Download Total Mesorectal Excision: Tips and Techniques.

Total Mesorectal Excision: Tips and Techniques.
Jirawat Pattana-arun, MD.
Songphol Malakorn, MD.
Colorectal Division, Department of Surgery, Chulalongkorn University
Background: Total mesorectal excision (TME) is a gold standard for rectal cancer surgery
since 1990s. The principles is complete excision of mesorectal tissue within the intact
envelope of fascia propia of the rectum. Also, preservation of autonomic nerve is warranted to
avoid genitourinary complication and sexual dysfunction. We present a stepwise TME
technique with emphasis on critical points.
Method: A 40-year-old Thai male with active sexual life was diagnosed with welldifferentiated adenocarcinoma of lower rectum. Low anterior resection was planned.
Lithotomy position was used with special precaution on pressure free of peroneal nerve and
bony prominent. Lower midline incision was performed. Careful small bowel packing
provided a good exposure and minimized post-operative ileus. Left-sided colon was
mobilized by lateral to medial approach, begin at 2 mm anterior to the white line of Toldt.
The left side colon was mobilized by lateral to medial approach, begin at 2 mm. above the
white line of Toldt. By extending this plane upwardly, the splenic flexure was mobilized as in
laparoscopic surgery. Mesocolic dissecion began just below superior rectal artery and extend
laterally to join the previously dissected plane from the lateral. High ligation of inferior
mesenteric artery and ligation of inferior mesenteric vein at the same level was performed.
Sharp dissection under direct vision along avascular plane between fascia propia of the
rectum and parietal pelvic fascia started at the sacral promontary downwards in the same
plane as colonic mobilization. Retraction of the rectum anteriorly facilitated the posterior
dissection which was carried on as far as the pelvic floor. Care should be taken on
identification and preservation of hypogastric nerves. Then, the dissection extended laterally
on both sides with identification of pelvic plexus and hypogastastric vessels. Anterior
dissection started by transverse division of peritoneal reflexion and went further down in the
plane behind the seminal vesicle and anterior to anterior mesorectal fascia. Surgeon’s hand
and St. Mark’s retractor provided a good exposure in the pelvic cavity. Circumferential
dissection ended at the pelvic floor where the mesorectum ended. After rectal resection,
tension-free coloanal anasomosis was performed by stapling devices.
Result: TME technique was showed. The patient returned to normal bowel function within 2
days without immediate complications. Pathological report confirmed free circumferential
margin.
Conclusion: Understanding the correct surgical plane is a key for good TME which will and
will result in a better oncologic outcome and low complication.