Presacral Fascia

fascia praesacralis Waldeyeri

The presacral fascia is the part of the parietal pelvic fascia that covers the front of the sacrum and coccyx. It lies behind the rectum and its mesorectal fascia, separated from them by the loose retrorectal space, and it covers the presacral veins, which can bleed heavily if the fascia is torn.

Anatomical Data

Boundaries & Contents

Location	Back of the pelvis, lying on the front of the sacrum and coccyx
Boundaries	Attached to the anterior surface of the sacrum and coccyx Continuous laterally with the parietal pelvic fascia Separated from the mesorectal fascia in front by the retrorectal space Joined to the mesorectal fascia at about S4 by the rectosacral fascia
Contents	Covers the median sacral vessels and the presacral (sacral) venous plexus behind it

Biomechanics

Function & Actions

Covers and protects the presacral veins and sacral vessels; dissection in the plane in front of it during rectal surgery avoids severe bleeding from these veins.

Clinical Relevance

Clinical Notes

Division of the presacral fascia at the correct level during TME is the key to entering the sacred plane of Holy Plane anterior to the sacral venous plexus, avoiding catastrophic presacral venous bleeding. If the dissection strays too posteriorly through Waldeyer fascia, the presacral venous plexus is entered, producing difficult-to-control venous haemorrhage from the valveless presacral veins. Thumbtacks (gauze pledgets with metal tacks) or sterile pushpins are the last resort for presacral vein haemorrhage when sutures and cautery fail.

Pathology

Common Injuries & Conditions

Presacral Venous Haemorrhage During TME

Inadvertent posterior dissection through Waldeyer fascia into the presacral venous plexus during rectal cancer excision produces massive haemorrhage from the valveless presacral veins that is extremely difficult to control by suturing or cautery, occasionally requiring direct pressure with gauze thumbtacks or surgical gauze packing as a last resort.

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