More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
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Our breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
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“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
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Additionally, each book published by IntechOpen contains original content and research findings.
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We are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
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Simba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
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IntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\n
Since the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\n
Our breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n
“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\n
Additionally, each book published by IntechOpen contains original content and research findings.
\n\n
We are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
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\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"7480",leadTitle:null,fullTitle:"Neurochemical Basis of Brain Function and Dysfunction",title:"Neurochemical Basis of Brain Function and Dysfunction",subtitle:null,reviewType:"peer-reviewed",abstract:"Neurochemistry is a vitally important academic discipline that contributes to our understanding of molecular, cellular, and medical neurobiology. As a field, neurochemistry focuses on the role of the chemical entities that build the nervous system, the function of neurons and glial cells in health and disease, aspects of cell metabolism and neurotransmission, and degenerative processes and aging of the nervous system. Accordingly, this book contains chapters on a variety of topics related to the neurochemical basis of brain function and dysfunction. The volume is organized into four chapters: I. The Chemical Basis of Neural Function and Dysfunction; II. Synaptic Transmission and Amino Acid Neurotransmitters; III. Trends of Protein Aggregation in Neurodegenerative Diseases; IV. Targeting the NO/cGMP/CREB Phosphorylation Signaling Pathway in Alzheimer's Disease. Chapters contain comprehensive reviews of these different areas written by experts in their respective fields. This book is a valuable resource for neurochemists and other scientists alike. 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After graduating, he was a research associate at the Institute of Physiology, Otto-von-Guericke-University School of Medicine, Magdeburg, Germany. Prior to his arrival at Howard University, Dr. Heinbockel held joint research faculty appointments in the Department of Anatomy and Neurobiology and the Department of Physiology at the University of Maryland School of Medicine, Baltimore, Maryland, USA. He still maintains an adjunct appointment in these departments.",institutionString:"Howard University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"10",totalChapterViews:"0",totalEditedBooks:"8",institution:{name:"Howard University",institutionURL:null,country:{name:"United States of America"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"245650",title:"Dr.",name:"Antonei B.",middleName:null,surname:"Csoka",slug:"antonei-b.-csoka",fullName:"Antonei B. 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Chemical and electrical synapses are specialized biological structures found in the nervous system; they connect neurons together and transmit signals across the neurons. The process of synaptic transmission generates or inhibits electrical impulses in a network of neurons for the processing of information. Glutamate is the primary excitatory neurotransmitter in the brain, while GABA is the principal inhibitory neurotransmitter. The balance of glutamatergic and GABAergic tone is crucial to normal neurologic function. Through synaptic transmission, this information is communicated from the presynaptic cell to the postsynaptic cell. Amino acid neurotransmitters primarily glutamic acid, GABA, aspartic acid, and glycine are single amino acid residues released from presynaptic nerve terminals in response to an action potential and cross the synaptic cleft to bind with specific receptor on the postsynaptic membrane. 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1. Introduction
Colorectal cancer is the third most common cancer and the fourth leading cause of cancer-related deaths worldwide [1]. Especially, rectal cancer accounts for 30–40% of colorectal cancer, and the treatment strategy is different and more complicated compared to colon cancer because of its anatomical features. Although the treatment outcome of rectal cancer has greatly improved with the development of multimodality treatment including neoadjuvant radiotherapy, cytotoxic chemotherapy, and target agents, surgery remains the mainstay of therapy. Since the concept of total mesorectal excision (TME) was first described by Richard Heald in 1979, this procedure became the gold standard technique for rectal cancer surgery until now [2]. The fundamental principle of TME is en bloc resection of the rectum with its surrounding fatty tissue complex which contains the blood vessels and lymphatics down to the pelvic floor. To achieve complete TME and sphincter preserving surgery in low-lying rectal cancer, knowledge for regarding the pelvic fascia (mesorectal, parietal) and autonomic nerves, a thorough understanding of the pelvic floor anatomy is essential.
2. Pelvic anatomy
2.1 Basic anatomy of the rectum and mesorectum
The rectum is the most distal part of the large intestine that exists from the sacral promontory level to the anorectal ring. The anterior and lateral portion of the upper one-third of the rectum is covered with peritoneum, and the middle one-third of the rectum is covered with peritoneum on its anterior portion. The lower one-third cannot be observed in the intraperitoneal space because it is located in the extraperitoneal space. The taenia coli disappears in the rectum, forming one longitudinal muscle layer surrounding the rectum. The length of the rectum is approximately 12-15 cm and has three curvatures, which is related to Houston’s valves. The upper and lower part are convex to the right, and the middle portion is convex to the left. The middle valve is the most prominent and is located approximately equal to the level of peritoneal reflection [3].
The rectum is surrounded by a fatty tissue complex called the mesorectum, which corresponds to the mesentery of the rectum. Mesorectum contains abundant blood vessels, lymphatics, and lymph nodes, and it is enveloped by thin visceral pelvic fascia [4]. It is developed thickest in the posterolateral side and the anterior part is formed relatively thin. In addition, the volume of the mesorectum decreases as it approaches the pelvic floor, and disappears approximately 2 cm above the levator ani muscle (Figure 1). A number of studies have revealed that the mesorectum is an important structure for tumor spreading, and en bloc resection through sharp dissection of mesorectum is very important in improving treatment outcomes [2, 5, 6].
Figure 1.
Anatomy of the rectum and mesorectum. (a) Structures around the rectum. The rectum is surrounded by mesorectum, and the rectum and mesorectum are enveloped by the fascia propria of the rectum. (b) Total mesorectal excision (TME). En bloc resection of mesorectum is important.
2.2 Fascia structures around the rectum
Dissecting the correct anatomical plane can lead to good oncological outcomes and preserve the autonomic nerves to prevent postoperative urinary, sexual, and defecatory dysfunction. If pelvic dissection is performed along the exact embryologic fascial plane, the operation can be done without bleeding. To perform precise total mesorectal excision, a thorough understanding of the fascia around the rectum and pelvic cavity is essential. Figure 2 shows the anatomical relationship of the fascia around the rectum.
Figure 2.
Anatomy of fascia around the rectum. The fascia propria of the rectum covers the rectum and mesorectum. The presacral fascia covers the anterior surface of the sacrum. It combines with the fascia propria of the rectum at the S4 level (recto-sacral fascia = Waldeyer’s fascia). Denonvilliers’ fascia is a dense membrane between the rectum and seminal vesicles.
2.2.1 Fascia propria of the rectum and presacral fascia
The rectum and mesorectum are enveloped by the fascia propria of the rectum, also called as mesorectal fascia. The mesorectal fascia corresponds to the visceral fascia of the rectum. Caudally, it ends at the internal sphincter and laterally ends at the internal iliac artery, and is connected to the parietal pelvic fascia [7]. A magnetic resonance image scan (MRI) can clearly show the boundaries of these mesorectum and mesorectal fascia (Figure 3). During total mesorectal excision, it is important to completely excise this mesorectal fascia without damage to obtain optimal oncologic outcome [6, 8, 9].
Figure 3.
Magnetic resonance image scan. Magnetic resonance image scan (MRI) can clearly show the boundaries of these mesorectum and mesorectal fascia. (a) T2 weighted image on MRI. Axial view. The rectum and mesorectum are enveloped by the fascia propria of the rectum (mesorectal fascia). (b) T2 weighted image on MRI. Coronal view. Mesorectum, mesorectal fascia, and puborectalis muscle.
The presacral fascia, also called as parietal pelvic fascia, covers the anterior surface of the sacrum and encloses the sacral vessels and nerves. It combines with the mesorectal fascia at the S4 level and became part of the anococcygeal ligament at the level of anorectal junction. The presacral venous plexus is formed by the two lateral sacral veins, the middle sacral vein, and the communicating veins, and it runs underneath the presacral fascia. If the dissection plane is too deep to damage the presacral fascia during the posterior dissection, life-threatening massive bleeding can occur and it often is difficult to control. Therefore, dissection should be done along with the space between the mesorectal fascia and the presacral fascia until the recto-sacral fascia is encountered [10, 11].
2.2.2 Recto-sacral fascia (Waldeyer’s fascia)
Recto-sacral fascia, also known as Waldeyer’s fascia, is a dense connective tissue linking the presacral fascia to the mesorectal fascia at the S4 level. As the posterior dissection proceeds down along the plane between the mesorectal fascia and the presacral fascia, a dense, tough recto-sacral fascia is identified. To enter the retro-rectal space and reach the pelvic floor, this fascia must be incised and dissected further caudally. This fascia has a different thickness from individuals, it is not visible when it is too thin. Because the presacral artery and venous plexus and autonomic nerves pass behind this fascia, it is important to perform sharp division to avoid excessive bleeding due to presacral vein injury (Figure 4) [8, 12].
Figure 4.
Recto-sacral fascia (Waldeyer’s fascia). Recto-sacral fascia (Waldeyer’s fascia) is a dense connective tissue linking the presacral fascia to the mesorectal fascia at the S4 level. It is important to perform sharp dissection [11].
2.2.3 Denonvilliers’ fascia
During the anterior dissection of the rectum, a thin, dense connective tissue layer known as the Denonvilliers’ fascia presents between the seminal vesicles and rectum [13]. The rectum can be separated from the seminal vesicles and prostate by opening this membrane at the level of anterior peritoneal reflection. After incising the fascia and entering the embryologic plane between the rectum and the seminal vesicles, the dissection should be performed below the Denonvilliers’ fascia [14]. It is because there were neurovascular bundles running from the pelvic plexus to the ventral side of the Denonvilliers’ fascia, especially in the directions of 10 and 2 o’clock, and these neurovascular bundles were related to urogenital function (Figure 5) [15]. However, if the deeply infiltrative tumor is located on the anterior wall of the rectum, the dissection should be performed in front of the Denonvilliers’ fascia for curative resection. In females, there is a thin membranous structure that separates the rectum and vagina, which is called the rectovaginal septum. Although Denonvilliers reported that the Denonvilliers’ fascia was not present in females, many researchers considered that the rectovaginal septum was consistent with the Denonvilliers’ fascia in males (Figure 6) [16, 17, 18, 19]. During the anterior dissection of the rectum in female, care must be taken not to perforate the vagina since this septum is very thin.
Figure 5.
Denonvilliers’ fascia. During anterior dissection of the rectum. The dense connective tissue between rectum and seminal vesicles can be seen. The dissection should be performed below the Denonvilliers’ fascia.
Figure 6.
Rectovaginal septum. In female, the rectovaginal septum was consistent with the denonvilliers’ fascia in male.
2.3 Anal canal
The rectum enters the pelvic floor and becomes the anus. The anal canal is defined as from the dentate line to the anal verge by anatomists, but most surgeons consider the anal canal from the anorectal ring to the anal verge [20]. The anorectal ring is where the rectum enters the pelvic floor and is angled by the puborectalis muscle. This ring can be palpated by a meticulous digital rectal exam. The dentate line, which divides the upper two-thirds and lower third of the anal canal, is an anatomically important landmark of the anal canal, and there are 6–14 longitudinal folds on the dentate line known as columns of Morgagni (Figure 7). The upper and lower part of the anal canal differs in venous and lymphatic drainage, innervation, and the epithelial surface based on the dentate line. Above the dentate line, the blood drains into the portal venous system, and lymphatics drains to the superior rectal and iliac lymphatic chains. Below the dentate line, the blood drains into the caval system, and lymphatics drain into the inguinal lymph nodes.
Figure 7.
Anal canal and anal sphincter complex. (a) The dentate line divides the upper two thirds and lower third of the anal canal, and there are longitudinal folds known as columns of Morgagni. The external sphincter consists of three separate parts: Subcutaneous, superficial, and deep part [21]. (b) External anal sphincter. Lt. Hemipelvis.
There are two sphincter muscles surrounding the anus, the internal sphincter and the external sphincter. The internal sphincter is connected from the inner circular smooth muscle of the rectum and descends to 1–1.5 cm below the dentate line. Its length is about 2.5–4 cm and the mean thickness is about 0.5 cm. It is an involuntary smooth muscle and plays an important role in the maintenance of fecal incontinence because it contributes a majority of the resting pressure of the anal canal. The outer longitudinal muscle of the rectum conjoins the fibers from the puborectalis muscle and is located between the external and internal sphincter. The external sphincter muscle is a striated muscle surrounding the internal sphincter in the shape of a cylinder, and it extends slightly below the internal sphincter. The external sphincter consists of three separate parts: subcutaneous, superficial, and deep part. The subcutaneous external sphincter attaches to the perianal skin encircling the anus. The external anal sphincter is innervated by the rectal branch of the pudendal nerve and is under voluntary control [20, 22, 23]. The intersphincteric groove between the internal and external sphincter is an important landmark in surgery for patients with distal rectal cancer such as intersphincteric resection (ISR) [24].
2.4 Pelvic floor
The pelvic floor is a structure that forms the bottom of the pelvis, and plays an important role in supporting the pelvic organs. In the past, pelvic floor muscles could not be visualized clearly, however, the development of magnetic resonance imaging assessments and improvements in minimally invasive surgery techniques such as laparoscopy and robotic surgery can clearly show the anatomy of this region It is mainly composed of the levator ani muscle complex: pubococcygeus, iliococcygeus, and puborectalis muscle. The levator ani muscle received direct innervation from sacral nerve roots (S3-S5) and play an important role in cooperative action through coordinated contraction and relaxation during defecation [25]. The pubococcygeus is located in the most anterior portion of the levator ani muscles, and from both pubic bone to the coccyx. The iliococcygeus is the posterior part of the levator ani muscle and extends from the ischial spine to the anococcygeal raphe and coccyx. The puborectalis muscle, which is located below the pubococcygeus, forms a U-shaped ring around the rectum and makes an anorectal angle to prevent fecal incontinence. The coccygeus muscle, which is also a part of the pelvic floor, is located posterior portion of the levator ani muscle and reinforces the posterior pelvic floor (Figure 8) [20]. The pelvic floor has two hiatuses: the urogenital hiatus and the rectal hiatus. The rectal hiatus is located in the posterior of the pelvic floor through which the anal canal passes. The perineal body, a pyramidal fibromuscular mass, is located between the urogenital hiatus and the anal canal, strengthens the pelvic floor [26]. During distal rectal cancer surgery for sphincter preservation such as ISR, the intersphincteric space between the puborectalis muscle and the rectal wall should be identified, and the dissection continues down to the deep part of the anal canal through the intersphincteric space (Figure 9) [24]. On the other hand, during an abdominoperineal resection, the levator ani muscles must be cut [27].
Figure 8.
Anatomy of the pelvic floor. (a) Inferior view. The levator ani muscle consists of pubococcygeus, iliococcygeus, and puborectalis muscle [21]. (b) Pelvic floor muscles and anal sphincter complex [20].
Figure 9.
Levator ani muscles and intersphincteric space. (a) Puborectalis and pubococcygeus muscle. (b) Intersphincteric space between rectum and puborectalis muscle.
2.4.1 Anococcygeal ligaments
The anococcygeal ligament is a fibrous membrane, which extends between the coccyx and the margin of the anal canal. In an anatomical study, the anococcygeal ligament was divided into two layers. The ventral layer of the ligament was loose and rich in small and fragile vessels and extended from the presacral fascia to the conjoint longitudinal muscle layer of the anal canal. The dorsal layer of the ligament was thin and dense and extended between the coccyx and external anal sphincter (Figure 10) [28]. To fully mobilize the rectum from the pelvic floor at the final stage of total mesorectal excision, the anococcygeal ligament must be divided. If the anococcygeal ligament cannot be seen in the final step, it can be visualized after the mesorectum is completely mobilized from the pelvic floor.
Figure 10.
Anococcygeal ligament. (a) Anococcygeal ligament and pelvic floor. During posterior dissection of the rectum. (b) Anococcygeal ligament during cadeveric dissection. Lt. hemipelvis.
2.5 Surgical plane for very low-lying rectal cancer
In case of very low-lying rectal cancer, several surgical options can be considered (Figure 11). If the tumor did not invade the anal sphincter complex, the ultra-low anterior resection with coloanal anastomosis could be considered. If the tumors are located close to the dentate line, the intersphincteric resection (ISR) could be considered. The ISR is the partial or complete resection of the internal anal sphincter along the intersphincteric plane. However, if the tumor invades the external sphincter complex, the abdominoperineal resection (APR) should be performed. For invasive low rectal cancer which invades the levator ani muscle, extralevator APR (ELAPE) should be considered to achieve adequate resection margin. The ELAPE is the cylindrical anorectal excision and removes more tissue around the tumor including levator ani muscle (Figure 12). This procedure has the advantage of reducing the risk of tumor perforation during operation and acquiring sufficient safety resection margin, but there is still controversy about the long-term oncologic outcome [29]. In addition, the postoperative complications can be increased due to the wide resection range.
Figure 11.
Low-lying rectal cancer. (a) T2 weighted image on MRI. Coronal view. The low-lying rectal cancer invades internal anal sphincter. (b) T2 weighted image on MRI. Sagittal view.
In terms of quality of life, the importance of not only oncological outcomes but also functional outcomes such as urinary function, sexual function, and defecatory function after rectal cancer surgery have been emphasized. Urinary dysfunction after rectal surgery occurs in approximately 27%, and it includes difficulty emptying the bladder and incontinence [30, 31]. Sexual dysfunction for males consists of erectile dysfunction, absence of ejaculation, or retrograde ejaculation. For females, it causes sexual dysfunction such as impaired ability to achieve orgasm, decreased vaginal secretion, or dyspareunia [15]. The major cause of postoperative urogenital dysfunction is autonomic nerve damage that occurs during surgery. As minimally invasive surgery such as laparoscopy and robotic approach develops, meticulous nerve preserving surgery became possible with good visualization of the pelvic autonomic nerves [32, 33, 34]. To preserve the postoperative urogenital function, a thorough understanding of the anatomy of the pelvic autonomic nerve is crucial.
2.6.1 Superior hypogastric plexus and hypogastric nerves
The superior hypogastric plexus, which is a collection of sympathetic nerve bundles arising from T10-L3, forms a dense nerve plexus at the anterior area to the body of L5 and bifurcates into hypogastric nerves at the level of the sacral promontory (Figure 13). The superior hypogastric plexus runs around the inferior mesenteric artery. Therefore, this nerve can be damaged during dissection around the origin of the inferior mesenteric artery, and it results in retrograde ejaculation, urinary incontinence [35]. The hypogastric nerve crosses the left common iliac artery at the level of the first sacrum and descends to the pelvic cavity along the lateral pelvic wall.
Figure 13.
Hypogastric nerves. The hypogastric nerves run from the superior hypogastric plexus and descend to the pelvic cavity and meet the pelvic splanchnic nerves.
2.6.2 Pelvic splanchnic nerves
The pelvic splanchnic nerves are considered to be parasympathetic nerves that arise from the second to fourth sacral spinal nerves. These nerves enter the pelvis through the sacral foramen, posterior to the parietal fascia that covers the piriformis muscle and crosses the retrorectal space, to enter the visceral compartment through the visceral fascia about 4 cm from the midline. Small branches of the pelvic splanchnic nerves run medially and enter the mesorectum (Figure 14). These nerves regulate the emptying of the urinary bladder and influence erectile functions and motility of the rectum. Therefore, damage to these nerves causes erectile dysfunction and decreased blood flow to the vagina and vulva, which can reduce vaginal lubrication.
Figure 14.
Pelvic splanchnic nerves. The pelvic splanchnic nerves arise from the S2 to S4 spinal nerves. Small branches of the pelvic splanchnic nerves run medially and enter the mesorectum.
2.6.3 Inferior hypogastric (pelvic) plexus
The pelvic splanchnic nerves meet the hypogastric nerves and form the inferior hypogastric plexus at the lateral pelvic wall. It lies outside the fascia propria in the superficial layer of the parietal fascia. The inferior hypogastric plexus can be observed as a mesh-like structure at the posterolateral pelvic wall close to the prostate and seminal vesicles. Because the inferior hypogastric plexus consists of both sympathetic and parasympathetic efferent fibers, any damage to this plexus may cause severe disturbances in urogenital and sexual function including erection and ejaculation. It extends forward to form neurovascular bundles running down the seminal vesicle at 2 o’clock and 10 o’clock direction (Figure 15). These neurovascular bundles run through the posterolateral border of the prostate and continue to the periprostatic plexus, which supplies to the prostate, seminal vesicles, corpi cavernosi, and the vas deferens [15, 36]. Injury to the neurovascular bundles during anterior dissection may cause urinary and sexual dysfunction. Meticulous dissection is required because nerve damage may occur when surgery is performed along the wrong plane or excessive traction is performed.
Figure 15.
Inferior hypogastric (pelvic) plexus. The inferior hypogastric (pelvic) plexus is a network of sympathetic and parasympathetic fibers arising from the hypogastric nerves and the pelvic splanchnic nerves. It can be observed as a mesh-like structure at the posterolateral pelvic wall. It extends forward to form neurovascular bundles running down the seminal vesicle on both sides.
3. Conclusion
The rectum is surrounded by a fatty tissue complex called the mesorectum, which contains abundant blood vessels, lymphatics, and lymph nodes. The rectum and mesorectum are enveloped by the mesorectal fascia. During total mesorectal excision, it is important to completely excise this mesorectal fascia without damage. The mesorectal fascia conjoins with the recto-sacral fascia, which extends forward from the presacral fascia at the level of S4, and descends to the pelvic floor. To enter the retro-rectal space and reach the pelvic floor, this fascia must be incised and sharp dissection should be performed to prevent severe bleeding due to injury to the presacral plexus. During the anterior dissection of the rectum, it is important to recognize Denonvillers’ fascia located between the rectum and seminal vesicles, and dissection should be performed below the Denonvilliers’ fascia. The pelvic floor is a structure that forms the bottom of the pelvis and is mainly composed of the levator ani muscle complex: pubococcygeus, iliococcygeus, and puborectalis muscle. The levator ani muscle received direct innervation from sacral nerve roots (S3-S5) and play an important role in cooperative action during defecation. To reach the deep part of the anal canal, the dissection should be performed between the puborectalis muscle and the rectal wall. During the whole process of TME, surgeons should take care to identify and preserve the autonomic nerve in order to avoid postoperative urogenital dysfunction. Care should be taken not to damage the superior hypogastric nerve during IMA ligation, and not to damage the pelvic plexus during posterolateral pelvic dissection. In addition, during anterior dissection of the rectum, it is important to perform meticulous dissection so as not to injure small numerous neurovascular bundles running in the 2 o’clock and 10 o’clock directions of the seminal vesicle. Based on a sufficient understanding of pelvic anatomy, precise surgical techniques using advanced surgical tools will give favorable oncologic and functional outcomes for rectal cancer patients.
Conflict of interest
The authors declare no conflict of interest.
Notes/thanks/other declarations
None.
\n',keywords:"rectal neoplasms, anatomy, colorectal surgery, autonomic nervous system, pelvic floor",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/78676.pdf",chapterXML:"https://mts.intechopen.com/source/xml/78676.xml",downloadPdfUrl:"/chapter/pdf-download/78676",previewPdfUrl:"/chapter/pdf-preview/78676",totalDownloads:206,totalViews:0,totalCrossrefCites:0,dateSubmitted:"February 26th 2021",dateReviewed:"June 28th 2021",datePrePublished:"September 20th 2021",datePublished:null,dateFinished:"September 20th 2021",readingETA:"0",abstract:"Worldwide, colorectal cancer is the third most common cancer and one of the leading causes of cancer-related deaths. Currently, total mesorectal excision (TME) is considered as the gold standard surgical procedure for rectal cancer. To achieve a good oncologic outcome and functional outcome after TME in distal rectal cancer, exact knowledge regarding the pelvic anatomy including pelvic fascia, pelvic floor, and the autonomic nerve is essential. Accurate TME along the embryologic plane not only reduces local recurrence rate but also preserves urinary and sexual function by minimizing nerve damage. In the past, pelvic floor muscles and autonomic nerves could not be visualized clearly, however, the development of imaging studies and improvements of minimally invasive surgical techniques such as laparoscopic and robotic surgery can clearly show the anatomy of the pelvic region. In this chapter, we will provide accurate anatomy of the rectum and the anal canal, pelvic fascia, and the pelvic autonomic nerve. This anatomical information will be an important indicator for performing an adequate operation for distal rectal cancer.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/78676",risUrl:"/chapter/ris/78676",signatures:"Sanghyun An and Ik Yong Kim",book:{id:"10865",type:"book",title:"Current Topics in Colorectal Surgery",subtitle:null,fullTitle:"Current Topics in Colorectal Surgery",slug:null,publishedDate:null,bookSignature:"Associate Prof. John Camilleri-Brennan",coverURL:"https://cdn.intechopen.com/books/images_new/10865.jpg",licenceType:"CC BY 3.0",editedByType:null,isbn:"978-1-83962-336-3",printIsbn:"978-1-83962-335-6",pdfIsbn:"978-1-83962-337-0",isAvailableForWebshopOrdering:!0,editors:[{id:"169437",title:"Associate Prof.",name:"John",middleName:null,surname:"Camilleri-Brennan",slug:"john-camilleri-brennan",fullName:"John Camilleri-Brennan"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Pelvic anatomy",level:"1"},{id:"sec_2_2",title:"2.1 Basic anatomy of the rectum and mesorectum",level:"2"},{id:"sec_3_2",title:"2.2 Fascia structures around the rectum",level:"2"},{id:"sec_3_3",title:"2.2.1 Fascia propria of the rectum and presacral fascia",level:"3"},{id:"sec_4_3",title:"2.2.2 Recto-sacral fascia (Waldeyer’s fascia)",level:"3"},{id:"sec_5_3",title:"2.2.3 Denonvilliers’ fascia",level:"3"},{id:"sec_7_2",title:"2.3 Anal canal",level:"2"},{id:"sec_8_2",title:"2.4 Pelvic floor",level:"2"},{id:"sec_8_3",title:"2.4.1 Anococcygeal ligaments",level:"3"},{id:"sec_10_2",title:"2.5 Surgical plane for very low-lying rectal cancer",level:"2"},{id:"sec_11_2",title:"2.6 Pelvic autonomic nerve system",level:"2"},{id:"sec_11_3",title:"2.6.1 Superior hypogastric plexus and hypogastric nerves",level:"3"},{id:"sec_12_3",title:"2.6.2 Pelvic splanchnic nerves",level:"3"},{id:"sec_13_3",title:"2.6.3 Inferior hypogastric (pelvic) plexus",level:"3"},{id:"sec_16",title:"3. Conclusion",level:"1"},{id:"sec_20",title:"Conflict of interest",level:"1"},{id:"sec_17",title:"Notes/thanks/other declarations",level:"1"}],chapterReferences:[{id:"B1",body:'Ferlay J, Colombet M, Soerjomataram I, Parkin DM, Pineros M, Znaor A, et al. Cancer statistics for the year 2020: An overview. International Journal of Cancer. 2021. DOI: 10.1002/ijc.33588'},{id:"B2",body:'Heald RJ, Husband EM, Ryall RDH. The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? British Journal of Surgery. 1982;69:613-616. DOI: 10.1002/bjs.1800691019'},{id:"B3",body:'Engin O. Colon polyps and the prevention of colorectal cancer: Springer; 2015. 249 p. DOI: 10.1007/978-3-319-17993-3'},{id:"B4",body:'Culligan K, Walsh S, Dunne C, Walsh M, Ryan S, Quondamatteo F, et al. The mesocolon: a histological and electron microscopic characterization of the mesenteric attachment of the colon prior to and after surgical mobilization. Annals of Surgery. 2014;260:1048-1056. 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Essential anatomy of the anorectum for colorectal surgeons focused on the gross anatomy and histologic findings. Annals of Coloproctology. 2018;34:59-71. DOI: 10.3393/ac.2017.12.15'},{id:"B21",body:'Richard L. Drake, A. Wayne Vogl and Adam W.M. Mitchell. Gray\'s Atlas of Anatomy, 5, 213-292'},{id:"B22",body:'Kim NK, Sugihara K, Liang J-T. Surgical treatment of colorectal cancer: Asian perspectives on optimization and standardization; : Springer Singapore 2018. 414 p. DOI: 10.1007/978-981-10-5143-2'},{id:"B23",body:'Fritsch H, Brenner E, Lienemann A, Ludwikowski B. Anal sphincter complex: reinterpreted morphology and its clinical relevance. Diseases of the Colon and Rectum. 2002;45:188-194. DOI: 10.1007/s10350-004-6144-x'},{id:"B24",body:'Rullier E, Zerbib F, Laurent C, Bonnel C, Caudry M, Saric J, et al. Intersphincteric resection with excision of internal anal sphincter for conservative treatment of very low rectal cancer. Diseases of the Colon and Rectum. 1999;42:1168-1175. 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Extralevator abdominoperineal excision for advanced low rectal cancer: Where to go. World Journal of Gastroenterology : WJG. 2020;26:3012-3023. DOI: 10.3748/wjg.v26.i22.3012'},{id:"B30",body:'Kim NK, Kim YW, Cho MS. Total mesorectal excision for rectal cancer with emphasis on pelvic autonomic nerve preservation: Expert technical tips for robotic surgery. Surgical Oncology. 2015;24:172-180. DOI: 10.1016/j.suronc.2015.06.012'},{id:"B31",body:'Chew MH, Yeh YT, Lim E, Seow-Choen F. Pelvic autonomic nerve preservation in radical rectal cancer surgery: changes in the past 3 decades. Gastroenterology Report. 2016;4:173-185. DOI: 10.1093/gastro/gow023'},{id:"B32",body:'Luca F, Valvo M, Ghezzi TL, Zuccaro M, Cenciarelli S, Trovato C, et al. Impact of robotic surgery on sexual and urinary functions after fully robotic nerve-sparing total mesorectal excision for rectal cancer. Annals of Surgery. 2013;257:672-678. DOI: 10.1097/SLA.0b013e318269d03b'},{id:"B33",body:'Garbarino GM, Canali G, Tarantino G, Costa G, Ferri M, Balducci G, et al. Laparoscopic versus open rectal resection: a 1:2 propensity score-matched analysis of oncological adequateness, short- and long-term outcomes. International Journal of Colorectal Disease. 2021;36:801-810. DOI: 10.1007/s00384-021-03841-w'},{id:"B34",body:'Hur H, Bae SU, Kim NK, Min BS, Baik SH, Lee KY, et al. Comparative study of voiding and male sexual function following open and laparoscopic total mesorectal excision in patients with rectal cancer. Journal of Surgical Oncology. 2013;108:572-578. DOI: 10.1002/jso.23435'},{id:"B35",body:'Mari GM, Crippa J, Cocozza E, Berselli M, Livraghi L, Carzaniga P, et al. Low ligation of inferior mesenteric artery in laparoscopic anterior resection for rectal cancer reduces genitourinary dysfunction: Results from a randomized controlled Trial (HIGHLOW Trial). Annals of Surgery. 2019;269:1018-1024. DOI: 10.1097/SLA.0000000000002947'},{id:"B36",body:'Hollabaugh Jr RS, Steiner MS, Sellers KD, Samm BJ, Dmochowski RR. Neuroanatomy of the pelvis: Implications for colonic and rectal resection. Diseases of the Colon and Rectum. 2000;43:1390-1397. DOI: 10.1007/BF02236635'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Sanghyun An",address:null,affiliation:'
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The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. 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His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:null},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). 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Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. 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A dynamic career research platform which is based on the thematic areas of comparative vertebrate physiology, stress endocrinology, reproductive endocrinology, animal health and welfare, and conservation biology. \nEdward has supervised 40 research students and published over 60 peer reviewed research.",institutionString:null,institution:{name:"University of Queensland",institutionURL:null,country:{name:"Australia"}}},editorTwo:null,editorThree:null,series:{id:"13",title:"Veterinary Medicine and Science",doi:"10.5772/intechopen.73681",issn:"2632-0517"},editorialBoard:[{id:"258334",title:"Dr.",name:"Carlos Eduardo",middleName:null,surname:"Fonseca-Alves",slug:"carlos-eduardo-fonseca-alves",fullName:"Carlos Eduardo Fonseca-Alves",profilePictureURL:"https://mts.intechopen.com/storage/users/258334/images/system/258334.jpg",institutionString:null,institution:{name:"Universidade Paulista",institutionURL:null,country:{name:"Brazil"}}},{id:"191123",title:"Dr.",name:"Juan José",middleName:null,surname:"Valdez-Alarcón",slug:"juan-jose-valdez-alarcon",fullName:"Juan José Valdez-Alarcón",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSBfcQAG/Profile_Picture_1631354558068",institutionString:"Universidad Michoacana de San Nicolás de Hidalgo",institution:{name:"Universidad Michoacana de San Nicolás de Hidalgo",institutionURL:null,country:{name:"Mexico"}}},{id:"161556",title:"Dr.",name:"Maria Dos Anjos",middleName:null,surname:"Pires",slug:"maria-dos-anjos-pires",fullName:"Maria Dos Anjos Pires",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bS8q2QAC/Profile_Picture_1633432838418",institutionString:null,institution:{name:"University of Trás-os-Montes and Alto Douro",institutionURL:null,country:{name:"Portugal"}}},{id:"209839",title:"Dr.",name:"Marina",middleName:null,surname:"Spinu",slug:"marina-spinu",fullName:"Marina Spinu",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRLXpQAO/Profile_Picture_1630044895475",institutionString:null,institution:{name:"University of Agricultural Sciences and Veterinary Medicine of Cluj-Napoca",institutionURL:null,country:{name:"Romania"}}},{id:"92185",title:"Dr.",name:"Sara",middleName:null,surname:"Savic",slug:"sara-savic",fullName:"Sara Savic",profilePictureURL:"https://mts.intechopen.com/storage/users/92185/images/system/92185.jfif",institutionString:'Scientific Veterinary Institute "Novi Sad"',institution:{name:'Scientific Veterinary Institute "Novi Sad"',institutionURL:null,country:{name:"Serbia"}}}]},onlineFirstChapters:{paginationCount:12,paginationItems:[{id:"82285",title:"Parvovirus Vectors: The Future of Gene Therapy",doi:"10.5772/intechopen.105085",signatures:"Megha Gupta",slug:"parvovirus-vectors-the-future-of-gene-therapy",totalDownloads:4,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Recent Advances in Canine Medicine",coverURL:"https://cdn.intechopen.com/books/images_new/11580.jpg",subseries:{id:"19",title:"Animal Science"}}},{id:"81793",title:"Canine parvovirus-2: An Emerging Threat to Young Pets",doi:"10.5772/intechopen.104846",signatures:"Mithilesh Singh, Rajendran Manikandan, Ujjwal Kumar De, Vishal Chander, Babul Rudra Paul, Saravanan Ramakrishnan and Darshini Maramreddy",slug:"canine-parvovirus-2-an-emerging-threat-to-young-pets",totalDownloads:16,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Recent Advances in Canine Medicine",coverURL:"https://cdn.intechopen.com/books/images_new/11580.jpg",subseries:{id:"19",title:"Animal Science"}}},{id:"81271",title:"The Diversity of Parvovirus Telomeres",doi:"10.5772/intechopen.102684",signatures:"Marianne Laugel, Emilie Lecomte, Eduard Ayuso, Oumeya Adjali, Mathieu Mével and Magalie Penaud-Budloo",slug:"the-diversity-of-parvovirus-telomeres",totalDownloads:38,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Recent Advances in Canine Medicine",coverURL:"https://cdn.intechopen.com/books/images_new/11580.jpg",subseries:{id:"19",title:"Animal Science"}}},{id:"79209",title:"Virtual Physiology: A Tool for the 21st Century",doi:"10.5772/intechopen.99671",signatures:"Carmen Nóbrega, Maria Aires Pereira, Catarina Coelho, Isabel Brás, Ana Cristina Mega, Carla Santos, Fernando Esteves, Rita Cruz, Ana I. 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