Rectal resection, open, low anterior with total mesorectal excision (TME)

  • Universitätsklinik Lübeck

    Dr. Tilman Laubert

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  • Descending and sigmoid colon

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    • Splenic flexure attached to the diaphragm by the phrenicocolic ligament

    • Descending colon situated in secondary retroperitoneal position

    • Transition between descending and sigmoid colon in the left iliac gutter

    • Sigmoid colon situated intraperitoneally (→ sigmoid mesocolon)

    • Transition between sigmoid colon and rectum anterior to the body of S2/S3

  • Rectum

    The rectum is divided into thirds. The level of their borders is measured with rigid rectoscopy and referenced to the anocutaneous line. Distal third at 0-6cm, middle third at 6-12cm, proximal third at 12-16cm

  • Fascia systems

    • The pelvic parietal fascia covers the pelvic wall with its vessels, autonomic nerves and plexus of the presacral veins/nerves

    • The rectosacral fascia and visceral pelvic fascia meet proximal to the anorectal transition

    • The visceral fasciae comprise the proper pelvic fascia (encasing the posterior and lateral mesorectum) and the anterior Denonvilliers fascia

  • Vessels

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    • Anastomoses between branches of the superior and inferior mesenteric artery (middle and left colic artery respectively) near the splenic flexure (anastomosis of Riolan).

    • Left hemicolon, sigmoid colon and upper rectum supplied by the inferior mesenteric artery and its branches: left colic artery, sigmoid arteries with Drummond marginal artery, superior rectal artery.

    • Proximal third of the rectum supplied by the superior rectal artery dividing posteriad into two terminal branches; middle third by the middle rectal artery (paired, each originating from the internal iliac artery); and the distal third by the inferior rectal artery (paired, each originating from the internal iliac artery). The middle rectal arteries course in the so-called lateral ligaments of the rectum and are divided in total mesorectal excision.

    • Venous blood from the left hemicolon flows via veins of the same name into the area drained by the portal vein.

    • Venous drainage of the proximal and middle third via the inferior mesenteric vein (draining into the portal vein), while venous blood from the distal third returns via the area drained by the inferior vena cava.

  • Lymphatic drainage

    • For all rectal segments along the course of the superior rectal artery and inferior mesenteric artery.

    • In the distal third also via lymphatics paralleling the middle rectal and internal iliac arteries to lymph nodes around the levator ani muscles and ischioanal fossa.

  • Topographical relations

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    Descending colon, retroperitoneum and rectum

    • Course of the descending colon from proximal to distal closely related to the spleen (splenic flexure), omental bursa (posteromedial to the splenic flexure), left kidney and pancreatic tail (proximal segment of descending colon).

    • Root of the sigmoid mesocolon from the left iliac gutter coursing mediad, crossing the common left iliac vessels, left ureter and left ovarian/testicular vessels

    Left ureter coursing on the psoas muscle, which it crosses from superolaterad to inferomediad.

  • Lateral rectal topography

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    In men, the Denonvilliers fascia covers the posterior wall of the bladder, the seminal vesicles and the posterior wall of the prostate.

  • Klinikum Großhadern

    Herr Prof. Dr. med. Dr. h.c. Karl-Walter Jauch

  • Charite Berlin

    Prof. Dr. Martin Kreis

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 26.04.2009
  • Klinikum Großhadern

    Herr Prof. Dr. med. Dr. h.c. Karl-Walter Jauch

  • Charite Berlin

    Prof. Dr. Martin Kreis

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  • Skin incision and exposure

    36-7

    Median laparotomy starting at the symphysis and terminating a few centimeters superior to the umbilicus. (It is very important to carry the skin incision down to the symphysis because otherwise this would greatly impair access to the lesser pelvis). If necessary, mobilize the bladder somewhat. Insert a circular wound edge protector followed by a retractor. Intraoperative exploration.

  • Freeing the sigmoid laterally

    36-9

    Retract the colon mediad and sharply divide the lateral peritoneal adhesions of the colon with the abdominal wall. Carefully ensure that the preparation is not carried too deeply, i.e., down to the psoas muscle and posterior to the kidney, but that only the mesosigmoid will be mobilized. This will automatically expose the left ureter posteriorly which can then be identified. There is no need to dissect the ureter as in ureterolysis.

  • Freeing the splenic flexure

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    Mobilize the splenic flexure by alternating between inferiorly dissecting the descending colon off the anterior left kidney in the areolar plane and superiorly by freeing the greater omentum from the transverse colon and entering the lesser sac. As last step divide the links with the spleen.

  • Dividing the inferior mesenteric artery

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    Now identify the inferior mesenteric artery by medial incision of the mesosigmoid peritoneum anterior to the aorta. Divide the inferior mesenteric artery with its lymph nodes approximately 1–2cm distal to its origin at the aorta. Primary division of the vessel is indicated apriorion oncologic principles, but studies have not demonstrated any benefit for this. Dividing the artery close to the aorta will prevent injury to the nerve plexus coursing there.

  • Dividing the inferior mesenteric vein

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    Expose and divide the inferior mesenteric vein at the lower aspect of the pancreatic head. Carefully respect the duodenum.

  • Entering the lesser pelvis

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    Starting on the left lateral side, incise the peritoneum at its reflection and extend the dissection down into the lesser pelvis. Now enter the areolar mesorectal layer and extend the dissection caudad while carefully sparing the nerves in the lesser pelvis and the mesorectum.

  • Mesorectal dissection

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    Then complete the dissection posteriorly, laterally on the right and finally anteriorly. Keep respecting the correct layer by applying traction and counter-traction, since this will leave the autonomous nerves in the lesser pelvis unharmed.

  • Dividing the rectum

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    Once the mesorectal dissection has been completed, divide the rectum distal to the tumor. After division check the mesorectum for integrity.

    Tip: Identification of the nerves
    The presacral course of both the right and left iliohypogastric nerves can be identified, if the dissection in the lesser pelvis was carried out in the correct layer and the nerves were not transected.

  • Dividing the specimen

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    Unimpaired anastomotic healing requires that the anastomosis between the rectal stump and descending colon is fashioned without any tension. To this end, check whether the length achieved so far is adequate.
    Now divide the mesentery at its transition from the descending colon to the sigmoid and transect the specimen with a linear cutter.

  • Preparing the anastomosis

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    After shortening the proximal limb to a section with excellent blood supply, divide the bowel there, arm it with a purse-string suture and tighten it over the inserted anvil of a circular stapler.

  • Constructing the pouch

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  • Stapling the anastomosis

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  • Checking the anastomotic integrity

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  • Klinikum Großhadern

    Herr Prof. Dr. med. Dr. h.c. Karl-Walter Jauch

  • Charite Berlin

    Prof. Dr. Martin Kreis

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  • Intraoperative complications

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  • Postoperative complications

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  • MVZ St. Marien Köln - Ärztliche Leiterin

    Edith Leisten

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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • Reviews

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  • Guidelines

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  • Literature search

    Literature search under: http://www.pubmed.com