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