ORIGINAL CONTRIBUTION
Perirectal Fascial Anatomy: New Insights Into an
Old Problem
Sigmar Stelzner, M.D., Ph.D.1 • Tillmann Heinze M.D.2 • Taxiarchis K. Nikolouzakis, M.D.2,3
Sören Torge Mees, M.D., M.M.I.S., M.H.B.A.1 • Helmut Witzigmann, M.D., Ph.D.1
Thilo Wedel, M.D., Ph.D.2
1 Department of General, Visceral and Thoracic Surgery, Dresden-Friedrichstadt General Hospital, Dresden, Germany
2 Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Germany
3 Laboratory of Anatomy, Histology, Embryology, Medical School of Heraklion, University of Crete, Heraklion, Crete, Greece
Downloaded from http://journals.lww.com/dcrjournal by BhDMf5ePHKbH4TTImqenVA+lpWIIBvonhQl60EtgtdlLYrLzSPu+hUapVK5dvms8 on 12/12/2020
BACKGROUND: The architecture of perirectal fasciae is
complex as mirrored by different anatomical concepts.
OBJECTIVE: This study aimed to perform a
comprehensive visualization of perirectal fasciae
to facilitate strategies of rectal surgery such as total
mesorectal excision, intersphincteric resection, and
transanal total mesorectal excision.
DESIGN: Macroscopic dissection and histologic studies
of perirectal fasciae and autonomic pelvic nerves were
performed.
SETTINGS: This study was conducted in a university
laboratory of macroscopic and microscopic anatomy.
PATIENTS: Thirteen (5 female) pelvic specimens were
obtained from body donors (67–92 years of age).
MAIN OUTCOME MEASURES: The primary outcomes
measured were the photodocumentation of perirectal
fasciae, spaces and fusion zones, and histologic and
immunohistochemical analysis of key structures.
RESULTS: The retrorectal space is a mesofascial interface
between the mesorectal fascia and the parietal pelvic
fascia. The parietal pelvic fascia is composed of 2 lamellae
Funding/Support: None reported.
Financial Disclosures: None reported.
Presented at the meeting of the German Society of Coloproctology, Mu-
nich, Germany, March 15 to 16, 2019, and at the meeting of the Euro-
pean Society of Coloproctology, September 25 to 27, 2019, Vienna.
Correspondence: Sigmar Stelzner, M.D., Department of General, Vis-
ceral and Thoracic Surgery, Dresden-Friedrichstadt General Hospital,
Friedrichstr. 41, 01067 Dresden Germany. E-mail: stelzner-si@khdf.de
Dis Colon Rectum 2021; 64: 91–102
DOI: 10.1097/DCR.0000000000001778
© The ASCRS 2020
DISEASES OF THE COLON & RECTUM VOLUME 64: 1 (2021)
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
ensheathing the autonomic pelvic nerves. The outer
lamella of the parietal pelvic fascia and the presacral
fascia confine the presacral space. The presacral fascia
covers the median sacral blood vessels. Approximately
at the fourth sacral vertebra, all fascial layers fuse in the
midline and are densely connected to the posterior rectal
wall via the rectosacral ligament. The parietal pelvic fascia
fuses with the pubococcygeal and longitudinal rectal
muscles at the anorectal junction. Anterolaterally, the
neurovascular bundles are closely related to this fascial
fusion zone and the rectogenital septum.
LIMITATIONS: Because of the increased age of the body
donors, the findings may be subjected to age-related
degenerative processes.
CONCLUSIONS: The 2 lamellae of the parietal pelvic
fascia and the fascial fusion zones are key structures of
perirectal anatomy. For autonomic nerve preservation,
the recognition of the inner lamella of the parietal pelvic
fascia is crucial. To avoid inadvertent rectal perforation or
accidental presacral dissection, the rectosacral ligament
must be identified and transected for complete rectal
mobilization. See Video Abstract at http://links.lww.com/
DCR/B389.
ANATOMÍA FASCIAL PERIRRECTAL: NUEVOS
CONCEPTOS SOBRE UN ANTIGUO PROBLEMA
ANTECEDENTES: La arquitectura de las fascias
perirrectales es compleja, reflejada por distintos
conceptos anatómicos.
OBJETIVO: Integración de conceptos sobre las fascias
perirrectales para facilitar las estrategias de cirugía
rectal, como la escisión mesorrectal total, la resección
interesfintérica y la escisión mesorrectal total transanal.
DISEÑO: Disección macroscópica y estudios histológicos
de fascias perirrectales y nervios pélvicos autonómicos.
91
 92
AJUSTES: Laboratorio universitario de anatomía
macroscópica y microscópica.
PACIENTES: Trece (5 mujeres) muestras pélvicas
obtenidas de donantes de cuerpo (67-92 años).
PRINCIPALES MEDIDAS DE RESULTADO: Foto
documentación de fascias perirrectales, espacios y zonas
de fusión, análisis histológico e inmunohistoquímico de
estructuras claves.
RESULTADOS: El espacio retrorectal es una interfaz
mesofascial entre la fascia mesorrectal y la fascia pélvica
parietal. Este último se compone de dos láminas que
envuelven los nervios pélvicos autonómicos. La lámina
externa de la fascia pélvica parietal y la fascia presacra
definen el espacio presacro. La fascia presacra cubre los
vasos sanguíneos sacros medianos. Aproximadamente en
la cuarta vértebra sacra, todas las capas fasciales se unen
en la línea media y están densamente conectadas a la
pared rectal posterior a través del ligamento rectosacro.
La fascia pélvica parietal se une con los músculos rectal
pubococcígeo y longitudinal en la unión anorrectal.
Anterolateralmente, los haces neurovasculares están
estrechamente relacionados con esta zona de fusión
fascial y el tabique rectogenital.
LIMITACIONES: Debido al aumento de la edad de los
donantes de cuerpos, los hallazgos pueden estar sujetos a
procesos degenerativos relacionados con la edad.
CONCLUSIONES: Las dos láminas de la fascia pélvica
parietal y las zonas de fusión fascial son estructuras
claves de la anatomía perirrectal. Para la preservación
del nervio autónomo de nervios pélvicos autonómicos,
el reconocimiento de la lámina interna de la fascia
pélvica parietal es importante. Para evitar la perforación
rectal inadvertida o la disección presacra accidental, el
ligamento rectosacro debe ser identificado y seccionado
para una movilización rectal completa. Consulte
Video Resumen en http://links.lww.com/DCR/B389.
(Traducción—Dr. Adrian Ortega)
KEY WORDS: Autonomic pelvic nerve preservation;
Mesorectal fascia; Parietal pelvic fascia; Perirectal fasciae;
Rectosacral ligament; Total mesorectal excision.
T
he understanding of the anatomy of pelvic fasciae
surrounding the rectum has evolved as a key factor
for successful surgery in rectal cancer. Dissection a-
long correct planes is fundamental to achieving optimal
oncologic results and to preserving anal, urinary, and sex-
ual functions.1–3 Since the introduction of total mesorectal
excision (TME) in the late 1970s,4 several concepts have
been propagated to describe the organization of perirec-
tal fasciae; however, these differed considerably regarding
both anatomical architecture and terminology.5–9
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STELZNER ET AL: PERIRECTAL FASCIAE
As early as in 1961, Friedrich Stelzner proposed his
model of adjacent lamellae in the true pelvis and described
the course of autonomic pelvic nerves along the multilay-
ered parietal pelvic fascia.10,11 However, although mobili-
zation of the upper rectum is readily achieved by adhering
to well-described dissection planes, the fusion of fascial
layers and the absence of self-opening planes at the an-
orectal junction often render the dissection of the lower
rectum difficult and require sharp transection. Inadvert-
ent opening and dissection along “wrong” interfaces can
lead to severe damage to autonomic pelvic nerves or trou-
blesome bleedings. Therefore, the recognition of perirec-
tal fasciae and their corresponding interfaces is mandatory
for rectal surgery, in particular, in procedures involving
the lower anorectum, eg, low anterior and transanal TME,
intersphincteric rectal resection, and abdominoperineal
excision.
The present anatomical study aimed to describe the
complex system of perirectal fasciae with respect to their
multilayered architecture, corresponding interfaces, and
fusion zones. Moreover, the course of autonomic pelvic
nerves was identified in relation to the perirectal fascial
envelope. Relevant conceptual steps during macroscopical
studies were complemented by histologic and immuno-
histochemical studies.
MATERIAL AND METHODS
Body Donors
Nine hemipelves (5 male, 4 female) and 4 entire pelves (3
male, 1 female) were obtained from body donors (67–92
years of age; mean age, 78.7 years) recruited from the body
donation program of the Institute of Anatomy, Christian-
Albrechts-University of Kiel, Germany. Body donors were
fixed by formalin (3%) perfusion via femoral arteries and
postfixed in ethanol (70%) before use. Previous pelvic dis-
eases were excluded, with the exception of 1 female spec-
imen with total hysterectomy. Hemipelves were divided
either midsagittally (n = 7) or parasagittally (n = 2). Two
of the complete pelves were exarticulated in the pubic
symphysis and sacroiliac joint at 1 side to gain access to the
true pelvis; the other 2 pelves were divided in an oblique-
coronal plane along the axis of the anal canal.
Macroscopic Studies
Dissection was performed using a magnification glass
(Zeiss KS, magnification 3.2×, focal distance 500 mm).
Procedural dissection steps were photodocumented with
a full HD digital camera (Olympus E 620, digital ED lens,
50 mm, 1:2 Macro) and processed by a software program
(Olympus Studio 2, version 2.3). Regions of interest were
preserved for further histologic workup. Macroscopic dis-
sections were tailored to the configuration of the speci-
mens and the resulting access to the pelvis.
 DISEASES OF THE COLON & RECTUM VOLUME 64: 1 (2021) 93

The first important step was the identification of the

mesorectal fascia and parietal pelvic fascia. The rectum
was mobilized following this interface in craniocaudal
direction and from medial to lateral as in TME. Dorsally,
connecting structures between the mesorectal and parie-
tal pelvic fascia were documented before separation. The
same procedure was performed for the lateral rectal con-
nections, before the rectum was released from the pelvic
side wall. Anteriorly, dissection started by incising the per-
itoneal reflection, followed the plane between the anterior
mesorectal fascia and the rectogenital septum, and was
performed from medial to lateral. Dissection stopped at
the level of the anorectal junction.
In a further step, the fascial layers and structures be-
yond the parietal pelvic fascia were identified and followed
again in craniocaudal and mediolateral direction. In this
way, all perirectal fasciae, interfaces, and fusion zones, as
well as autonomic pelvic nerves, were exposed. Finally,
at the level of the pelvic floor, the topographic relations
between the anorectal junction, levator ani muscle, exter-
nal anal sphincter, and nerve fibers from the pelvic plexus
were studied. All findings were numerically protocolled.
However, because of a tailored access to the regions of in-
terest, not all features were investigated in every specimen.

Microscopic Studies
For histologic examination, tissue samples were taken from
key structures such as the parietal pelvic fascia including
ensheathed nerve fibers, the insertion site of the rectosa-
cral ligament into the rectal wall, and the rectogenital sep-
tum. Samples were dehydrated, embedded in paraffin wax,
cut into sections (6 µm), and processed for hematoxylin-
eosin and Azan stainings. Immunohistochemical stain-
ings were performed to identify autonomic nerve fibers
(peripheral glial cell marker S-100) and smooth muscle tis-
sue (alpha smooth muscle actin) as described previously.12
Slides were assessed with a light optical microscope
(Axiophot, Zeiss, Germany) and photographed with a dig-
ital camera (AxioCam, Zeiss, Germany).

RESULTS
Parietal Pelvic Fascia
Dorsolateral rectal mobilization following the surface of the
mesorectal fascia was possible in all specimens (Fig. 1A).
This step opened the retrorectal space that was posterolat-
erally confined by the parietal pelvic fascia (PPF). The PPF
was investigated in detail in 10 of 13 specimens and could be
lifted up from the sacrum like a distinct tarpaulin contain-
ing the hypogastric nerves and, more laterally, the ureters
(Figs. 1B and 2A). Subtle inspection showed that the PPF
was composed of an inner and outer lamella, the inner la-
mella bordering the retrorectal space and the outer lamella
FIGURE 1. Dorsolateral anatomy of perirectal fasciae and spaces.
A, The retrorectal space is opened by total mesorectal excision-like
mobilization of the mesorectum and delineated by the mesorectal
fascia anteriorly and the inner lamella of the parietal pelvic fascia
(PPF) posteriorly. B, Mobilization of the parietal pelvic fascia along
its outer lamella reveals the presacral space bordered posteriorly
by the presacral fascia. The parietal pelvic fascia ensheathes the
hypogastric nerves and the ureters. C, The presacral fascia can
be further dissected off the sacrum, exposing the median sacral
vessels. CIA = common iliac artery; CIV = common iliac vein;
EIA = external iliac artery; EIV = external iliac vein; IIA = internal iliac
artery. Formalin-fixed male pelvis, cranial view.

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 94 STELZNER ET AL: PERIRECTAL FASCIAE

FIGURE 2. Macroscopic and microscopic anatomy of the parietal pelvic fascia (PPF). A, The PPF is lifted up and depicted by diaphanoscopy.
The ensheathed superior hypogastric plexus and diverging hypogastric nerves are clearly discernible. Note the irregularly distributed adipose
tissue (asterisks) in between the lamellae of the PPF. Tissue for histologic studies was harvested from the red-dotted area. CIA = common iliac
artery. Formalin-fixed male pelvis, cranial view. B, Histologic section of the PPF containing hypogastric nerve fibers (NF, yellow-dotted circles)
of different sizes with occasionally intermingled nerve cells (NC), blood vessels, and adipose tissue. The inner and outer lamella (red-dotted
lines) of the PPF are clearly discernible and consist of connective tissue fibers (blue structures). Azan staining, magnification: 10×.

bordering another virtual space in front of the sacrum, thus
named presacral space (Figs. 1B and C, and 2A).
Diaphanoscopy revealed that the superior hypogastric
plexus, both hypogastric nerves and the craniodorsal por-
tion of the pelvic plexus, was ensheathed by the 2 lamellae
of the PPF, which also contained interposed adipose and
connective tissues of varying degree (Fig. 2A). Histologic
studies of the PPF confirmed the presence of an inner and
outer lamella and illustrated that the hypogastric nerve
was subdivided into multiple nerve bundles of different
sizes accompanied by small blood vessels (Fig. 2B).
At the level of the lateral rectal connections to the pel-
vic sidewall, autonomic rectal nerves diverged from the pel-
vic plexus, pierced the inner lamella of the PPF, and entered
into the rectum mostly at its dorsolateral aspect (Fig. 3).
Rectal nerve branches were accompanied by blood vessels
of varying size and number in 37.5% of cases. The PPF was
cranially continuous with the parietal fascia of the abdomi-
nal cavity and fused caudally with the conjoint longitudinal
muscle at the level of the anorectal junction (Fig. 4).
Separation of the mesorectal fascia from the inner
lamella of the PPF became more difficult, the more cau-
dally the dissection advanced. Anterolaterally, the in-
ner lamella of the PPF was contiguous with the inner
fringes of the Denonvilliers fascia. Nerve fibers embed-
ded within the PPF left the merging fascial tissue and
entered into the rectal wall at the anorectal junction just
above the fusion of the conjoint longitudinal muscle

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 DISEASES OF THE COLON & RECTUM VOLUME 64: 1 (2021) 95

FIGURE 3. Lateral anatomy of perirectal fasciae and connections to the rectum. The mesorectum is shifted contralaterally to expose the pelvic
sidewall. The inner lamella of the parietal pelvic fascia (PPF) is removed dorsolaterally to fully expose the herein embedded pelvic autonomic
nerves. The interface between the mesorectum and the PPF is bridged by numerous nerve fiber strands (green strips) supplying the rectum
(rectal nerves) and the internal anal sphincter. IASN = internal anal sphincter nerves. Formalin-fixed female right hemipelvis, medial view.

(Fig. 4A). These nerve fibers were identified as internal
anal sphincter nerves. In this way, a band-like fusion area
between the inner lamella of the PPF and the mesorectal
fascia extended along the lateral side of the rectum in o-
blique direction (Fig. 3). Whereas this lateral connection
was continuous with only small gaps between the nerve
fascicles in 33.3%, in the remaining 66.7% of cases a dis-
tinct space between rectal branches posterolaterally and
internal anal sphincter nerves anterolaterally could be
identified.
The outer lamella of the PPF exhibited a correspond-
ing area of fusion lateral to the rectum, beginning along
the pelvic splanchnic nerves on either side and stretching
out in a triangular shape over the branches of the internal

FIGURE 4. Anterolateral anatomy of perirectal fasciae and spaces at the level of the anorectal junction. The left (A) and right (B) two-thirds of
the specimen are shown at different stages of dissection. On the right side, the fused parietal pelvic fascia (PPF) merges with the longitudinal
muscle fibers of the rectum to form the conjoint longitudinal muscle together with the levator ani muscle (LAM). On the left side, this zone
of fusion (asterisk) is dissected from above giving access to the internal anal sphincter nerves (IASN) anterolaterally that diverge from the
neurovascular bundle (NVB) to penetrate into the rectal wall. IOM = internal obturator muscle. Formalin-fixed male pelvis, frontal section,
dorsocranial view.

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 96 STELZNER ET AL: PERIRECTAL FASCIAE

FIGURE 5. Anatomy of the presacral fascia. The mesorectum is shifted anteriorly. After dissection of the parietal pelvic fascia (PPF, pinned
laterally) and opening of the presacral space, the presacral fascia can be lifted from the sacrum, thereby exposing the median sacral vessels
running on the sacral periosteum. Formalin-fixed right male hemipelvis, medial view.

iliac vessels. From there, the PPF continued anteriorly to
encase the urogenital organs.
Presacral Fascia
The PPF could easily be separated from the sacrum,
thereby opening the presacral space (Figs. 1B and 2A).
This step was also performed in 10 of 13 specimens. The
concave sacral surface was covered by another thin fascia
that was clearly recognizable in all specimens investigated
for that purpose and termed presacral fascia. When lifting
up the presacral fascia from the sacral periosteum, sacral
blood vessels could be exposed, running mostly in the cra-
niocaudal direction in front of the sacral bone (Figs. 1C
and 5). These vessels corresponded to the median and lat-
eral sacral arteries and veins, and showed only a moderate
branching pattern, leaving most of the sacral bone surface
free of blood vessels; a dense presacral venous plexus could
not be found. Laterally, the presacral fascia was continuous
with the fascial covering of the internal iliac vessels and
their branches. In this area, the pelvic splanchnic nerves
originating from sacral spinal nerves (S2–S4) penetrated
into the outer lamella of the PPF to join the pelvic plexus.
Rectosacral Ligament
In 12 of 13 specimens, the midline area between the sac-
rum and the rectum was exposed. In 10 of 12 (83.3%) spec-
imens, a connective tissue condensation could be observed
extending between the sacrum and the rectum. This liga-
mentous structure (width approximately 1.5 cm) connect-
ed the lower dorsal rectal wall with the sacral periosteum
and corresponded to the rectosacral ligament (Fig. 6). The
sacral insertion site of the rectosacral ligament varied and
was found at the level of S2 (8.3%), S3 (33.3%), S4 (25.0%),
S5 (8.3%), and coccyx (8.3%). Along the course of the rec-
tosacral ligament, the presacral fascia fused with the PPF.
In this way, the rectosacral ligament represented both the
dorsal fusion area of perirectal fasciae and the sacral sus-
pension of the lower rectum (Figs. 7A and B). Histologic
studies could demonstrate that the connective tissue fiber
bundles firmly attached to the rectal wall and were accom-
panied by intermingled blood vessels originating from the
median sacral vessels (Figs. 7C and D).
Rectogenital Septum (Denonvilliers Fascia)
The anterior rectogenital area was dissected in 7 of 13
specimens. Following a TME-like approach, the Denonvil-
liers fascia could be identified between the anterior rectum
and the vaginal wall (Fig. 8A) or prostate (Fig. 8B) . The
distinctiveness of this fascia varied, but was recognizable
in both sexes. Its cranial portion appeared to be thicker
than the caudal portion. Mobilization of Denonvilliers
fascia was possible in a U-shaped area, but limited laterally
and caudally. Whereas the lateral extensions were fused
with the inner lamella of the PPF and closely related to the
neurovascular bundles, the caudal border was fixed at the
perineal body (Figs. 8B and 4). On histologic examination,
Denonvilliers fasciae exhibited features of a multilayered
septum and displayed dispersed smooth muscle cells and
autonomic nerve fibers in most cases (Figs. 8C and D).
DISCUSSION
Our study provides comprehensive insights into the ar-
chitecture of perirectal fasciae, featuring an interplay of

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 DISEASES OF THE COLON & RECTUM VOLUME 64: 1 (2021) 97

FIGURE 6. Anatomy of the rectosacral ligament. A, The mesorectum is mobilized as in TME and shifted anteriorly. When the retrorectal space
is further opened toward the pelvic floor, the rectosacral ligament appears in the midline connecting the mesorectum with the parietal pelvic
fascia (PPF) and the sacrum. Formalin-fixed male pelvis, cranial view. B, Same anatomical topography depicted in a patient during laparoscopic
TME. For further dissection of the mesorectum, sharp transection of the rectosacral ligament is necessary. TME = total mesorectal excision.

different lamellae and interfaces with fusion zones that
converge toward the anorectal junction. The appreciation
of the bilaminar architecture of the PPF as well as the rec-
ognition of the presacral fascia and fusion zones allows a
new approach to the multiple concepts that exist regard-
ing perirectal anatomy. This also explains many seemingly
contradictory results published so far and summarized by
Kinugasa et al.8 We were able to clearly demonstrate the
key role of the PPF with its inner and outer lamella and the
autonomic nerves in between. The fascial system is most
distinct posterolaterally, involving 4 fascial structures,
namely the mesorectal fascia, the inner and the outer la-
mella of the PPF, and the presacral fascia. Whereas the in-
terface between the mesorectal fascia and the inner lamella
of the PPF represents the retrorectal space (“perimesorec-
tal space”) corresponding to the “holy plane” of TME, the
interface between the outer lamella of the PPF and the pre-
sacral fascia represents the presacral space. Anteriorly, this
fascial system is supplemented by the rectogenital septum
(Denonvilliers fascia) separating the rectal from the uro-
genital compartments. Furthermore, the perirectal fasciae
are fused, first along the lateral rectal connections bridging
the PPF and mesorectal fascia to allow access of nerves and
blood vessels to the rectum, and second along the rectosacral

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 98
FIGURE 7. Macroscopic and microscopic anatomy of the
rectosacral ligament. A, The mesorectum, the parietal pelvic fascia
(PPF), and the presacral fascia are mobilized from above and shifted
anteriorly. The rectosacral ligament extends from the 4th sacral
vertebra to the mesorectum and is fused with both the PPF and
presacral fascia. B, The course of the rectosacral ligament (red-
dotted area in A) originates from the sacral periosteum, bridges the
retrorectal (1 asterisk) and presacral (2 asterisks) space, and inserts
into the rectal wall (pulled by forceps). IIA = internal iliac artery;
LAM = levator ani muscle. Formalin-fixed female right hemipelvis,
parasagittal section, medial view. C, Histologic section displays the
insertion area (red-dotted area in B) of the rectosacral ligament
into the rectal wall. D, The rectosacral ligament (red-dotted area in
C) is composed of parallel oriented connective tissue fiber bundles
(arrowheads) firmly attached to the muscular rectal wall and
contains intermingled blood vessels. Azan staining, magnification:
12.5× (C), 25× (D).
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STELZNER ET AL: PERIRECTAL FASCIAE
FIGURE 8. Macroscopic and microscopic anatomy of Denonvilliers
fascia. A, Denonvilliers fascia is cranially connected to the peritoneal
reflexion and caudally to the perineal body. In females, the
rectovaginal septum extends between the posterior vaginal wall
and anterior rectal wall. Formalin-fixed right female hemipelvis,
medial view. B, In males, the rectoprostatic septum extends between
the seminal vesicles/prostate and anterior rectal wall and exhibits
a U-shaped lateral connection to the neurovascular bundles (NVB).
Formalin-fixed male anterior pelvis, dorsocranial view. C and D,
Histologic sections of the rectoprostatic septum (red-dotted area
in B) illustrate its multilayered architecture and the presence of
intermingled smooth muscle cells (C, anti-alpha smooth muscle
actin immunohistochemistry) and nerve fibers (D, anti-S100B-
protein immunohistochemistry). Magnification: 100×.
ligament connecting the posterior rectal wall with the sac-
rum at the midline. The relevant findings are summarized
in 3-dimensional schematic drawings (Fig. 9).
Posterolateral Fascial System
The fascial system enveloping the rectum has been stud-
ied previously both by macroscopic and microscopic
techniques leading to inconsistent findings. The diverging
 DISEASES OF THE COLON & RECTUM VOLUME 64: 1 (2021) 99

FIGURE 9. Three-dimensional schematic overview of perirectal fasciae. The key structure is the parietal pelvic fascia (PPF) with its inner and
outer lamella ensheathing the autonomic pelvic nerves. The PPF fuses caudally with the conjoint longitudinal muscle at the anorectal junction,
posteriorly the PPF displays a ventral interface to the mesorectal fascia (retrorectal space) and a dorsal interface to the presacral fascia
(presacral space). At the level of 3rd/4th sacral vertebra, the rectosacral ligament connects all fascial structures along the midline. Laterally,
rectal nerve branches diverge from the pelvic plexus to enter into the mesorectum. From there, an area of fusion continues in anterocaudal
direction. Anteromedially, the inner lamella of the PPF is continuous with Denonvilliers fascia. A, Anterolateral view; B, lateral view with sagittal
section of the rectum, mesorectum, and posterior fasciae; C, fusion area at the mesorectal level (dark yellow area), fasciae and autonomic
nerves removed, caudo-lateral view; and D, cranial view with rectum and mesorectum removed. SV = seminal vesicles. Red arrows (A, B, D)
indicate the proper dissection plane for total mesorectal excision (innermost dissectable plane around the rectum). Red dotted lines (D)
indicate the transection of rectal nerve branches required for lateral rectal mobilization and the transection area of the rectosacral ligament for
full posterior rectal mobilization.

concepts are most likely due to the complex fascial topog-
raphy and the high degree of anatomical variations. The
most comprehensive overview was given by Kinugasa et
al,8 discussing a total of 9 different concepts. All referenced
authors agree that the mesorectum is covered by a fascia
either named visceral fascia, fascia propria of the rectum,
or visceral endopelvic fascia. In daily clinical practice, this
fascia is referred to as mesorectal fascia.13 However, with
regard to those fasciae surrounding the mesorectal fascia
posterolaterally, the conceptions are substantially differ-
ent, eg, 1 or 2 fascial structures with different topographi-
cal relations to the hypogastric nerves have been described.
At the histologic level, Kinugasa et al8 demonstrated
1 fascia, termed prehypogastric nerve fascia, that bor-
dered to the mesorectal fascia and covered the hypogastric
nerves. Posterior to this fascia, they recognized a parietal
presacral fascia that covered the presacral vessels. At the
level of S4, the prehypogastric nerve fascia approached
the presacral fascia, and it was difficult to discriminate the
mesorectal fascia from the prehypogastric nerve fascia.
The macroscopic dissections of the present study support
this concept. However, for pragmatic reasons, we propose
the term parietal pelvic fascia as given in the Terminologia
Anatomica,14 because it represents the parietal lining of the
true pelvis being continuous with the abdominal parietal
fascia. Because the PPF provides a sheath for autonomic
pelvic nerves, it was also termed “hypogastric sheath.”15,16
Other research groups also distinguished between the ret-
rorectal and presacral space and described the separating
fascia corresponding to the PPF as “posterior leaf of the
visceral pelvic fascia”17 or “presacral fascia.”18 Although in
both reports its continuity with the parietal fascia of the
abdominal wall was recognized, the different terminology
led to apparently incongruent receptions.

Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
 100
The multilayered nature of perirectal fasciae was con-
firmed by Kraima et al19 based on whole-mount micro-
scopic sections. They emphasized that histologic studies
are a valuable tool to unravel the histologic organization
of fascial structures, because “untouched” tissues can be
investigated under surgically unaltered conditions. How-
ever, the surgical challenge consists primarily in separat-
ing a diseased compartment (mesorectum) from a healthy,
functionally intact compartment (urogenital organs/
nerves) at macroscopic level. This aim implicates the iden-
tification and opening of virtual spaces by subtle surgical
dissection of bordering fascial planes. The use of mag-
nification glasses applied in the present study, as well as
optical magnification tools available in both laparoscopic
and robot-assisted surgery settings, enables the depiction
and dissection of these structures at submacroscopic level
allowing the reliable identification of the aforementioned
perirectal fasciae. The same principles also apply to the
presacral space, which has been described by Heald20 and
is surgically equally relevant, because inadvertent dissec-
tion within this space leads to inevitable damage of the au-
tonomic pelvic nerves. However, in surgery for recurrence
this space may serve as a guiding plane in an otherwise
difficult surgical area.
In routine TME it is important to clearly identify the
mesorectal fascia and the retrorectal (perimesorectal)
space as the innermost dissectable plane around the rec-
tum. This is usually accomplished by the initial identifica-
tion of the mesosigmoid interface from where the pedicle
of the superior rectal artery must be followed. As a rule,
the superior rectal artery becomes visible just underneath
the mesorectal fascia.21 In contrast, the access to the presa-
cral space is found from the surface of the iliac vessels. If,
in TME, the iliac vessels lie inadvertently bare, every effort
must be taken to reenter the retrorectal space by cautiously
peeling off the parietal pelvic fascia (and the nerves run-
ning within) from the superior rectal artery’s pedicle.
Anterior Fascial System
Anteriorly, the Denonvilliers fascia separates the rectum
from the genital organs. This rectogenital septum extends
from the peritoneal reflection toward the perineal body
and exhibits a U-shaped form fitting into the pelvic fun-
nel. On either side, it divides into several lamellae of which
the innermost is continuous with the inner lamella of the
PPF.22,23 However, these lateral extensions are variable,
and, in some instances, the clear delineation toward the
anterior mesorectum is missing.24
Importantly, within the triangle formed by the De-
nonvilliers fascia, the PPF, and the anterolateral rectal wall,
autonomic nerves are found on both sides that correspond
to the neurovascular bundles and give off the internal anal
sphincter nerves. These nerves approach the rectum an-
terolaterally and enter into the rectal wall at the level of
the anorectal junction where the fascial components are
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
STELZNER ET AL: PERIRECTAL FASCIAE
fused.12,25 Caudally, the Denonvilliers fascia is continuous
with the perineal body.26 To preserve the aforementioned
nerve structures, the dissection must keep close to the yel-
low-gold surface of the mesorectum, because self-opening
planes do not exist in this fusion area. In surgery done for
low tumors, however, the dissection plane must be tailored
to the circumstances.
Anorectal Junction
The anchoring of the anorectal junction into the pel-
vic floor has gained much interest with respect to surgi-
cal procedures such as intersphincteric rectal resection
or transanal TME.26,27 The intersphincteric space is not
continuous with the retrorectal space dorsolaterally be-
cause of the fusion of the longitudinal rectal muscle and
the puborectal sling (conjoined longitudinal muscle).
Thus, dissection from the intersphincteric space upward,
as performed in intersphincteric resection, leads between
the puborectal sling and the outer surface of the pubo-
coccygeal muscle. To gain access to the retrorectal space,
the fusion area of the conjoint longitudinal muscle has
to be divided. Anteriorly, the region of the perineal body
requires careful division because of the fusion of multi-
ple pelvic floor structures including longitudinal smooth
muscle fibers of the anterior rectal wall extending toward
this fibromuscular body.28 Whereas smooth muscle fibers
were detected within the perineal body, the identification
of a distinct rectourethral muscle in men has been a mat-
ter of debate.29–31 We were not able to clearly delineate such
a separate structure. When dissecting in this area, eg, for
intersphincteric resection including transanal TME or
extralevator abdominoperineal excision, the superficial
transverse perineal muscle, the neurovascular bundles,
and the lower apex of the prostate are key landmarks to
preserve the urethra and the integrity of the anterior ano-
rectal specimen.32
Rectosacral Ligament
Along the posterior midline, the lower rectum is fixed to
the sacrum via the rectosacral ligament. This fibrous con-
nective tissue condensation extends in dorsocranial to
ventrocaudal direction and fuses with both the PPF and
the presacral fascia. In transanal TME, this fusion zone
may mislead the dissection plane from the retrorectal
space to the anterior surface of sacrum bearing the risk
of bleeding from the sacral blood vessels.27 It is therefore
important to explore the posterior rectal space in the 5
and 7 o’clock position first and then to dissect toward the
midline after clear identification of the mesorectal fascia
and the PPF. Inadvertent dissection behind the PPF within
the presacral space may remain unnoticed, because it re-
sembles most of the dissection criteria also experienced in
the retrorectal space, eg, self-opening planes and loosely
arranged connective tissue. The “wrong” dissection plane
will only be recognized when the lateral area with the pel-
 DISEASES OF THE COLON & RECTUM VOLUME 64: 1 (2021)
vic splanchnic nerves is reached that block further ante-
rior dissection.
Whereas in abdominal TME the retrorectal space and
the rectosacral ligament are exposed consecutively by the
cranial approach (Fig. 6), in transanal TME the rectosacral
ligament is the first structure to be divided and therefore
deserves special attention in view of the variations of its
sacral insertion site. In our series, fixation of the rectosa-
cral ligament ranged from S2 to the coccyx. These findings
are reflected by 2 larger series from Garcia-Armengol et
al33 (n = 15, 15% S2, 38% S3, 46% S4) and Sato and Sato34
(n = 35, 5% S2, 55% S3, 30% S4, 2.5% S5, 7.5% coccyx).
Limitations of the present study are 2-fold: First, the
number of specimens was limited (n = 13). We could,
however, demonstrate repetitive key features of perirectal
fascial anatomy, as well as important variations with direct
impact on surgical dissection that render the conclusions
valid. Second, because of the increased age of body donors,
degenerative changes must be taken into account. It is un-
likely, however, that the anatomic findings differ grossly
from those of younger individuals, because pelvic fasciae
are determined during prenatal life.16,35,36
CONCLUSION
The perirectal fascial anatomy is multilaminar in nature
and characterized by distinct interfaces and areas of fu-
sion. Based on the macroscopic studies we could provide
a 3-dimensional topographic portrayal of the perirectal
fascial system and accompanying autonomic pelvic nerves
that may serve as an anatomic roadmap for rectal surgery.
ACKNOWLEDGMENTS
The authors thank Stefanie Gundlach and Merle Winkler
for their support in gross anatomical dissections and pho-
todocumenation, Rita Kirsch for her support in histologic
studies, Clemens Franke for his assistance in processing the
figures, and Florian Keller for providing the 3-dimensional
schematic drawings.
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