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Total Mesorectal Excision (Tme)

Total mesorectal excision (TME) is the gold standard surgery for rectal cancers of the middle and lower rectum. TME involves the complete removal of the mesorectum and surrounding fatty and lymphatic tissues along with the intact fascia envelope. Key steps of TME include high ligation of the inferior mesenteric artery, sharp dissection in the correct holy plane within the pelvis, and complete removal of the mesorectum specimen. TME has significantly improved outcomes for rectal cancer patients by reducing local recurrence rates to around 5% compared to 10-25% for older surgical techniques. While TME carries a slightly higher risk of anastomotic leakage, this can usually be prevented or

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Mehtab Jameel
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266 views19 pages

Total Mesorectal Excision (Tme)

Total mesorectal excision (TME) is the gold standard surgery for rectal cancers of the middle and lower rectum. TME involves the complete removal of the mesorectum and surrounding fatty and lymphatic tissues along with the intact fascia envelope. Key steps of TME include high ligation of the inferior mesenteric artery, sharp dissection in the correct holy plane within the pelvis, and complete removal of the mesorectum specimen. TME has significantly improved outcomes for rectal cancer patients by reducing local recurrence rates to around 5% compared to 10-25% for older surgical techniques. While TME carries a slightly higher risk of anastomotic leakage, this can usually be prevented or

Uploaded by

Mehtab Jameel
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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TOTAL MESORECTAL EXCISION (TME)

DR MEHTAB JAMEEL
RESIDENT YEAR 1
SURGICAL UNIT 4
CIVIL HOSPITAL KHI
RECTUM
BASIC ANATOMY
 Starts from recto
sigmoid junction till
dentate line ,15 cm in
length
 Upper 1/3 : mobile
and has a peritoneal
covering anteriorly
and laterally
 Middle 2/3: has
peritoneal fold just
anteriorly
 Lower 1/3: found
deep in pelvis, no
peritoneal covering.
RECTAL CARCINOMA
 Colorectal cancer are 2nd most common malignant tumours
in western countries.
 Adenocarcinoma is the most common form.
 Local spread usually occurs in a circumferential direction
than in longitudinal direction.
 Lymphatic spread from carcinoma of above and middle 1/3
occurs in an upward direction.
 Below that level, the spread is still upwards but when tumor
lies in the field of middle rectal artery, lateral spread is not
infrequent

Bailey and love short practice of surgery 26th edition


RECTAL CARCINOMA
RECENT ADVANCES:
 It is helpful to understand the progression of concepts and
techniques in rectal surgery

Local excision Radicle procedures Sphincter saving


procedures

Clear radial margin Total mesorectal excision


TOTAL MESORECTAL EXCISION
was first described by Heald in 1979 1
 Heald was the first one to mention the importance of
complete removal of mesorectum as the indicator of
local recurrence and prognosis
 Complete TME is defined as the “ complete removal of
lymph node containing mesorectum along with its intact
enveloping fascia”

1. Heald R J. A new approach to rectal cancer. Br J Hosp


Med. 1979;22(3):277–281. [PubMed
TOTAL MESORECTAL EXCISION
INDICATION
 TME is indicated as a part of low anterior resection for patients
with adenocarcinoma of the middle and lower rectum. It is now
considered the gold standard for tumors of the middle
and the lower rectum
 Anterior resections involving the upper rectum may be completed
with mobilization of the rectum to beyond 5 cm of the lower
margin of the tumor, and which is often above the level of the
levator and is sometimes referred to as partial mesorectal
excision.
 In an abdominoperineal excision of the rectum where the tumor
exists below the level of the levators, the lateral margins of the
tumor are inferior to the mesorectum, and the benefits of TME do
not apply.
2.TOTAL MESORECTAL EXCISION BY AUTHOR NANDA KISHOR MAROJU
(http://emedicine.medscape.com/article/1893507-overview#a1)
PRINCIPLES OF TME
TME has main components including
 High ligation of IMA
 Mobilization of descending colon up to splenic flexure
 Division of colon at descending sigmoid junction
 Sharp dissection in HOLY PLANE inside the pelvis
 Complete removal of all pelvic fat and lymphatic material
inside mesorectum with its enveloping fascia

Techniques in total mesorectal excision surgery by Warren E.Lichliter Clin Colon


Rectal Surg. 2015 Mar; 28(1): 21–27.
STEPS OF TME
STEPS OF TME
Kirks 6th general surgery operations
STEPS OF TME
STEPS OF TME
Kirks 6th general surgery operations
Grading of mesorectum specimen by
CAP(college of American pathologist )
Mesorectum
Mesorectal plane (complete) Intact mesorectum with only minor
irregularities
No defects deeper than 5 mm
No coning toward the distal margin of the
resection specimen
Smooth CRM on transverse sections
Intramesorectal plane (nearly complete) Moderate bulk to the mesorectum
One or more defects greater than 5 mm
deep within the mesorectum
Moderate coning
No visible muscularis propria
Irregular CRM on transverse sections
Muscularis propria plane (incomplete) Exposed muscularis propria
Moderate to marked coning
Irregular CRM on transverse sections
OUTCOME
 The circumferential resection margin positivity rate is about
5% or less for low anterior resections with TME, whereas it
is between 10% and 25% for abdominoperineal excision of
the rectum. There is, understandably, a higher local
recurrence rate following abdominoperineal excision of the
rectum. The 5-year survival and disease-free survival rates
are significantly higher with TME(87.5%).2
 TME is associated with a slightly higher incidence of
anastomotic leakage, which can usually be prevented (and the
effects minimized) by a diverting ostomy.3
2.TOTAL MESORECTAL EXCISION BY AUTHOR NANDA KISHOR MAROJU
(http://emedicine.medscape.com/article/1893507-overview#a1
3.PRINCIPLES OF TOTAL MESORECTAL INCIOSION FOR RECTAL CANCER BY CARLOS M.
MARY, Seminars in colon and rectal surgery: Volume 16, Issue 3, Pages 117–127
CONCLUSION
 Advances in the surgical management of rectal cancer have
placed the quality of total mesorectal excision (TME) as the
major predictor in overall survival.
 Newer techniques like NOME( nerve oriented mesorectal
excision), lap TME, TAME ( transanal mesorectal excision)
have also been the subject of considerable interest so far.
 Quality measurements of TME will place increasing demands
on surgeons maintaining competence with present and future
techniques. These efforts will improve the outcome of the
rectal cancer patients
QUESTIONS

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