Anatomy of the middle rectal artery: a review of the historical literature

The middle rectal artery is a very important anatomical structure in rectal cancer surgery. It is the only vessel that penetrates through the proper rectal fascia into the pelvic cavity, and therefore threatens the integrity of total mesorectal excision. Moreover, it is very closely related to the lateral lymphatic drainage root. The definition of the middle rectal artery is ambiguous, and different frequencies, origins, and trajectories have been reported in various papers. The frequency of the middle rectal artery is reported to range from 12 to 97 %. Traditionally, the middle rectal artery is described as an artery that penetrates the pelvic plexus from the lateral side along with the lateral ligament; the frequency of this lateral type of middle rectal artery ranges from 20 to 30 %. However, the reports that describe higher frequency values also consider another type of middle rectal artery, which penetrates the neuro-vascular bundle from the antero-lateral direction; this antero-lateral type of middle rectal artery tends to be a small vessel, and frequently forms a common trunk with the prostatic artery. With advancements in endoscopic surgery, the knowledge of the precise anatomy of this structure is becoming more crucial for optimal rectal cancer surgery.