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Rectal Cancer pp 109-121 | Cite as

Total Mesorectal Excision

  • Abhi SharmaEmail author
  • John Monson
Chapter

Abstract

Total mesorectal excision (TME) is now the standard surgical technique for management of rectal cancer. This involves dissection in a well-defined anatomical plane with an embryological basis. TME has improved results of rectal cancer surgery all over the world. TME can safely be performed laparoscopically and the use of robot for TME is also gaining acceptance.

Understanding the anatomy of rectum is crucial to performing a good TME. The relationship of nerves and vessels around the mesorectum is well defined, and identification can reduce neurovascular complications associated with surgery. This chapter discusses the anatomy of mesorectum, advantages and complications of TME, and our technique of performing TME.

Keywords

Total mesorectal excision Rectal cancer Anatomy of rectum Rectum 

References

  1. 1.
    Chapuis P, Bokey L, Fahrer M, et al. Mobilization of the rectum: anatomic concepts and the bookshelf revisited. Dis Colon Rectum. 2002;45:1–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Jonnesco T. In: Poirier P, Charpy A, editor. Traite d’anatomie Humaine. Vol. IV. 2nd ed. Paris: Masson et Cie; 1901. Appareil digestif. p. 372–3.Google Scholar
  3. 3.
    Moran B, Heald RJ. Manual of total mesorectal excision. 2013. ISBN 9781444117165.Google Scholar
  4. 4.
    Acar HI, Kuzu MA. Important points for protection of the autonomic nerves during total mesorectal excision. Dis Colon Rectum. 2012;55(8):907–12.CrossRefPubMedGoogle Scholar
  5. 5.
    Havenga K, Huang Y, Enker WE, Welvaart K, De Roy Van Zuidewijn DB, Cohen AM. Aggressive versus conventional strategies in the treatment of rectal adenocarcinoma. Surg Oncol. 1996a;5(4):183–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Brown G, Kirkham A, et al. High-resolution MRI of the anatomy important in total mesorectal excision of the rectum. Am J Roentgenol. 2004;182(2):431–9.CrossRefGoogle Scholar
  7. 7.
    Abel AL. The modern treatment of cancer of the rectum. Milwaukee Proc. 1931:296–300.Google Scholar
  8. 8.
    Dixon CF. Anterior resection for malignant lesions of the upper part of the rectum and lower part of the sigmoid. Ann Surg. 1948;128l:425–42.CrossRefGoogle Scholar
  9. 9.
    Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery-the clue to pelvic recurrence? Br J Surg. 1982;691:613–6.CrossRefGoogle Scholar
  10. 10.
    Heald RJ. A new approach to rectal cancer. Br J Hosp Med. 1979;22:277–81.PubMedGoogle Scholar
  11. 11.
    Heald RJ, Husband EM, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet. 1986;1:1479–82.CrossRefPubMedGoogle Scholar
  12. 12.
    Aitken RJ. Mesorectal excision for rectal cancer. Br J Surg. 1996;83:214–6.CrossRefPubMedGoogle Scholar
  13. 13.
    Enker WE, Thaler HT, Cranor ML, et al. Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg. 1995;181:335–46.PubMedGoogle Scholar
  14. 14.
    MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet. 1993;341(8843):457–60.CrossRefPubMedGoogle Scholar
  15. 15.
    Grinnell RS. Distal intramural spread of carcinoma of the rectum and rectosigmoid. Surg Gynecol Obstet. 1954;99:421–30.PubMedGoogle Scholar
  16. 16.
    Kirwan WO, Drumm J, Hogan JM, Keohane C. Determining safe margins of resection in low anterior resection for rectal cancer. Br J Surg. 1988;75:720–1.CrossRefPubMedGoogle Scholar
  17. 17.
    Paty PB, Enker WE, Cohen AM, et al. Treatment of rectal cancer by low anterior resection with coloanal anastomosis. Ann Surg. 1994;219:365–73.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Vernava AM, Moran M. A prospective evaluation of distal margins in carcinoma of the rectum. Surg Gynecol Obstet. 1992;175:333–6.PubMedGoogle Scholar
  19. 19.
    Williams NS, Dixon MF, Johnston D. Reappraisal of the 5 centimetre rule for distal excision of carcinoma of the rectum: a study of distal intramural spread and of patients’ survival. Br J Surg. 1983;70:150–4.CrossRefPubMedGoogle Scholar
  20. 20.
    Heald RJ, Moran B, Ryall RDH, et al. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg. 1998;133:894–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Piso P, Dahlke MH, et al. Total mesorectal excision for middle and lower rectal cancer: a single institution experience with 337 consecutive patients. J Surg Oncol. 2004;86(3):115–21.CrossRefPubMedGoogle Scholar
  22. 22.
    Wibe A, Møller B, et al. A national strategic change in treatment policy for rectal cancer-implementation of total mesorectal excision as routine treatment in Norway. A national audit. Dis Colon Rectum. 2002;45(7):857–66.CrossRefPubMedGoogle Scholar
  23. 23.
    Kapiteijn E, Putter H, et al. Impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands. Br J Surg. 2002;89(9):1142–9.CrossRefPubMedGoogle Scholar
  24. 24.
    Kapiteijn E, Marijnen C, Nagtegaal I, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001;345(9):638–46.CrossRefPubMedGoogle Scholar
  25. 25.
    Quirke P, Steele R, Monson J, Grieve R, Khanna S, Couture J, O'Callaghan C, Myint AS, Bessell E, Thompson LC, Parmar M, Stephens RJ, Sebag-Montefiore D. Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet. 2009;373(9666):821.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Sauer R, Fietkau R, Wittekind C, et al. Adjuvant vs. neoadjuvant radiochemotherapy for locally advanced rectal cancer: the German trial CAO/ARO/AIO-94. Color Dis. 2003;5:406–15.CrossRefGoogle Scholar
  27. 27.
    Sauer R, Liersch T, Merkel S, Fietkau R, Hohenberger W, Hess C, Becker H, Raab HR, Villanueva MT, Witzigmann H, Wittekind C, Beissbarth T, Rödel C. Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years. J Clin Oncol. 2012;30(16):1926–33.CrossRefPubMedGoogle Scholar
  28. 28.
    Delaney CP, Lavery IC, et al. Preoperative radiotherapy improves survival for patients undergoing total mesorectal excision for stage T3 low rectal cancers. Ann Surg. 2002;236(2):203–7.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Beets-Tan RG. MRI in rectal cancer: the T stage and circumferential resection margin. Color Dis. 2003;5:392–5.CrossRefGoogle Scholar
  30. 30.
    Martling A, Holm T, Bremmer S, Lindholm J, Cedermark B, Blomqvist L. Prognostic value of preoperative magnetic resonance imaging of the pelvis in rectal cancer. Br J Surg. 2003;90:1422–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Mathur P, Smith JJ, Ramsey C, et al. Comparison of CT and MRI in the pre-operative staging of rectal adenocarcinoma and prediction of circumferential resection margin involvement by MRI. Color Dis. 2003;5:396–401.CrossRefGoogle Scholar
  32. 32.
    Hiotis SP, Weber SM, Cohen AM, et al. Assessing the predictive value of clinical complete response to neoadjuvant therapy for rectal cancer: an analysis of 488 patients. J Am Coll Surg. 2002;194:131–5.CrossRefPubMedGoogle Scholar
  33. 33.
    Law WL, Chu KW. Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients. Ann Surg. 2004;240:260–8.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Leong AFPK. Selective total mesorectal excision for rectal cancer. Dis Colon Rectum. 2000;43(9):1237–40.CrossRefPubMedGoogle Scholar
  35. 35.
    Eriksen MT, Wibe A, Norstein J, et al. Anastomotic leakage following routine mesorectal excision for rectal cancer in a national cohort of patients. Color Dis. 2005;7(1):51–7.CrossRefGoogle Scholar
  36. 36.
    Milgrom SA, Goodman KA, et al. Neoadjuvant radiation therapy prior to total mesorectal excision for rectal cancer is not associated with postoperative complications using current techniques. Ann Surg Oncol. 2014;21(7):2295–302.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Bennis M, Parc Y, et al. Morbidity risk factors after low anterior resection with total mesorectal excision and coloanal anastomosis: a retrospective series of 483 patients. Ann Surg. 2012;255(3):504–10.CrossRefPubMedGoogle Scholar
  38. 38.
    Bruce J, Krukowski ZH, Al-Khairy G, Russell EM, Park KG. Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg. 2001;88:1157–68.CrossRefPubMedGoogle Scholar
  39. 39.
    Carlsen E, Schlichting E, Guldvog I, Johnson E, Heald RJ. Effect of the introduction of total mesorectal excision for the treatment of rectal cancer. Br J Surg. 1998;85:526–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Peeters KCMJ, Tollenaar RAEM, et al. Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg. 2005;92(2):211–6.CrossRefPubMedGoogle Scholar
  41. 41.
    Van P, Slors JFM, et al. Prospective evaluation of anorectal function after total mesorectal excision for rectal carcinoma with or without preoperative radiotherapy. Am J Gastroenterol. 2002;97(9):2282.CrossRefGoogle Scholar
  42. 42.
    Wiltink LM, Chen TYT, et al. Health-related quality of life of patients 14 years after short-term preoperative radiotherapy and total mesorectal excision for rectal cancer: report of a multicenter randomized trial. Eur J Cancer. 2014;50:2390.CrossRefPubMedGoogle Scholar
  43. 43.
    Kollmorgen CF, Meagher AP, Wolf BG, et al. The long-term effect of adjuvant postoperative chemoradiotherapy for rectal carcinoma on bowel function. Ann Surg. 1994;220:676–82.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Karanjia ND, Schache DJ, Heald RJ. Function of the distal rectum after low anterior resection for carcinoma. Br J Surg. 1992;79:114–6.CrossRefPubMedGoogle Scholar
  45. 45.
    Graf W, Ekstrom K, Glimelius B, Pahlman L. A pilot study of factors influencing bowel function after colorectal anastomoses. Dis Colon Rectum. 1996;39:744–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Dehni N. Effects of aging on the functional outcome of coloanal anastomoses with colonic J-pouch. Am J Surg. 1998;175:209–12.CrossRefPubMedGoogle Scholar
  47. 47.
    Ho P, Law WL, Chan SC, Lam CK, Chu KW. Functional outcome following low anterior resection with total mesorectal excision in the elderly. Int J Color Dis. 2003;18:230–3.Google Scholar
  48. 48.
    Yamana T, Oya M, Komatsu J, et al. Preoperative anal sphincter high-pressure zone, maximal tolerable volume, and anal mucosal electrosensitivity predict early postoperative defecatory function after low anterior resection for rectal cancer. Dis Colon Rectum. 1999;42:1145–51.CrossRefPubMedGoogle Scholar
  49. 49.
    Fleming FJ, Påhlman L, Monson JR. Neoadjuvant therapy in rectal cancer. Dis Colon Rectum. 2011;54(7):901–12.CrossRefPubMedGoogle Scholar
  50. 50.
    Havenga K, DeRuiter MC, et al. Anatomical basis of autonomic nerve-preserving total mesorectal excision for rectal cancer. Br J Surg. 1996b;83(3):384–8.CrossRefPubMedGoogle Scholar
  51. 51.
    Lindsey I, Warren BF, et al. Denonvillier’s fascia lies anterior to the fascia propria and rectal dissection plane in total mesorectal excision. Dis Colon Rectum. 2005;48(1):37–42.CrossRefPubMedGoogle Scholar
  52. 52.
    Junginger T, Kneist W, et al. Influence of identification and preservation of pelvic autonomic nerves in rectal cancer surgery on bladder dysfunction after total mesorectal excision. Dis Colon Rectum. 2003;46(5):621–8.CrossRefPubMedGoogle Scholar
  53. 53.
    Maurer CA, Z’Graggen K, et al. Total mesorectal excision preserves male genital function compared with conventional rectal cancer surgery. Br J Surg. 2001;88(11):1501–5.CrossRefPubMedGoogle Scholar
  54. 54.
    Shirouzu K, Ogata Y, Araki Y. Oncologic and functional results of total mesorectal excision and autonomic nerve-preserving operation for advanced lower rectal cancer. Dis Colon Rectum. 2004;47:1442–7.CrossRefPubMedGoogle Scholar
  55. 55.
    Kim NK, Aahn TW, Park JK, et al. Assessment of sexual and voiding function after total mesorectal excision with pelvic autonomic nerve preservation in males with rectal cancer. Dis Colon Rectum. 2002;45:1178–85.CrossRefPubMedGoogle Scholar
  56. 56.
    Marijnen CA, van de Velde CJ, Putter H, et al. Impact of short-term preoperative radiotherapy on health-related quality of life and sexual functioning in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol. 2005;23:1847–58.CrossRefPubMedGoogle Scholar
  57. 57.
    Liang JT, Lai HS, et al. Comparison of functional and surgical outcomes of laparoscopic-assisted colonic J-pouch versus straight reconstruction after total mesorectal excision for lower rectal cancer. Ann Surg Oncol. 2007;14(7):1972–9.CrossRefPubMedGoogle Scholar
  58. 58.
    Berger A, Tiret E, Frileux P, et al. Excision of the rectum with colonic J pouch-anal anastomosis for adenocarcinoma of the low and mid rectum. World J Surg. 1992;16:470–7.CrossRefPubMedGoogle Scholar
  59. 59.
    Lazorthes F, Fages P, Chiotasso P, Lemozy J, Bloom E. Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum. Br J Surg. 1986;73:136–8.CrossRefPubMedGoogle Scholar
  60. 60.
    Koperna T. Cost-effectiveness of defunctioning stomas in low anterior resections for rectal cancer. A call for benchmarking. Arch Surg. 2003;138:1334–8.CrossRefPubMedGoogle Scholar
  61. 61.
    Williams N, Seow-Choen F. Physiological and functional outcome following ultra-low anterior resection with colon pouch-anal anastomosis. Br J Surg. 1998;85(8):1029–35.CrossRefPubMedGoogle Scholar
  62. 62.
    Ho YH, Brown S, Heah SM, et al. Comparison of J-pouch and coloplasty patch for low rectal cancers: a randomized, controlled trial investigating functional results and comparative anastomotic leak rates. Ann Surg. 2002;236:49–55.CrossRefPubMedPubMedCentralGoogle Scholar
  63. 63.
    Koninger JS, Butters M, et al. Transverse coloplasty pouch after total mesorectal excision: functional assessment of evacuation. Dis Colon Rectum. 2004;47(10):1586–93.CrossRefPubMedGoogle Scholar
  64. 64.
    Remzi FH, Fazio VW, Gorgun E, et al. Quality of life, functional outcome, and complications of coloplasty pouch after low anterior resection. Dis Colon Rectum. 2005;48(4):735–43.CrossRefPubMedGoogle Scholar
  65. 65.
    Hüser N, Michalski CW, Erkan M, Schuster T, Rosenberg R, Kleeff J, Friess H. Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg. 2008;248(1):52–60.CrossRefPubMedGoogle Scholar
  66. 66.
    Sharma A, Deeb AP, Rickles AS, Iannuzzi JC, Monson JR, Fleming FJ. Closure of defunctioning loop ileostomy is associated with considerable morbidity. Color Dis. 2013;15(4):458–62.CrossRefGoogle Scholar
  67. 67.
    Den DM, Smit M, et al. A multivariate analysis of limiting factors for stoma reversal in patients with rectal cancer entered into the total mesorectal excision (TME) trial: a retrospective study. Lancet Oncol. 2007;8(4):297.CrossRefGoogle Scholar
  68. 68.
    Wolthuis A, Kurniawan N, et al. Results of an audit on the selective use of a defunctioning stoma at TME. Color Dis. 2009;11:47.Google Scholar
  69. 69.
    O'Leary DP, Fide CJ, Foy C, Lucarotti MR. Quality of life after low anterior resection with total mesorectal excision and temporary loop ileostomy for rectal cancer. Br J Surg. 2001;88(9):1216–20.CrossRefPubMedGoogle Scholar
  70. 70.
    Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM, MRC CLASICC Trial Group. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet. 2005;365(9472):1718–26.CrossRefPubMedGoogle Scholar
  71. 71.
    Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der Pas MH, de Lange-de Klerk ES, Lacy AM, Bemelman WA, Andersson J, Angenete E, Rosenberg J, Fuerst A, Haglind E, COLOR II Study Group, Breukink S, Pierie J, et al. Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database Syst Rev. 2006;(4):CD005200.Google Scholar
  72. 72.
    Lee SH, Lim S, Kim JH, Lee KY. Robotic versus conventional laparoscopic surgery for rectal cancer: systematic review and meta-analysis. Ann Surg Treat Res. 2015;89(4):190–201.Google Scholar
  73. 73.
    Kim NK. Anatomic basis of sharp pelvic dissection for curative resection of rectal cancer. Yonsei Med J. 2005a;46(6):737–49.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Consultant Surgeon and Honorary Senior LecturerUniversity Hospital of South Manchester and The University of Manchester, MAHSCManchesterUK
  2. 2.Florida Hospital System Center for Colon and Rectal SurgeryFlorida Hospital Medical GroupOrlandoUSA

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