascia,
package of adipose tissue surrounding the rectal or visceral pelvic fascia. It creates a thin envelope
tube in a distinct fascial layer (fascia propria of the surrounding the mesorectum and the anterior part
rectum or FPR). The mesorectum contains vessels, of the bowel not covered by the mesorectum, thus
lymphatics, and lymph nodes as well as minor forming a distinct anatomical package. This pack-
nerve fibers. In obese individuals, the lower half of age can be surgically dissected out in toto during
the rectum is often completely surrounded by the total mesorectal excision. Moving cephalad, the
mesorectum due to abundant anterior fat deposits. mesorectal fascia is an equivalent of the mesocolic
The significance of the mesorectum is mainly fascia that covers the left colon. It fuses with the
related to the lymph nodes, which are frequently endopelvic fascia and the presacral fascia.
1  Rectal Anatomy: Clinical Perspective 5

Fig. 1.8  Endopelvic fascia in a patient with visceral obe-

sity, presacral segment, upper half of total mesorectal
excision

ers (Fig. 1.8). On the other hand, in a thin patient,

it can be translucent (Fig. 1.9). In the lateral
Fig. 1.6 MRI, T2 sequence, thin male; thinned out
aspects of the pelvis, the endopelvic fascia
(absent) mesorectum in the lower aspect of the posterior
rectum extends to the sides, covering the origin of the
levator ani muscles at the tendinous arch along
the internal obturator muscle.

Presacral Fascia

The presacral fascia lines the posterior aspect of

the cylindrical mesorectal compartment in front
of the sacrum. In the posterior midline, it covers
the promontory as a continuation of the abdomi-
nal Toldt’s fascia into the pelvis (Fig. 1.8).
Descending deeper into the pelvis, this fascia
lines the midline portion of the sacrum, spreading
anteriorly and laterally in the arcuate fashion in
Fig. 1.7  Posterior pelvis after total mesorectal excision: a order to cover the medial portion of the pirifor-
rectal stump, b pubococcygeus muscle, c dome of the ilio- mis muscles, the sacral foramina containing
coccygeus muscles, d coccygeus muscle, e anococcygeal sacral nerves roots, and the midline and posterior
raphe, f anterior pelvic structures covered by an intact
portion of the levators.
Denonvilliers’ fascia

Endopelvic Fascia Denonvilliers’ Fascia

The endopelvic fascia is a distinct fascial layer In the anterior aspect of the extraperitoneal rec-
that covers the floor and sidewalls of the entire tum, extending slightly above the peritoneal reflec-
pelvis. In obese individuals, a certain amount of tion, there is a distinct layer of fibroelastic tissue
adipose tissue can be found underneath the endo- called the Denonvilliers’ fascia. It is a trapezoidal
pelvic fascia or even in between its particular lay- sheet separating the mesorectal compartment from
6 S. Marecik et al.

Fig. 1.9  Endopelvic fascia in a thin patient, presacral Fig. 1.11  Denonvilliers’ fascia cut and deflected posteri-
segment, upper half of total mesorectal excision. Visible orly, exposing the seminal vesicles
presacral structures: veins, arteries, sympathetic ganglia

prostate, while in women, it exposes the sinusoidal

vessels of the vaginal wall. In addition, seminal
vesicles and associated neurovascular structures can
be exposed and at risk for injury (Fig. 1.11).

Waldeyer’s Fascia

There is some controversy with regard to

Waldeyer’s fascia in rectal anatomy texts [14–17].
While this fascia, also known as rectosacral fas-
cia, has been an anatomical and cadaveric obser-
vation, it has limited impact on rectal cancer
Fig. 1.10  Denonvilliers’ fascia, male patient, level of
seminal vesicles (visible cut edge) surgery, as long as the principles of total meso-
rectal excisions are followed. Many textbooks
depict Waldeyer’s fascia as an anteroinferior
the anterior pelvic structures (Fig. 1.10). In men, extension of the presacral fascia, separated from
Denonvilliers’ fascia stretches in a concave fash- the latter at the S4 level and running toward the
ion between both pelvic sidewalls as a cover of the rectal tube [14, 15, 17]. Others have depicted it as
anterior pelvic compartment, which includes the a layer penetrating the mesorectum [16, 18] or a
bladder, seminal vesicles, vasa deferentia, ureters, layer running closer to the levator muscles that
prostate, and both neurovascular (genitourinary) requires sharp division in order to provide full
bundles. In women, Denonvilliers’ fascia stretches posterior rectal mobilization [15].
in a concave fashion from both pelvic sidewalls
covering the posterior wall of the vagina as well as
the genitourinary neurovascular bundles.  arietal Fascia (Fascia of the Lateral
P
During anterior rectal mobilization, the dissec- Compartment)
tion can be carried out on either side of Denonvilliers’
fascia as indicated by the tumor. It is important to The parietal fascia (PF) separates the mesorectal
note, however, that in men, this exposes the fine compartment from the lateral pelvic compartment
neurovascular plexus of the seminal vesicles and and transitions into Denonvilliers’ fascia anteriorly.
1  Rectal Anatomy: Clinical Perspective 7

Fig. 1.12  Parietal fascia of the mesorectal compartment

(blue) originating from the endopelvic presacral fascia sep- Fig. 1.13  Lateral tethered surface (LTS) on the left side,
arates the mesorectal compartment (MC) from the lateral the point of insertion (arrow) of nerve fibers from the pel-
compartments (L) and transitions into Denonvilliers’ fascia vic plexus (b) to the mesorectum (c); left hypogastric
(DF) in the region of the lateral tethered surface (LTS) nerve (a)

The PF is closely related to the hypogastric nerve Anatomical Relations

and the pelvic plexus, putting these structures at
risk during dissection. At the mid-rectal level, it The anatomic relations of the rectum should be
can also be adhered to the mesorectal fascia, a carefully considered during surgical resection,
result of small nerve endings (nervi recti) entering particularly with locally advanced tumors which
the mesorectum from the pelvic plexus. When extend beyond the mesorectal fascial plane.
medial retraction is applied to the mesorectum, a Posteriorly, these structures include the sacrum,
tethering can be observed [19] (Figs. 1.12 and coccyx, piriformis, and levator ani muscles, as
1.13). This has been described in the literature as well as the sacral nerve roots. Anteriorly, the
the “lateral ligament” [20]. We prefer the term “lat- bladder or uterus and vagina in women and semi-
eral tethered surface” (LTS). The tethering is nal vesicles, neurovascular bundles, and the pros-
caused by the small nerve structures, fatty and con- tate or urethra in men may be at risk. Potentially
nective tissue, and small blood vessels crossing involved lateral structures may include the hypo-
from the lateral to mesorectal compartment [21]. gastric nerve trunks, the ureter, or the lateral
structures such as the internal iliac vessels or
associated nodal compartments.
Peritoneal Coverage

The upper portion of the rectum is invested by Anus

peritoneum anteriorly and laterally, while the
middle part only anteriorly. Finally, the lower The anus is the terminal portion of the alimentary
rectum is completely extraperitoneal below the tract. It consists of the anal canal and the anal
peritoneal reflection. Thus, in an average-sized margin. In the clinical sense (surgical and also
individual, the peritoneal reflection corresponds functional), the anal canal extends from the ano-
to the level of the second valve of Houston. This rectal junction, at the superior border of the leva-
translates to the level at about 6–8 cm from the tor hiatus, to the anal verge (Fig. 1.3). The anal
anal verge in women and 7–10 cm in men. Patient verge is the point of contact of the examiner’s
habitus such as height, obesity, and pelvic mus- thumb made to the anoderm during digital rectal
culature can affect these distances. exam using the index finger. The average length
8 S. Marecik et al.

of the anal canal in women is 2.5–3.5 cm, and in

men it is 3–4 cm. This length is dependent on the
muscle tension and is shorter under general anes-
thesia and deep sedation.
The anal margin is a circular, doughnut-­
shaped area located outside the anal verge within
a 3–3.5 cm radius. The anal canal is a functional
unit created by the sphincter muscle complex
which can dilate to accommodate stool evacua-
tion. It is located anteriorly and inferiorly from
the coccyx, anterior to the deep postanal space
and next to the ischioanal space. In women, it is
posterior to the distal vagina, while in men it is
posterior to the membranous portion of the ure- Fig. 1.14  Avascular intersphincteric plane; longitudinal
thra, the origin of bulbospongiosus (often conjoined tendon covering the internal sphincter; view
from the pelvic side (courtesy of Prof. Amjad Parvaiz)
described as bulbocavernosus) muscles, and
Cooper’s glands.

The internal sphincter muscle is a 2.5–3.5 cm

Sphincter Complex long tubular structure located inside the longer
tube of the external sphincter muscle. It is made
The sphincter muscle complex is comprised of by concentric smooth muscles lamellae. Overall,
two muscular tubes (Fig. 1.2). The external tube the thickness of the internal sphincter tube is
(external sphincter) is longer and thicker and approximately 2–4 mm. At the anorectal junc-
derived from striated (skeletal) muscle. The tion, the internal sphincter transitions into the
internal tube (internal sphincter) is significantly inner circular muscle layer of the rectal wall. An
thinner and slightly shorter and comprised of outer longitudinal layer of the rectal wall,
smooth muscle. The difference in length between together with some fibers of the levator muscles,
the two sphincter tubes creates the intersphinc- creates a very thin muscular layer called the con-
teric groove which is an easily palpated impor- joined longitudinal muscle (CLM) [23]. The
tant landmark. CLM runs within the intersphincteric space thus
The external anal sphincter is a 3–4 cm long separating both the internal and external sphinc-
elliptically shaped structure. It works as one ter tubes. This observation is strictly anatomical
functional unit comprised of four subunits, and does not have any specific clinical implica-
including the most cephalad puborectalis sling tions for rectal cancer surgery. However, for the
and three ring-like layers: deep, superficial, and surgeon performing intersphincteric dissection, it
subcutaneous [22]. The puborectalis muscle is a is more practical to associate the conjoined longi-
U-shaped muscular band originating from the tudinal muscle with the internal sphincter. The
pubis and linking the levators plate to the rest of intersphincteric space is a potential space of
the external sphincter. This muscle is responsi- ­surgical dissection and does not contain any rel-
ble for creation of the anorectal angle and, in evant vasculature (Fig. 1.14).
large measure, for overall fecal continence. The
external sphincter complex, through its superfi-
cial unit, is fixed to the coccyx by the anococ- Lining of the Anal Canal
cygeal ligament located below the levators plate.
It is also fixed anteriorly to the perineal body The anal canal lining consists of rectal-type
where it merges with the transverse perineal mucosa in the upper half and cutaneous coverage
muscles. in the lower half. The demarcation line between
1  Rectal Anatomy: Clinical Perspective 9

these embryologically different types of epithe- fascia on its cephalad surface called the urogeni-
lium is called the dentate line (pectinate line), a tal membrane (also known as hiatal ligament)
sawtooth line located in the middle of the anal (Fig. 1.15).
canal. Above the dentate line, an interposed tran-
sitional zone exists (6–12 mm segment) contain-
ing the columnar, transitional, and squamous Internal Obturator Muscle
epithelia [24]. The upper half of the anal canal
contains 6–12 longitudinal mucosal folds (col- Proper understanding of the levator ani muscles
umns of Morgagni), which also extend below the involves discussion about the internal obturator
dentate line as the anodermal folds. These folds muscle. The lateral attachments of the levator ani
are the result of the constricting effect of the muscles are directly associated with this struc-
sphincter complex on the lining of the anal canal. ture. The internal obturator muscle is attached to
The columns of Morgagni are connected at their the inner surface of the superior and inferior ileo-­
bases by the anal valves covering the outlets of pubic rami as well as to the obturator membrane
the anal crypts. spread over the obturator foramen (Figs. 1.15 and
The lining of the upper half of the anal canal is 1.16). From here, the muscle runs in the posterior
purple due to abundant underlying internal hem- direction, lining the entire lateral portion of the
orrhoidal plexus. The lining of the lower half of true pelvis and exiting it via the lesser obturator
the anal canal, called the anoderm, is pale pink, foramen (Fig. 1.17). The fascial coverage of this
smooth and shiny, and devoid of true skin struc- muscle creates an insertion place for the levator
tures like hair, sweat, or sebaceous glands. At the ani muscles (tendinous arch) . The tendinous arch
level of the anal verge, the skin acquires pigmen- runs dorsally as a straight line from the pubic
tation and hair follicles, as well as typical dermal symphysis, parallel to the superior ileo-pubic
structures, including the apocrine glands. ramus, reaching the ischial spine. The insertion
Proximal to the dentate line, the bowel is derived of the levator ani muscles, together with the lower
from the endoderm and is supplied by the auto- aspect of the internal obturator muscle, can be
nomic (sympathetic and parasympathetic) nerves, appreciated from underneath the pelvic floor dur-
while distal to the dentate line, the epithelium has ing the perineal phase of the abdominoperineal
somatic innervation. resection. It is also an important landmark during
wide transection of the levators. In fact, in indi-
viduals with well-developed pelvic musculature,
Pelvic Floor the bulky internal obturator muscle may be one
of the structures narrowing the pelvic space,
The pelvic floor, also known as the pelvic dia- thereby adding difficulty during pelvic dissection
phragm, is a sheet-like muscular structure cre- (Fig. 1.17).
ated by a complex of muscle units. The purpose
of the pelvic floor is to support the pelvic viscera
and allow for secure passage for the alimentary Levator Ani Muscles
and genitourinary tracts. While the levator ani
muscle complex makes up the main “bulk” of the The levator ani muscle complex is a widely span-
pelvic floor, complete coverage of the pelvic out- ning sheet-like muscular structure covering the
let involves three additional areas. The symmet- majority of the pelvic outlet. It is approximately
rical greater sciatic foramina in the posterolateral 2–4 mm thick. The four structural subunits of the
pelvis are covered by two piriformis muscles. levator ani muscle are identified and named after
The midline defect in the anterior pelvis is cov- their origin and final insertion. These include the
ered by the deep transverse perineal muscle sup- puborectalis, pubococcygeus, iliococcygeus, and
ported by a thickened portion of the endopelvic coccygeus (Fig. 1.15).
10 S. Marecik et al.

Superior view

Fascia deep
Pubic
transverse
symphysis
perineal mm.

Puborectalis and
pubococcygeus mm.
Urethra
Obturator canal
Vagina
Tendinous arch of
levator ani m.
Rectum
Obturator internus
(covered by fascia)
Ischial spine
Iliococcygeus m.
Coccyx
(Ischio-)coccygeus m.
Piriformis m.

Medial view

Piriformis m.

Obturator internus m.
and obturator fascia
(cut)

Iliococcygeus m. (Ischio-)coccygeus
m.
Pubococcygeus m. Rectum
(part of levator ani m.)
Urethra Left levator ani m.
(cut)
Vagina

Sphincter urethra m.

Left puborectalis m.
and perineal
membrane

Fig. 1.15  Muscles of the pelvic floor

Puborectalis Muscle around the anorectal junction. This muscle is

responsible for creating the anorectal angle, exert-
The puborectalis muscle has a band-like structure ing a compression effect on the anorectal junction
that forms the middle portion of the levator ani. and contributing to fecal continence. Controversy
It originates from the posterior pubis and slings exists over the association of the puborectalis
1  Rectal Anatomy: Clinical Perspective 11

Abdominal
aorta
Internal iliac Right common
artery iliac artery
Posterior division of Left common
internal iliac artery iliac artery
Anterior division of Median sacral
internal iliac artery artery
External iliac artery Iliolumbar artery
Obturator artery Superior gluteal
artery
Umbilical artery
(patent part) Lateral sacral
arteries
Middle rectal
artery Piriformis muscle
Uterine artery Inferior gluteal
Vaginal artery artery

Inferior vesical Internal pudendal

arteries artery

Medial umbilical (Ischio-) coccygeus

ligament (included muscle
part of umbilical
artery) Sacrotuberous
ligament
Superior vesical
arteries Obturator fascia (of
obturator internus
Pubic symphysis muscle)

Levator ani Internal pudendal

muscle (cut edge) artery in pudendal
canal (alcock)

Fig. 1.16  Relation of pelvic arteries to pelvic floor muscles and the sacral plexus

muscle with either the levator ani complex or the the levator hiatus. The posterior aspect of the
external sphincter complex [25–28]. As a result, levator hiatus accommodates the anorectal junc-
from the clinical perspective, it is acceptable to tion (rectal hiatus), and the anterior aspect is
consider the puborectalis muscle as an anatomical reserved for the urogenital structures (urogeni-
and functional link between the levator and tal hiatus). A thickening of the endopelvic fascia
sphincter muscle complexes. creates the urogenital membrane (hiatal liga-
ment), thereby fixing the urogenital structures to
the levator muscle complex. During standard
Pubococcygeus Muscle dissection, the rectal surgeon will see only a
small medial portion of the pubococcygeus
The pubococcygeus originates from the anterior muscle since most of it is covered by the ante-
half of the internal obturator fascia along the rior pelvic structures.
tendinous arch. It then runs dorsally, medially,
and downward toward the lower sacrum. In the
midline, the fibers intertwine with the fibers Iliococcygeus Muscle
from the opposite site to create anterior part of
the anococcygeal raphe. More anterior, some of The iliococcygeus muscle is the largest part of
the fibers do not come together, and it is here, the levator ani muscle that is visible during the
joining the puborectalis muscle, that they create rectal dissection. It is a paired, symmetrical mus-
an open space in the anterior pelvic floor, called cle and has a sheet-like structure that undergoes
12 S. Marecik et al.

coccyx, and the anococcygeal raphe. Additionally,

these fibers crisscross with the fibers of the vesti-
gial sacrococcygeal muscle. This crisscross can
create a tiered posterior attachment of the levator
ani muscle to the sacrum, which should be taken
into account during abdominoperineal resection
when the posterior levators are being transected.

Other Muscles of Pelvic Floor

Fig. 1.17  Internal obturator muscle (arrows), MRI, T2 Rectococcygeus Muscle

sequence in a muscular male, contributing to narrowing of
the mesorectal compartment The rectococcygeus muscle is a small, paired
muscle located at the posterior aspect of the leva-
tor hiatus. It is associated with the most anterior
significant deformation into dome-like surfaces. portion of the anococcygeal raphe and frequently
The anterior portion of the muscle originates has a V-like shape, “hugging” the posterior aspect
from the posterior part of the internal obturator of the very distal rectal tube (Fig. 1.19). It is
fascia. The posterior origin of the iliococcygeus located just above the posterior sling of the
muscle is located at the ischial spine. Bilateral puborectalis muscle where it “guards” the
iliococcygeus muscles are joined in the midline entrance to the posterior intersphincteric space.
groove of the anococcygeal raphe, which extends In colloquial surgical language, it is frequently
posteriorly to the coccyx and lower sacrum referred to as the “last band” to cut during open
(Figs. 1.7). In most individuals, the lateral origins posterior mesorectal excision.
of the muscles are covered by the contents of the
lateral pelvic compartments. Additionally, the
more muscular the individual is, the steeper the Piriformis Muscle
domes of the iliococcygeus muscles are. The
dome effect is also indirectly related to obesity The piriformis muscle is a paired muscle originat-
because the increased amount of adipose tissue ing from the lateral aspect of the sacral bone
within the ischioanal fossa exerts a mass effect between the S2 and S4 segments (Fig 1.15).
from underneath the muscle, which contributes to Contrary to other pelvic floor muscles, it origi-
significant bulging of the posterior levator ani nates medially and runs laterally (and inferiorly)
muscles (Figs. 1.7 and 1.18). where it exits the pelvis through the greater sciatic
foramen, finally attaching to the greater trochan-
ter. From the standpoint of the pelvic floor, the
Coccygeus Muscle important function of this muscle is its coverage
of the symmetrical posterolateral space (greater
The coccygeus muscle, also known as the ischio- sciatic foramen) that is not covered by the levator
coccygeus, is a short, sheet-like structure cover- ani complex. For this reason, it should also be
ing the sacrospinous ligament (Figs. 1.7 and considered as the muscle of the pelvic floor
1.15). It is located just below the inferior border (Figs. 1.15 and 1.20). A bulky piriformis muscle
of the piriformis muscle and is considered to be may contribute to narrowing of the mesorectal
rudimentary in humans [29]. The coccygeus compartment. The medial origin of the muscle is
muscle creates the most posterior part of the leva- directly related to the sacral foramina and the
tor ani muscle, and some of the fibers of this sacral nerve roots. The sacral nerve plexus rests
muscle are able to reach the lower sacrum, upper on the anterior surface of the piriformis muscle
1  Rectal Anatomy: Clinical Perspective 13

Fig. 1.18  Bulging of

posterior levator ani
muscles (domes of
iliococcygeus muscles
marked with white
arrow), mesorectal
compartment (red
arrow), lateral
compartment (green
arrow), parietal fascia
(dotted line) MRI, T2
sequence, coronal view

(Fig. 1.16). The piriformis fascia covers the sur-

face of the muscle and is in direct contact with the
endopelvic (presacral) fascia.

Deep Transverse Perineal Muscle

The deep transverse perineal muscle is a sheet-­

like structure between the inferior pubic rami.
It is located anterior to the sphincter muscle
complex and directly underneath the hiatal liga-
ment, covering the urogenital hiatus of the leva-
tor ani. It also contains an anterior opening Fig. 1.19  Rectococcygeus muscle (white arrow), right
surrounded by the circular urethral sphincter iliococcygeus muscle (red arrow)
as well as the vaginal opening in women
(Fig. 1.21).

Superficial Transverse Perineal Muscle

The superficial transverse perineal muscle is a

narrow band-like, paired muscular structure that
is spread between the ischial tuberosity across the
center of the perineum (Fig. 1.21). Both muscles
join in the center, in front of the sphincter muscle
complex, and contribute to the creation of the
perineal body. The muscles are in direct contact
with the deep transverse perineal muscle located
directly above them. Fig. 1.20  Piriformis muscle, MRI, T2 sequence
14 S. Marecik et al.

 ther Structures Associated

O the sacral bone, the sacrospinous ligament is
with Pelvic Floor closely related to the sacrotuberous ligament,
which spans from the lower sacrum to the
 acrospinous and Sacrotuberous
S ischial tuberosity. Both of these ligaments
Ligaments should be divided during sacral amputations.
The pudendal nerve and the internal pudendal
The sacrospinous ligament (SSL) is a triangular-­ vessels pass behind the SSL, wrapping around
shaped ligament attached to the lower sacrum it medially and inferiorly to enter Alcock’s
and the ischial spine (Fig. 1.22). At its base on canal.

Mons pubis

Clitoris

Bulbospongiosus Urethra
Gracilis muscle
Vagina
Semitendinosus
muscle Deep transverse
perineal muscle
Ischio cavernosus
Ischial tuberosity Superficial transverse
perineal muscle
External anal
sphincter muscle Anus
sacrotuberous Levator ani muscle
ligament
Obturator fascia Gluteus maximus
muscle
Anococcygeal
ligament Coccyx

Ischio cavernosus
Gracilis muscle
Bulbospongiosus
Semitendinosus
muscle Deep transverse
Anus perineal muscle

Ischial tuberosity Superficial transverse

perineal muscle
Alcock’s canal External anal sphincter

Anococcygeal Levator ani muscle

ligament
Gluteus maximus

Coccyx

Fig. 1.21  Muscles of perineum

1  Rectal Anatomy: Clinical Perspective 15

Iliolumbar lig.

Posterior
sacro-iliac ligs

Greater sciatic
foramen

Superifical
Posterior
sacrococcygeal Deep
ligs. Sacrospinous lig.
Lateral
Sacrotuberous lig.
sacrococcygeal
lig. Lesser sciatic
foramen

Ischial tuberosity

Tendon of long head

of biceps femoris m.

Posterior view

Anterior longitudinal lig.

Iliolumbar lig.

Anterior
sacro-iliac lig.

Intervertebral
disc
Greater sciatic
foramen

Sacrotuberous lig.

Sacrospinous lig.

Ischial spine
Lesser sciatic
foramen
Anterior
sacrococcygeal
ligs.

Obturator foramen
Pubic symphysis

Anterior view

Fig. 1.22  Sacrospinous and sacrotuberous ligaments

16 S. Marecik et al.

Alcock’s Canal of the left colon vascular anatomy is critical to

maintain sufficient blood supply in the segment
Alcock’s canal, also known as the pudendal canal, used for reconstruction.
is a tunnel-like fascial structure containing the
internal pudendal vessels and the pudendal nerve.
It originates at the inferior sciatic foramen just Inferior Mesenteric Artery
below the ischial spine and the sacrospinous liga-
ment. Alcock’s canal runs anteriorly along the infe- The inferior mesenteric artery (IMA) originates
rior border of the internal obturator muscle and the from the abdominal aorta [30]. In most cases, the
inferior ileo-pubic ramus and then pierces the uro- IMA is located 3–4 cm below the third portion of
genital membrane to supply the genitals (Fig. 1.21). the duodenum (Fig. 1.25). In obese patients, the
IMA is surrounded by the adipose tissue of the
mesocolon. Occasionally, some adhesions are
Arterial Blood Supply encountered between the mesentery of the small
bowel and the mesocolon, thus obscuring access
The inferior mesenteric artery provides the to the vessel root. The fibers of the (pre)aortic
blood supply to the left colon and the rectum nerve plexus condensate below the inferior mes-
(Fig.  1.23). The rectum and the anus are also enteric artery and can adhere to it (Fig. 1.27). The
supplied by the internal iliac system or hypo- main trunk of the IMA gives the left colic artery,
gastric vessels (Fig. 1.24). The rectum, in con- while the main vessel continues along the left
trast to the colon, is almost never subject to side of the aorta toward the promontory. The left
significant ischemia, unless due to iatrogenic colic artery gives away its first ascending branch
reasons. Because the left colon is often used as that runs cephalad in the direction of the splenic
a substitute of the resected rectum, knowledge flexure in close proximity to the inferior mesen-

Fig. 1.23  Arterial blood

supply to the left colon

Ascending branch
of left colic artery

Marginal artery
of Drummond
Inferior mesenteric
artery
Left colic artery
Sigmoid arteries

Left common iliac

artery
Bifurcation of
superior rectal
artery
1  Rectal Anatomy: Clinical Perspective 17

Abdominal aorta

Right common
iliac a.
Ureters

External iliac a. Umbilical artery.

(cut) (patent part)
Internal iliac a. Superior gluteal a.
Posterior division Piriformis m.
Anterior division Internal pudendal a.
Obturator a. Inferior gluteal a.
Uterine a. (Ischio-)Coccygeus m.

Superior Middle rectal a.

vesical aa. Vaginal a.
Inferior vesical a.
Obturator canal
Internal
Medial umbilical lig, pudendal a.
(occluded distal part
Inferior rectal a.
of umbilical a.)
Levator ani m.

Fig. 1.24  Arterial blood supply to the pelvis

Marginal Artery

The marginal artery of Drummond is a conduit

system of collateral arterial networks along the
mesenteric border of the entire colon. This system
connects the superior and inferior mesenteric
arteries, which is of particular importance during
rectal and sigmoid resections when the inferior
mesenteric artery is divided. The marginal artery
of Drummond provides the main blood supply to
the segment of the left colon used for reconstruc-
tion (Fig. 1.23).

Fig. 1.25  Origin of the inferior mesenteric artery several

centimeters below the third portion of duodenum
Superior Rectal Artery

teric vein, usually within 1 or 2 cm although this The superior rectal artery (SRA) is a continuation
anatomy is quite variable. The rest of the left of the IMA. The SRA runs in the base of the
colic artery continues to supply the left colon and rectosigmoid mesentery and comes closer to the
also communicates with the sigmoid branches. bowel due to the shortening of the mesocolon at
18 S. Marecik et al.

the rectosigmoid junction. Here, it gives away the eral sacral artery, and the superior gluteal artery.
rectosigmoid branch followed by the upper rectal During dissection in this lateral compartment, a
branches which split into the left and right termi- “trifurcation” of vessels may be encountered and
nal branches running downward in the posterolat- can lead to bleeding if not adequately identified
eral aspects of the mesorectum. In the lower half and controlled. The anterior trunk runs through
of the mesorectum, they communicate with the the lateral pelvic compartment and gives off the
branches from the middle rectal vessels and via obturator artery, umbilical and superior vesical
the intramural network with the inferior rectal vessels, uterine artery (in women), inferior vesi-
arteries [31]. cal artery, middle rectal artery, inferior gluteal
artery, and the terminal branch, the internal
pudendal artery. A loose fascial plane can be
Middle Rectal Arteries found spread between the IIA and its branches
extending toward the bladder (Fig. 1.24).
The middle rectal artery (MRA) is a branch of the
internal iliac artery. The MRA participates in the
intensive collateral network with the SRA and Internal Pudendal Arteries
the inferior rectal arteries.
The internal pudendal artery (IPA) is the terminal
branch of the anterior trunk of the internal iliac
Inferior Rectal Arteries artery. It originates at the level of the inferior bor-
der of the piriformis muscle and crosses the pel-
The inferior rectal artery (IRA) is the main vessel vic floor to enter the pudendal canal (Alcock’s
supplying the blood flow to the anal canal and the canal) after wrapping behind the sacrospinous
sphincter muscle complex. It is a branch of the ligament. In the posterior (proximal) aspect of
internal pudendal artery arising in the proximal the pudendal canal, it gives away the inferior rec-
(posterior) portion of Alcock’s canal. After leav- tal artery (IRA) and continues anteriorly to sup-
ing Alcock’s canal, the IRA traverses the fat of ply the genitals (Figs. 1.21 and 1.24).
the ischioanal fossa from the posterolateral direc-
tion. It subsequently splits into the smaller
branches supplying the sphincter muscle com- Middle Sacral Artery
plex. There is no extramural communication
between the IRA and MRA. Rather, a very effi- The middle sacral artery originates in the poste-
cient intramural collateral network exists between rior aspect of the aortic bifurcation, and it
these two vessels. descends in the midline on the surface of the
sacrum.

Internal Iliac Arteries

Venous Drainage
The internal iliac artery (IIA), traditionally
known as the hypogastric artery, is the main The veins of the left colon and the anorectum
artery supplying the pelvis. The IIA supplies the generally follow the corresponding arteries. The
walls and viscera of the pelvis, the buttocks, and main exception involves the cephalad part of the
the genitourinary organs, as well as the medial inferior mesenteric vessels. The venous drainage
compartment of the thigh. The IIA originates of the left colon is directed into the liver via the
next to the promontorium and descends toward inferior mesenteric vein (IMV) to the portal sys-
the greater sciatic foramen. The posterior trunk is tem. The rectum is drained through both the por-
short and gives off the iliolumbar artery, the lat- tal and the caval systems.
1  Rectal Anatomy: Clinical Perspective 19

 ectal Veins (Superior, Middle,

R the inferior pancreatic border and cephalad to its
Inferior) splenic flexure branch.
The IMV can almost always be seen at the
The superior rectal vein drains the rectum and base of the descending mesocolon, even in obese
upper anal canal and is one of the main tributar- individuals. This is in contrast to the IMA, which
ies of the IMV. The middle rectal veins drain the is frequently obscured at its origin by the adipose
lower rectum and the upper anal canal and return tissue. It is not uncommon, however, for
the blood to the internal iliac veins. The inferior ­adhesions between the small bowel mesentery,
rectal veins drain the lower anal canal via the the transverse, and the left mesocolon to obscure
internal pudendal veins into the internal iliac access.
veins.

Internal Iliac Veins

Inferior Mesenteric Vein
The internal iliac vein with its tributaries is a
The IMV is created by the confluence of the paired vessel, accompanying its namesake artery.
superior rectal vein and the left colic vein. It joins the external iliac vein to form the com-
Initially, it runs in the base of the left mesocolon mon iliac vein just above the sacroiliac joint.
lateral from the inferior mesenteric artery. After
crossing the left colic artery, it then runs cephalad
as the most medial vascular structure accompa- Presacral Venous Plexus
nied by the ascending branch of the left colic
artery. Of note, there is no corresponding artery The middle (median) sacral vein, two lateral
to this segment of the IMV. At approximately sacral veins, and the intercommunicating veins
2–3 cm below the pancreatic border, it receives comprise the presacral venous plexus. It is an
its last branch from the splenic flexure (Fig. 1.26). avalvular system communicating with the internal
It then passes laterally from the ligament of Treitz vertebral venous system of the sacrum through
and behind the body of the pancreas to enter the the basivertebral vessels emerging from the sacral
splenic vein. In order to obtain full mobilization foramina [32]. These veins are easily avulsed dur-
of the left colon for reconstruction following rec- ing improper dissection. The hydrostatic pressure
tal resection, the IMV should be ligated below of the basivertebral vein system can achieve
20 cm H2O [32] and can cause life-­threatening,
difficult to control hemorrhage. The lateral sacral
veins run in close relation to the sacral foramina,
on the surface of the sacral nerve roots and the
sacral origin of the piriformis muscle.

Lymphatic Drainage

The mesorectum is the most important site of the

lymph node metastasis from rectal cancer.
Although rare, it is possible to develop distant
metastasis without locoregional metastasis within
the mesorectum or the lateral pelvic compart-
Fig. 1.26  Base of the inferior mesenteric vein (white ment. The lymphatic drainage of the anorectum
arrow), right below the pancreas (a); the splenic flexure follows the corresponding arteries, with the
tributary is marked with the red arrow
exception of the vessels of the lower anal canal.
20 S. Marecik et al.

Thus, the upper two thirds of the rectum drains

into the local lymph nodes along the superior rec-
tal vessels, and from there, it is transported to the
lymph nodes along the inferior mesenteric artery
and subsequently to the para-aortic lymph nodes.
Lymph drainage from the lower third of the rec-
tum and proximal anal canal travels cephalad
along the superior r­ectal vessels and laterally to
the internal iliac and obturator lymph nodes.
From the proximal anal canal, drainage follows
the same pattern as for the lower third of the rec-
tum, whereas below the dentate line, the drainage
may lead to the deep and superficial inguinal Fig. 1.27  Inferior mesenteric plexus (left and right side
lymph nodes. components)

Innervation

The colon, rectum, anus, and urogenital organs

are innervated by sympathetic and parasympa-
thetic fibers of the autonomic nervous system.
The pelvic floor and the external sphincter are
comprised of skeletal muscle and innervated by
motor neurons, while the anus is also supplied by
sensory nerve fibers.

I nferior Mesenteric and Superior

Fig. 1.28  Superior hypogastric plexus (white arrow) and
Hypogastric Plexus hypogastric nerves (red arrows)

The inferior mesenteric plexus and the superior

hypogastric plexus (SHP) are the continuation of Hypogastric Nerves
the preaortic sympathetic plexus, located on the
anterior surface of the aorta with fibers originat- The fibers of the SHP condensate at the sacral
ing from the spinal cord segments L1–L3. The promontory to form two hypogastric nerves
inferior mesenteric plexus is situated around the (Fig.  1.28). These structures run distally toward
origin of the inferior mesenteric artery (Fig. 1.27). the deep posterior pelvis joining with the inferior
The SHP is located between the aortic bifurca- hypogastric (pelvic) plexus and should be identi-
tion and the sacral promontory. During surgical fied to avoid injury during rectal dissection. At the
dissection, it is important to appreciate the con- base of the rectosigmoid mesocolon, the hypogas-
tinuous network of nerve fibers that form a dis- tric nerves are located underneath the peritoneum.
tinct nerve layer on the anterior aortic surface and The hypogastric nerves are created by sympathetic
in front of the promontory. Along the left side of fibers, although they contain a few ascending para-
the aorta, this nerve layer runs close to the fascial sympathetic fibers (from the sacral plexus). At the
reflection, separating the left mesocolon from the level of the mid-rectum, each hypogastric nerve
retroperitoneum. This proximity makes it vulner- joins the parasympathetic nerve fibers from the
able to injury while incising and entering this fas- sacral plexus to form the inferior hypogastric
cial reflection. (pelvic) plexus (Figs. 1.29).
1  Rectal Anatomy: Clinical Perspective 21

sacral nerves running caudal and parallel to the

hypogastic nerve (Fig. 1.16). The parasympa-
thetic component is delivered by nervi erigentes
that originate from the sacral plexus (S2–S4) and
run in the posterior aspect of the lateral compart-
ment [33]. The efferent nerves continue on
within the neurovascular bundles along the pos-
terolateral aspect of the prostate gland (or
vagina), where they are particularly susceptible
to injury during the anterior dissection of the
distal rectum [34].

Fig. 1.29  Pelvic plexus (b) exposed after total mesorectal

excision with the left hypogastric nerve (a) and sacral Lumbosacral Plexus
splanchnic nerves (arrow); dome of the left iliococcygeus
muscle (x) and Denonvilliers’ fascia (y) The lumbosacral plexus is a major neural struc-
ture that provides motor-sensory innervation to
the lower leg, posterior thigh, and part of the
pelvis through its contributions to the sciatic
nerve. It is located on the anterior surface of the
piriformis muscle in the posterolateral aspect of
the upper pelvis [35]. Locally advanced tumors
with posterolateral extension or those with neural
invasion may require en bloc resection of the
sacral nerve roots. Unilateral resection of S2 and
below will produce minimal functional deficits.

Obturator Nerve

Fig. 1.30  Lateral pelvic compartment on the left side; The obturator nerve that originates from the lum-
obturator nerve (n), obturator artery (oa) and internal iliac
bar plexus enters the pelvis underneath the com-
artery (iia) [courtesy of Prof. G.S. Choi]
mon iliac artery and just lateral from the internal
iliac artery and ureter. It is easily identified in the
Inferior Hypogastric (Pelvic) Plexus lateral pelvic compartment running toward the
obturator foramen and is a key anatomical land-
The pelvic plexus (PP) is the major autonomic mark during lateral pelvic lymph node dissection
coordinating center within the pelvis. Together (Fig. 1.30). This nerve carries the sensory fibers
with the SHP, it is frequently referred to as the from the inner thigh and the motor fibers to the
“pelvic brain”. The pelvic plexus is embedded adductor muscles. It does not, however, innervate
within the parietal pelvic fascia just above the the internal obturator muscle.
origin of the levators and associated with the
LTS (Figs. 1.12, 1.13 and 1.29). The PP is
formed by sympathetic and parasympathetic Pudendal Nerve
nerve fibers that supply the rectum and all other
pelvic organs. The sympathetic component is The pudendal nerve is the main nerve of the
delivered by the hypogastric nerve as well as the perineum, ultimately involved in sensation, pel-
presacral sympathetic ganglia via the splanchnic vic floor muscle innervation, and continence. It
22 S. Marecik et al.

originates from the fibers of the sacral plexus and rovascular bundle, or the prostate gland itself
leaves the pelvis between the piriformis and the requiring en bloc resection.
coccygeus muscles, wrapping around the sacro- Similarly, in women, locally advanced tumors
spinous ligament to enter Alcock’s canal where it may involve the uterus or vagina which should
accompanies the internal pudendal vessels also be resected with the principle of complete,
(Figs.  1.16, 1.21). It ultimately supplies the en bloc resection. There exists abundant blood
sphincter and the inferior surface of the pelvic supply to the vagina and an associated venous
floor muscles. The pudendal nerve carries sensa- plexus. Dissection too close to the vagina can
tion from the anus and external genitalia and result in unexpected bleeding.
innervates the external anal and urethral
sphincters.
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