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Updated: Aug 14, 2025

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer
Published on: February 12, 2022
The Middle Rectal Artery: Revisited Anatomy and Surgical Implications of a Neglected Blood Vessel
Tillmann Heinze1, Jordan Fletcher2, Danilo Miskovic2
1Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Kiel, Germany.
Background:
Although the middle rectal artery is a relevant anatomical landmark for rectal resection and lateral lymph node dissection, descriptions of this entity are highly divergent.
Objective:
Dissection, visualization, morphometry, and 3-dimensional reconstruction of the middle rectal artery to facilitate its management in surgery.
Design:
Macroscopic dissection, histologic study, morphometric measurements, and virtual modeling.
Setting:
University laboratory of applied surgical anatomy.
Patients:
This study includes formalin-fixed hemipelvis specimens (n=37) obtained from body donors (age, 67-97 y).
Main Outcome Measures:
The main outcome measures are photo documentation of origin, trajectory, diameter, and branching pattern; immunolabeling of lymphatics; and 3-dimensional reconstruction of the middle rectal artery.
Results:
The middle rectal artery was present in 71.4% of body donors (21.4% bilateral, 50% unilateral), originated from the anterior division of the internal iliac artery, and branched either from the internal pudendal artery (45.5%), the inferior gluteal artery (22.7%), the gluteal-pudendal trunk (22.7%), or a trifurcation (9.1%). One to 3 branches of varying diameters (0.5-3.5 mm) entered the mesorectum from the ventrolateral (35.7%), lateral (42.9%), or dorsolateral (21.4%) aspect. The middle rectal artery was accompanied by podoplanin-immunoreactive lymphatic vessels and gave off additional branches (81.8%) to the urogenital pelvic organs. Three-dimensional reconstruction revealed the complex course of the middle rectal artery from the pelvic sidewall through the pelvic nerve plexus and parietal pelvic fascia into the mesorectum.
Limitations:
Findings retrieved from body donors may be prone to age- and fixation-related processes.
Conclusions:
The investigation disclosed the rather high prevalence of the middle rectal artery, its 3-dimensional topographic anatomy, and its proximity to the autonomic pelvic nerves. These features play a role in the surgical management of this blood vessel. The data provide the anatomical rationale for the lateral lymphatic spread of rectal cancer and an anatomical basis for nerve-preserving lateral lymph node dissection.
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