International Journal of Colorectal Disease

, Volume 28, Issue 10, pp 1367–1375 | Cite as

Nerve-oriented mesorectal excision (NOME): autonomic nerves as landmarks for laparoscopic rectal resection

  • Norbert Runkel
  • Harald Reiser
Original Article



We have developed nerve-oriented mesorectal excision (NOME) as a novel concept in rectal cancer surgery by which autonomic pelvic nerves serve as landmarks for a standardized navigation along fascial planes. This article describes the technique step by step and presents our results from 2008 to 2012.

Material and methods

The key steps are: preparation of the splanchnic nerves at the mid-posterior sidewall, the hypogastric nerves at the upper sidewall, and the urogenital nerve branches (Walsh) at the caudal-anterior sidewall. The dissection of the lateral ligament is strictly performed as the last step. NOME was applied in 274 consecutive mesorectal excisions (partial 20.4 %, total 79.6 %); a subgroup of 42 male patients underwent a questionnaire-based interview on sexual activity.


The conversion rate was 0.7 %. High (complete) specimen quality and circumferential margin negativity were achieved in 90.1 % and 95.3 %, respectively. Anastomotic leaks occurred in 13 (4.7 %) patients. Mortality was 1.8 %. The frequency of prolonged urinary catheter was 1.8 %. Of 22 sexually active males interviewed, 18 (81.8 %) maintained activity postoperatively.


NOME achieves high-quality mesorectal specimens and a high rate of preservation of autonomic nerve function. The concept of using nerves as laparoscopic landmarks may help to standardize and master laparoscopic rectal cancer surgery.


Laparoscopy Rectal cancer Total mesorectal excision Nerve preservation Autonomic pelvic nerves 



We are indebted to Tilo Wedel (Institute of Anatomy, University Hospital Schleswig-Holstein, Campus Kiel, Germany) for his advice and support for the paper.


  1. 1.
    Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616PubMedCrossRefGoogle Scholar
  2. 2.
    Kinugasa Y, Murakami G, Suzuki D, Sugihara K (2007) Histological identification of fascial structures posterolateral to the rectum. Br J Surg 94:620–626PubMedCrossRefGoogle Scholar
  3. 3.
    Mike M, Kano N (2011) Laparoscopic-assisted low anterior resection of the rectum—a review of the fascial composition in the pelvic space. Int J Colorectal Dis 26:405–414PubMedCrossRefGoogle Scholar
  4. 4.
    Stelzner S, Holm T, Moran BJ, Heald RJ, Witzigmann H, Zorenkov D, Wedel T (2011) Deep pelvic anatomy revisited for a description of crucial steps in extralevator abdominoperineal excision for rectal cancer. Dis Colon Rectum 54:947–957PubMedCrossRefGoogle Scholar
  5. 5.
    Enker WE, Thaler HT, Cranor ML, Polyak T (1995) Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg 181:335–346PubMedGoogle Scholar
  6. 6.
    Clausen N, Wolloscheck T, Konerding MA (2008) How to optimize autonomic nerve preservation in total mesorectal excision: clinical topography and morphology of pelvic nerves and fasciae. World J Surg 32:1768–1775PubMedCrossRefGoogle Scholar
  7. 7.
    Nagtegaal ID, van de Velde CJ, van der Worp E, Kapiteijn E, Quirke P, van Krieken JH, Cooperative Clinical Investigators of the Dutch Colorectal Cancer Group (2002) Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control. J Clin Oncol 20:1729–1734PubMedCrossRefGoogle Scholar
  8. 8.
    Liang JT, Lai HS, Lee PH (2007) Laparoscopic pelvic autonomic nerve-preserving surgery for patients with lower rectal cancer after chemoradiation therapy. Ann Surg Oncol 14:1285–1287PubMedCrossRefGoogle Scholar
  9. 9.
    Selvindos PB, Ho YH (2008) Multimedia article. Laparoscopic ultralow anterior resection with colonic J-pouch-anal anastomosis. Dis Colon Rectum 51:1710–1711PubMedCrossRefGoogle Scholar
  10. 10.
    Fürst A, Schwandner O, Heiligensetzer A, Iesalnieks I, Agha A (2010) Laparoscopic TME in rectal cancer–electronic supplementary: op-video. Langenbecks Arch Surg 395:181–183PubMedCrossRefGoogle Scholar
  11. 11.
    Adamina M, Delaney CP (2011) Laparoscopic total mesorectal excision for low rectal cancer. Surg Endosc 25:2738–2741PubMedCrossRefGoogle Scholar
  12. 12.
    Cheung YM, Lange MM, Buunen M, Lange JF (2009) Current technique of laparoscpic total mesorectal excision (TME): an international questionnaire among 368 surgeons. Surg Endosc 23:2796–40PubMedCrossRefGoogle Scholar
  13. 13.
    Moriya Y (2006) Function preservation in rectal cancer surgery. Int J Clin Oncol 11:339–343PubMedCrossRefGoogle Scholar
  14. 14.
    Bosch SL, Nagtegaal ID (2012) The importance of the pathologist's role in assessment of the quality of the mesorectum. Curr Colorectal Cancer Rep 8:90–98PubMedCrossRefGoogle Scholar
  15. 15.
    Williams NS (2010) The rectal 'no man's land' and sphincter preservation during rectal excision. Br J Surg 97:1749–1751PubMedCrossRefGoogle Scholar
  16. 16.
    Huang MJ, Liang JL, Wang H, Kang L, Deng YH, Wang JP (2011) Laparoscopic-assisted versus open surgery for rectal cancer: a meta-analysis of randomized controlled trials on oncologic adequacy of resection and long-term oncologic outcomes. Int J Colorectal Dis 26:415–421PubMedCrossRefGoogle Scholar
  17. 17.
    Braga M, Frasson M, Vignali A, Zuliani W, Capretti G, Di Carlo V (2007) Laparoscopic resection in rectal cancer patients: outcome and cost-benefit analysis. Dis Colon Rectum 50:464–471PubMedCrossRefGoogle Scholar
  18. 18.
    Ng SS, Leung KL, Lee JF, Yiu RY, Li JC, Teoh AY, Leung WW (2008) Laparoscopic-assisted versus open abdominoperineal resection for low rectal cancer: a prospective randomized trial. Ann Surg Oncol 15:18–25CrossRefGoogle Scholar
  19. 19.
    Lujan J, Valero G, Hernandez Q, Sanchez A, Frutos MD, Parrilla P (2009) Randomized clinical trial comparing laparoscopic and open surgery in patients with rectal cancer. Br J Surg 96:982–989PubMedCrossRefGoogle Scholar
  20. 20.
    Kang SB, Park JW, Jeong SY, Nam BH, Choi HS, Kim DW, Lim SB, Lee TG, Kim DY, Kim JS, Chang HJ, Lee HS, Kim SY, Jung KH, Hong YS, Kim JH, Sohn DK, Kim DH, Oh JH (2010) Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 11:637–645PubMedCrossRefGoogle Scholar
  21. 21.
    Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM, MRC CLASICC trial group (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365:1718–1726PubMedCrossRefGoogle Scholar
  22. 22.
    Jayne DG, Guillou PJ, Thorpe H, Quirke P, Copeland J, Smith AM, Heath RM, Brown JM, UK MRC CLASICC Trial Group (2007) Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol 25:3061–3068PubMedCrossRefGoogle Scholar
  23. 23.
    Eveno C, Lamblin A, Mariette C, Pocard M (2010) Sexual and urinary dysfunction after proctectomy for rectal cancer. J Visc Surg 147:e21–e30PubMedCrossRefGoogle Scholar
  24. 24.
    Quah HM, Jayne DG, Eu KW, Seow-Choen F (2002) Bladder and sexual dysfunction following laparoscopically assisted and conventional open mesorectal resection for cancer. Br J Surg 89:1551–1556PubMedCrossRefGoogle Scholar
  25. 25.
    Kneist W, Heintz A, Junginger T (2005) Major urinary dysfunction after mesorectal excision for rectal carcinoma. Br J Surg 92:230–234PubMedCrossRefGoogle Scholar
  26. 26.
    Doeksen A, Gooszen JA, van Duijvendijk P, Tanis PJ, Bakx R, Slors JF, van Lanschot JJ (2011) Sexual and urinary functioning after rectal surgery: a prospective comparative study with a median follow-up of 8.5 years. Int J Colorectal Dis 126:1549–1557CrossRefGoogle Scholar
  27. 27.
    Sterk P, Shekarriz B, Günter S, Nolde J, Keller R, Bruch HP, Shekarriz H (2005) Voiding and sexual dysfunction after deep rectal resection and total mesorectal excision: prospective study on 52 patients. Int J Colorectal Dis 20:423–427PubMedCrossRefGoogle Scholar
  28. 28.
    Nishizawa Y, Ito M, Saito N, Suzuki T, Sugito M, Tanaka T (2011) Male sexual dysfunction after rectal cancer surgery. Int J Colorectal Dis 26:1541–1548PubMedCrossRefGoogle Scholar
  29. 29.
    Morino M, Parini U, Allaix ME, Monasterolo G, Brachet Contul R, Garrone C (2009) Male sexual and urinary function after laparoscopic total mesorectal excision. Surg Endosc 23:1233–1240PubMedCrossRefGoogle Scholar
  30. 30.
    Havenga K, Enker WE, McDermott K, Cohen AM, Minsky BD, Guillem J (1996) Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J Am Coll Surg 182:495–502PubMedGoogle Scholar
  31. 31.
    McGlone ER, Khan OA, Conti J, Iqbal Z, Parvaiz A (2012) Functional outcomes following laparoscopic and open rectal resection for cancer. Int J Surg 10:305–309PubMedCrossRefGoogle Scholar
  32. 32.
    McGlone ER, Khan O, Flashman K, Khan J, Parvaiz A (2012) Urogenital function following laparoscopic and open rectal cancer resection: a comparative study. Surg Endosc 26:2559–2565PubMedCrossRefGoogle Scholar
  33. 33.
    Kneist W, Kauff DW, Gockel I, Huppert S, Koch KP, Hoffmann KP, Lang H (2012) Total mesorectal excision with intraoperative assessment of internal anal sphincterinnervation provides new insights into neurogenic incontinence. J Am Coll Surg 214:306–312PubMedCrossRefGoogle Scholar
  34. 34.
    Maas CP, Moriya Y, Steup WH, Kiebert GM, Kranenbarg WM, van de Velde CJ (1998) Radical and nerve-preserving surgery for rectal cancer in The Netherlands: a prospective study on morbidity and functional outcome. Br J Surg 85:92–97PubMedCrossRefGoogle Scholar
  35. 35.
    Lange MM, Maas CP, Marijnen CA, Wiggers T, Rutten HJ, Kranenbarg EK, van de Velde CJ (2008) Cooperative Clinical Investigators of the Dutch Total Mesorectal Excision Trial. Urinary dysfunction after rectal cancer treatment is mainly caused by surgery. Br J Surg 95:1020–1028PubMedCrossRefGoogle Scholar
  36. 36.
    Hida K, Hasegawa S, Kataoka Y, Nagayama S, Yoshimura K, Nomura A, Kawada K,Kawamura J, Kinjo Y, Sakai Y (2012) Male Sexual Function after Laparoscopic Total Mesorectal Excision. Colorectal Dis (in press)Google Scholar
  37. 37.
    Song PH, Yun SM, Kim JH, Moon KH (2010) Comparison of the erectile function in male patients with rectal cancer treated by preoperative radiotherapy followed by surgery and surgery alone. Int J Colorectal Dis 25:619–624PubMedCrossRefGoogle Scholar
  38. 38.
    Hohenberger W, Merkel S, Hermanek P (2012) Volume and outcome in rectal cancer surgery: the importance of quality management. Int J Colorectal Dis (in press)Google Scholar
  39. 39.
    Baek JH, Alrubaie A, Guzman EA, Choi SK, Anderson C, Mills S, Carmichael J, Dagis A, Qian D, Kim J, Garcia-Aguilar J, Stamos MJ, Bening L, Pigazzi A (2012). The association of hospital volume with rectal cancer surgery outcomes. Int J Colorectal Dis [Epub ahead of print]Google Scholar
  40. 40.
    Chand M, Heald RJ (2011) Laparoscopic rectal cancer surgery. Br J Surg 98:166–167PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  1. 1.Department of General Surgery, Schwarzwald-Baar-KlinikumTeaching Hospital of the University of FreiburgVillingen-SchwenningenGermany

Personalised recommendations