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Rectal resection, open, low anterior with total mesorectal excision (TME) - general and visceral surgery
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Skin incision and exposure
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
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
Dividing the inferior mesenteric artery
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
Entering the lesser pelvis
Dividing the rectum
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
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
Constructing the pouch
Stapling the anastomosis
Checking the anastomotic integrity