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Total Mesorectal Excision A Practical Guide
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Total Mesorectal Excision Background Original description in 1982 Complete excision of the mesorectum Meticulous anatomical mobilisation of the rectum
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Total Mesorectal Excision Background Original description in 1982 Complete excision of the mesorectum Meticulous anatomical mobilisation of the rectum
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Total Mesorectal Excision
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MDT Process MRI Staging +/- Radiotherapy TME Pathological scrutiny
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Total Mesorectal Excision Left Colon Mobilisation Mobilisation of splenic flexure Separation of colon and mesocolon from posterior structures High tie IMA and IMV
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Total Mesorectal Excision Left Colon Mobilisation Mobilisation of splenic flexure Separation of colon and mesocolon from posterior structures High tie IMA and IMV
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Total Mesorectal Excision Left Colon Mobilisation Mobilisation of splenic flexure Separation of colon and mesocolon from posterior structures High tie IMA and IMV
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Total Mesorectal Excision Upper Pelvis Identify vascular envelope Identify hypogastric nerves Identify “holy plane”
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Total Mesorectal Excision Upper Pelvis Identify vascular envelope Identify hypogastric nerves Identify “holy plane”
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Total Mesorectal Excision Upper Pelvis Identify vascular envelope Identify hypogastric nerves Identify “holy plane”
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Total Mesorectal Excision Posterior Dissection Develop plane in midline Use sharp or diathermy dissection Proceed to recto- sacral fascia
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Total Mesorectal Excision Lateral Dissection Careful dissection anteriorly Identify and protect the hypogastric nerves Stop when plane disappears
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Total Mesorectal Excision Lateral Dissection Identify hypogastric nerves Careful dissection anteriorly Stop when plane disappears
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Total Mesorectal Excision Anterior Dissection Divide peritoneum above reflection Identify vesicles or vagina Identify Denonvilliers fascia
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Total Mesorectal Excision Mid Pelvis Plane more difficult to define anterolaterally “Lateral Ligaments” Dissect between mesorectum and neurovascular bundle
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Total Mesorectal Excision Mid Pelvis Plane more difficult to define anterolaterally “Lateral Ligaments” Dissect between mesorectum and neurovascular plexus
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Total Mesorectal Excision Mid Pelvis Divide recto-sacral fascia using sharp dissection Avoid excessive traction on mesorectum
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Total Mesorectal Excision Low Pelvis Divide Denonvilliers fascia Release the posterior mesorectum Identify the ano-rectal junction
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Total Mesorectal Excision The Specimen
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Total Mesorectal Excision The Specimen
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Total Mesorectal Excision APER Same dissection to pelvic floor Avoid the most distal mobilisation Excise the levators with the specimen
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