Total Mesorectal Excision

1. Total Mesorectal Excision A Practical Guide

2. Background Original description in 1982 Complete excision of the mesorectum Meticulous anatomical mobilisation of the rectum Total Mesorectal Excision

3. Background Original description in 1982 Complete excision of the mesorectum Meticulous anatomical mobilisation of the rectum Total Mesorectal Excision

4. Total Mesorectal Excision

5. MDT Process MRI Staging +/- Radiotherapy TME Pathological scrutiny Total Mesorectal Excision

6. Left Colon Mobilisation Mobilisation of splenic flexure Separation of colon and mesocolon from posterior structures High tie IMA and IMV Total Mesorectal Excision

7. Left Colon Mobilisation Mobilisation of splenic flexure Separation of colon and mesocolon from posterior structures High tie IMA and IMV Total Mesorectal Excision

8. Left Colon Mobilisation Mobilisation of splenic flexure Separation of colon and mesocolon from posterior structures High tie IMA and IMV Total Mesorectal Excision

9. Upper Pelvis Identify vascular envelope Identify hypogastric nerves Identify “holy plane” Total Mesorectal Excision

10. Upper Pelvis Identify vascular envelope Identify hypogastric nerves Identify “holy plane” Total Mesorectal Excision

11. Upper Pelvis Identify vascular envelope Identify hypogastric nerves Identify “holy plane” Total Mesorectal Excision

12. Posterior Dissection Develop plane in midline Use sharp or diathermy dissection Proceed to recto-sacral fascia Total Mesorectal Excision

13. Lateral Dissection Careful dissection anteriorly Identify and protect the hypogastric nerves Stop when plane disappears Total Mesorectal Excision

14. Lateral Dissection Identify hypogastric nerves Careful dissection anteriorly Stop when plane disappears Total Mesorectal Excision

15. Anterior Dissection Divide peritoneum above reflection Identify vesicles or vagina Identify Denonvilliers fascia Total Mesorectal Excision

16. Mid Pelvis Plane more difficult to define anterolaterally “Lateral Ligaments” Dissect between mesorectum and neurovascular bundle Total Mesorectal Excision

17. Mid Pelvis Plane more difficult to define anterolaterally “Lateral Ligaments” Dissect between mesorectum and neurovascular plexus Total Mesorectal Excision

18. Mid Pelvis Divide recto-sacral fascia using sharp dissection Avoid excessive traction on mesorectum Total Mesorectal Excision

19. Low Pelvis Divide Denonvilliers fascia Release the posterior mesorectum Identify the ano-rectal junction Total Mesorectal Excision

20. The Specimen Total Mesorectal Excision

21. The Specimen Total Mesorectal Excision

22. APER Same dissection to pelvic floor Avoid the most distal mobilisation Excise the levators with the specimen Total Mesorectal Excision