Tailoring rectal cancer surgery: Surgical approaches and anatomical insights during deep pelvic dissection for optimal outcomes in low-lying rectal cancer

This review article explores advanced surgical approaches and anatomical insights for tailoring rectal cancer surgery, particularly focusing on low-lying rectal cancer. With the evolution of imaging technologies, precise preoperative planning has become possible, enhancing the visualization of anatomy surrounding the rectum and enabling more accurate assessments of circumferential resection margin (CRM) involvement. The article emphasizes the dynamic nature of rectal cancer treatment, advocating for individualized surgical planning based on comprehensive preoperative imaging and intraoperative assessment. This approach aims to optimize patient care by integrating recent advancements and anatomical insights into clinical practice for the management of low-lying rectal cancer. Particularly, the article discusses the importance of customizing the excision of Denonvilliers' fascia (DVF) based on tumor characteristics for optimal oncologic and functional outcomes, especially for anteriorly located tumors. It highlights the need for precise dissection techniques to ensure a negative CRM while preserving critical anatomical structures. Additionally, the review addresses the surgical management of tumors at the anorectal ring and introduces the Gate Approach for deep anterolateral pelvic dissection. Special attention is given to tumors impacting the membranous and prostate urethra, emphasizing tailored surgical approaches to balance complete tumor resection with the preservation of urogenital functions.