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The presacral component of the visceral pelvic fascia and its relation to the pelvic splanchnic innervation of the bladder.

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The Presacral Component of the Visceral Pelvic
Fascia and its Relation to the Pelvic
Splanchnic Innervation of
the Bladder
W. H. ROBERTS A N D W. HOLMES TAYLOR
Department of Anatomy, Schools of Medicine and Dentistry,
Lorna Linda University, Lorna Linda, California 92354
ABSTRACT
The relation of the autonomic nerve supply of the pelvis to the visceral
pelvic fascia and i n particular that of the parasympathetic supply to the bladder
musculature is of particular consequence i n pelvic operations. It is observed that the
pelvic splanchnics, including those bramhes supplying the bladder, are embedded in
the peripheral component of the visceral pelvic fascia or presacral fascia throughout
a considerable part of their course. Early anatomists made no distinction between the
presacral fascia and the fascial sheath OF the rectum proper. Consequently their illustrations shown only a single fascial layer which they call the “rectal fascia” or “posterior fibrous sheath of the rectum” separating the middle sacral vessels from the
superior rectal vessels which lie in the pararcctal fat. While such a distinction has
since been made i n the surgical literature, most anatomical descriptions are still rather
vague in this respect. It is essential to develop the plane of cleavage between the
presacral fascia and the fascial sheath of the rectum if injury to the pelvic splanchnic
nerves is to be avoided.
The subperitoneal fascia of the posterior
body wall at the pelvic brim becomes the
presacral fascia and finally fuses with thc
fascial sheath of the rectum just above the
ano-rectal junction, as stated by Wilson
(’67). The true parietal fascia fuses with
the sacral periosteum after passing off the
parietal musculature, i.e., the obturator internus and piriformis muscles.
Waldeyer and Joessel (1899) did not differentiate between the presacral fascia and
the fibrous sheath of the rectum proper so
speak simply of a “rectal fascia,” corresponding to the “posterior fibrous sheath
of the rectum” of Paitre, Giraud and Dupret (’35). Pernkopf (’64) and the translator of the German text of 1943, likewise
show these layers as a single entity. Close
(’47), Bruce, Walmsley and Ross (’64)
and Goligher (’67) recognize the importance from an applied standpoint of differentiating what the first-mentioned calls
the “presacral component of the visceral
pelvic fascia” and the others the “parietal
fascia of Waldeyer” from the fascial sheath
of the rectum.
Paitre, Giraud and Dupret (’35) in their
drawings of dissections made from below,
ANAT. REC., 166: 207-212
show the pelvic splanchnics outside the
“posterior fibrous sheath of the rectum”
and hence outside the presacral fascia.
Goligher (’67) and Ballantyne and Smith
(’68) likewise state that these nerves, in
particular those supplying the bladder, lie
outside the “parietal pelvic fascia of Waldeyer,” at least until they enter the vesicovaginal septum. However, our findings are
in accord with those of Ashley and Anson
(’46), Uhlenhuth, Wolfe, Smith and Middleton (’48) and of Wilson (’67). The pelvic splanchnics, including those fibers supplying the bladder, we find to be embedded
in the presacral fascia for a considerable
part of their course as noted previously by
one of us (Roberts, Habenicht and Krishingner, ’64; Roberts, Hunt and Henken,
’68). Differences in methods of dissection
could explain the discrepancy.
The incidence of vesical dysfunction following abdorninoperineal resection of the
rectum, and due to unilateral or bilateral
paralysis of the bladder musculature, was
at one time surprisingly high, as shown by
Hill, Barnes and Courville (’38). Mallik
(’61) at the time of his study stated that
Received May 26, ’63. Accepted Sept. 24, ’69.
207
208
W. H. ROBERTS AND W. HOLMES TAYLOR
FINDINGS
the incidence was low for such surgery
but still high in certain gynecological operIn the intact specimen i t is quite easy
ations. Goligher ('67) believes that the to differentiate between the fibrous sheath
branches to the bladder are injured in rec- of the rectum and the presacral fascia. The
tal surgery, not so much by stripping the presacral fascia ensheaths the internal iliac
presacral fascia off the sacrum as by cut- artery and its parietal branches, including
ting the nerves too near their base. Bal- the umbilical artery, and also the ureters.
lantyne and Smith ('68) are of the opin- The latter, however, tend to withdraw from
ion that the nerves are damaged in the this fascia1 layer since they are anterior to
Wertheim type of radical hysterectomy the vessels. The presacral fascia attaches
either at the root of the broad ligament or laterally to the arcus tendineus of the pelwhere they lie in the vesicovaginal septum, vic fascia, at which level it is reflected onto
in the process of resecting the upper va- the pelvic viscera. The rectum and posterior urethra, and the vagina in the female,
gina.
paralleling as they do the pelvic axis, cross
MATERIALS AND METHODS
the line of the arcus tendineus at more or
In this particular study ten human pel- less right angles. The peripheral attachves were dissected, five male and five fe- ment of the presacral fascia to the arcus
male, both from above and below.
tendineus provides the viscera with, as
Fig. 1 Posterior view, body prone. The ischiorectal fossa has been cleared of its fat and
the inferior rectal nerve and vessels exposed. The anococcygeal body has been excised and
a window made i n the inferior fascia of the pelvic diaphragm to expose the levator ani
and the anococcygeal raphe.
PELVIC FASCIA AND PELVIC SPLANCHNICS
Close (’47) puts it, “efficient guy-ropes”
and at the same time adequately supports
the nervous elements embedded in it.
Figures 1-4 show the stages of dissection in an approach from below and behind and which is meant to display the
relation of the pelvic splanchnic nerves to
the presacral fascia. Before doing this it
is best to develop the fascial cleft between
the presacral fascia and the fascial sheath
of the rectum from above as far as it is
convenient to do so, which is almost to
the level of the pelvic floor. The presacral
fascia, as seen in figure 4 has two leavss,
an anterior and a posterior. The anterior
leaf is reflected back onto the rectum 2-3
cm above the anorectal junction and fuses
with the fascia propria at this level. The
posterior leaf, which is more firmly attached to the mid-sacrum, joins the converging fibers of the levator ani and its
209
fasciae to insert between the internal and
external anal sphincters. The presacral
fascia is seen to form a significant part of
the conjoined fasciae.
While the nerve to the levator ani is outside the presacral fascia the pelvic splanchnics are invested by it and lie between the
anterior and posterior leaves of the fascia.
One or the other of these leaves must be
broken through to expose them, depending
on whether the approach is from above or
below. The branches of the pelvic splanchnic nn. to the rectum, cervix and vagina
and bladder peel off at appropriate levels
as they pass from behind forwards within
the fascia. Those to the rectum traverse the
so-called “lateral ligaments of the rectum”
along with the middle rectal vessels when
these are present (fig. 5). It would be essential that the main body of the presacral
fascia be left intact if the branches of the
Fig. 2 The coccyx has been excised. Incisions to be made in the levator ani, as the dissection proceeds, are indicated. A n unusually well-defined puborectalis component of the
levator was present in this case.
Fig. 3 Reflection of the levator a n i and the superior fascia of the pelvic diaphragm brings the
presacral fascia into view. It is noted that the nerve to the levator ani supplies the muscle on its
superior surface. The incision to be made in the presacral fascia, and just above the level at which
it fuses with the fascia1 sheath of the rectum, is indicated.
Fig. 4 Sagittal section as viewed from the medial side and from behind. The posterior leaf of
the presacral fascia has been incised so as to develop the plane of cleavage between the rectum and
the posterior wall of the vagina. It is observed that the pelvic splanchnic nn. to the rectum, also
those to vagina and bladder are between the two leaves of the fascia, and anterior and a posterior.
PELVIC FASCIA A N D PELVIC SPLANCHNICS
211
Fig. 5 Posterior view of a second specimen showing rectum freed up and relation of
presacral fascia to it. “Lateral ligament of the rectum” or mesorectum containing branches
of pelvic splanchnics to the rectum, and middle rectal vessels is shown.
pelvic splanchnics to the bladder and viscera other than the rectum are to be preserved.
DISCUSSION
In a specimen where the body has be1.n
horizontally transected near the lumbosacId junction one is more likely in the process of dissection to reflect both the presacral fascia and the fascia propria of t.he
rectum as one. This is probably why earlier
anatomists did not distinguish between
them. Further if one concentrates on EXposing the pelvic splanchnics from below
it is often easy to inadvertently pull them
out of the Dresacral fascia in which they
are embeddkd. In specimens in which the
presacral fascia is well developed it is qujte
apparent that the nerves lie within it.
While only illustrations of the findings in
the female have been shown the relationships are essentially the same in the male.
CONCLUSIONS
Both the main sympathetic supply to
the pelvic viscera and the pelvic splanchnics are embedded in the presacral fascia.
A correct understanding of this relationship
would aid in reducing to the minimum the
incidence of bladder dysfunction due to a
unilateral or bilateral paralysis of the bladder wall musculature and resulting from
their injury.
ACKNOWLSDGMENT
The fine art work of Mrs. Lucille Innes
is much appreciated.
212
W. H. ROBERTS A N D W. HOLMES TAYLOR
LITERATURE CITED
Anson, B. J. 1963 A n Atlas of Human Anatomy. W. B. Saunders Co., Philadelphia, p. 507.
Ashley, F. L., and F. J. Anson 1946 The pelvic
autonomic nerves in the male. Surg. Gynec.
and Obstet., 82: 598-602.
Ballantyne, B., and P. H. Smith 1968 Surgical
anatomy of the extrinsic innervation of the
human female urinary bladder. J. Anat., 103:
199.
Bruce, J., R. Walmsley and J. A. Ross 1964
Manual of Surgical Anatomy. Williams and
Wilkins, Baltimore, p. 431.
Close, W. J. 1947 The pelvic fascia, its significance to the surgeon. Med. J. Australia, 1:
490-494.
Goligher, J. C. 1967 Surgery of the Anus, Rectum and Colon, 2nd Ed. Bailliere, Tindall and
Cassell, London, pp. 7-8, 15-16, 34-35.
Hill, M. R., R. W. Barnes and C. B. CourviIle
1937 Vesical dysfunction following abdominoperineal resection for carcinoma of the rectum. J. A. M. A., 109: 1184-1188.
Mallik, M. K. B. 1961 A study of the urinary
bladder following Wertheim hysterectomy with
special reference to the incompetence of the
urethral and ureteric orifices. J. Obstet. Gynaec.
Br. Commonw., 68: 945-951.
Paitre, F., D. Giraud and S. Dupret 1935 Pratique Anatomo-Chirurigicale Illustrke, Abdomen. Fasc. 11. G. Goin et Cie, Paris, pp. 379,
393, 412, 427.
Pernkopf, E. 1964 Atlas of Topographic and
Applied Human Anatomy. H. Ferner, ed., H.
Monsen, tr. W. B. Saunders Co., Philadelphia,
vol. 11, p. 292.
Roberts, W. H., J . Habenicht and G. Wishingner
1964 The pelvic and perineal fasciae and
their neural and vascular relationships. Anat.
Rec., 149: 707-720.
Roberts, W. H., G. M. Hunt and H. W. Henken
1968 Some anatomic factors having to do with
urinary continence. Anat. Rec., 162: 341-347.
Uhlsnhuth, E., W. M. Wolfe, E. M. Smith and
E. B. Middleton 1948 The rectogenital septum. Surg. Gynec. and Obstet., 86: 148-163.
Waldeyer, W., and G. Joessel 1899 Lehrbuch
der Topographisch-Chirurgischen Anatomie Des Becken. Zweiter Theil. F. Cohen, Bonn.
pp. 552-555, 633, 733, 905.
Wilson, P. M. 1967 Anchoring mechanisms of
the ano-rectal region. 11. S. Afr. Med. J., 41'
1138-1143.
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visceral, pelvic, relations, bladder, fasciae, components, presacral, innervation, splanchnic
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