Acta Chirurgica Belgica

ISSN: 0001-5458 (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/tacb20

Total mesorectal excision – 40 years of standard of

rectal cancer surgery

J. Votava, D. Kachlik & J. Hoch

To cite this article: J. Votava, D. Kachlik & J. Hoch (2020): Total mesorectal excision – 40 years of
standard of rectal cancer surgery, Acta Chirurgica Belgica, DOI: 10.1080/00015458.2020.1745529

To link to this article: https://doi.org/10.1080/00015458.2020.1745529

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Mar 2020.
Published online: 31 Mar 2020.

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ACTA CHIRURGICA BELGICA
https://doi.org/10.1080/00015458.2020.1745529

HISTORY OF SURGERY

Total mesorectal excision – 40 years of standard of rectal cancer surgery

J. Votavaa,b, D. Kachlikb and J. Hocha
a
Department of Surgery, Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic;
b
Department of Anatomy, Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic

ABSTRACT ARTICLE HISTORY

Total mesorectal excision (TME) was first described 40 years ago by Richard Heald. The pur- Received 20 August 2019
pose of this article is to point out importance of this surgical procedure. Starting from first Accepted 18 March 2020
attempts to surgically cure rectal carcinoma in the nineteenth century through Miles’ oper-
KEYWORDS
ation at the beginning of the twentieth century results were not satisfactory due to high
Total mesorectal excision;
number of local recurrences after resections for rectal cancer. Progress in surgical technique TME; rectal cancer;
and knowledge of anatomy and embryology of the rectum led to development of TME. rectal surgery
Principle of TME is surprisingly simple: removal of the rectum with complete embryonic
space containing lymph nodes which are site of primary dissemination of the disease. Main
advantages and drawbacks of TME as well as focus on newer procedures developed from
the concept of TME are presented in the form of a review.

Introduction surgical books, e.g. at the level of the interverte-

In 1979, Richard John Heald first described total
mesorectal excision (TME). By performing the TME
surgeon removes rectum afflicted by carcinoma
with complete mesorectum containing lymph
nodes which are site of primary dissemination of
the disease. This surgical procedure is even after
40 years of its existence still considered a gold
standard of the rectal cancer surgery. This article
takes look at history of the rectal cancer surgery
before the TME, the TME itself, its principles, bene-
fits and drawbacks and modern procedures which
are ‘products of evolution’ of the TME.
To highlight importance of the TME there are
few numbers. By searching PubMed for ‘total mes-
orectal excision’ 2780 articles have been found.
When searching for ‘total mesorectal excision’ plus
‘TME’ 1119 articles have been found. And simply
by searching Google ‘total mesorectal excision’
more than 295,000 references have been received.
Descriptive and clinical anatomy
Rectum is the last segment of the large intestine,
following on from the sigmoid colon. The border is
not sharp and is arbitrary located at the linea ter-
minalis (promontory) at the border between the
greater and lesser pelvis in descriptive anatomy.
But there can be different levels, described in
bral disc S2/S3, in front of the vertebral body of
L3, at the lowest point of the peritoneal cavity
(rectovesical pouch of Proust in males/rectouterine
pouch of Douglas in females), or 15 cm orally to
anocutaneous line (white line of Hilton).
Mesorectum is in descriptive anatomy a short
peritoneal duplication containing superior rectal
vessels and lymph nodes, located in the oral quar-
ter of the rectum; but in clinical anatomy it is the
connective tissue with vessel, nerves and lymph
nodes lateral and posterior to the whole rectum,
i.e. in the extent of the embryonic mesentery
which later gets subperitoneally.
History
During the nineteenth century rectal carcinoma
was considered a surgically incurable disease.
Therefore, defunctioning colostomy described by
Jean Amussat [1] in 1839 was almost only surgical
procedure available for treatment of the rectal car-
cinoma. Only few surgeons in the nineteenth cen-
tury performed perineal and sacral resections with
construction of sacral anus, which was difficult to
manage by patient2. First surgeon who successfully
performed resection of the rectal carcinoma from
perineal approach was Jacques Lisfranc in 1826 [2].
In Germany Paul Kraske developed sacral approach
by removal of the coccyx and lower part of the

CONTACT Jan Votava jan.votava@fnmotol.cz

ß 2020 The Royal Belgian Society for Surgery
2 J. VOTAVA ET AL.
sacrum. This provided good access to the posterior
aspect of the rectum, possibility of removal of
tumor and creation of sacral fecal fistula which
closure required second operation [3]. First suc-
cessful sphincter saving resection of the rectal car-
cinoma from the sacral approach without creation
of fecal fistula was performed by Julius von
Hochenegg in Vienna in 1888 [4].
Discovery and development of anesthesia
enabled better approach and visualization of the
pelvis during laparotomy and principles of asepsis
established by Joseph Lister helped to prevent
postoperative peritonitis. Those two events
enabled first abdominal resection of the proximal
part of the rectum performed by Carl Gussenbauer
in 1879 [5]. This procedure was popularized by
Henri Hartmann [6] and is nowadays still partly
used for treatment of acute perforated diverticu-
litis [5].
At the beginning of the twentieth century
Ernest Miles was dissatisfied by number of early
local recurrences (LR) after perineal resections. In
his set of 57 perineal resections, 54 patients had
early LR (95%). In 1908 he published a seminal
paper where he described radical combined
abdominoperineal resection for the rectal cancer
[7]. He postulated that the LR can be prevented
and the rectal cancer cured by removing as much
of the pelvic lymphatic vessels as possible. He
believed that spread of cancer through lymphatic
vessels is possible in all directions. Therefore,
removal of the complete rectum as well as anus
was necessary. With this approach he was able to
reduce the LR to 29.5% [8].
Dukes (1932) [9] reported that lateral and caudal
spread is much less important than Miles believed
and that majority of the lymphatic spread happens
proximal to the tumor. A half century later this fact
and development of circular stapling technique
opened the door for the anterior resection of the
rectum with primary anastomosis and preserving
function of the anal sphincters.
Total mesorectal excision (TME)
Rate of the LR after conventional anterior resection
technique, consisting in blunt dissection, was high.
In seventies, the LR variated from 20% to 45%
worldwide [10]. Pathologically proved negative dis-
tal margin was considered vital to for good onco-
logical outcome. Quirke et al. (1976) [11] pointed
out the importance of circumferential resection
margin (CRM) and connection between positive
CRM and high rate of LR. CRM is the closest dis-
tance between the radial resection margin and the
tumor tissue by either direct tumor spread, areas
of neural or vascular invasion, or the nearest
involved lymph node. The CRM of < ¼2 mm is
associated with a local recurrence risk of 16% com-
pared with 5.8% in patients with more mesorectal
tissue surrounding the tumor. In addition, patients
with margins < ¼1 mm have an increased risk for
distant metastases (37.6% vs 12.7%) as well as
shorter survival [12].
In 1979, Heald came up with a concept of
removing the rectum with a complete mesorectum
(Figure 1) . The basis of this concept consists in
embryology. The primitive gut is suspended dor-
sally by a mesentery throughout its length which
persists in the rectum as the mesorectum. The
blood supply and the venous and lymphatic drain-
age of the rectum lies within the mesorectum. The
mesorectum, derived from the dorsal mesentery, is
an integral visceral mesentery surrounding the rec-
tum and is covered by a layer of visceral fascia [13]
(this description corresponds to the
‘clinical mesorectum’).
As local patriots we have to point out work of
Friedrich Stelzner, a German surgeon, born in
Hornı Lomany (Oberlohma) in former
Czechoslovakia in 1921. His habilitation thesis
focused on the radical removal of the rectal cancer
with preservation of anal continence function [14].
Later in his career he was appointed as Professor
and Chairman at the University Hospital Hamburg-
Eppendorf in Germany, where he worked with
anatomist Dietrich Starck and together they identi-
fied and described the enveloping fasciae of
the rectum.
The TME can be defined as a sharp dissection
and a complete removal of the mesorectum, con-
taining pararectal lymph nodes, along with its
intact enveloping fascia [15]. Operative steps of
the TME as described by Heald [16] are: 1. ligation
of the inferior mesenteric artery at its origin; 2.
mobilization of the left colic flexure; 3. transection
of the left-sided colon at the junction between the
descending and sigmoid colon; 4. sharp dissection
in the avascular plane into the pelvis ventrally to
the presacral fascia (of Waldeyer) and outside the
enveloping visceral fascia of the rectum; 5. division
of the lymphatic vessels and middle rectal vessels
ventrolaterally at the level of the pelvic floor, 6.
inclusion of all pelvic fat tissue and lymphatic
structures to the level of the pelvic floor.
 ACTA CHIRURGICA BELGICA 3

Heald reduced the LR with use of the TME to In case of injury of autonomic nerves in pelvis
3.3% [17]. Such low LR gained after the TME is a problems with sexual function in both sexes, urin-
result of removal of all lymphatic tissue that is pri- ation and fecal continence may occur.
marily connected with tumor itself en bloc with
rectum. By performing the TME surgeon removes Tumor-specific mesorectal excision or partial
complete and embryologically defined organ as a mesorectal excision (PME)
single unit which means lower number of resec-
tions with positive CRM. Original concept of the TME required a removal of
Following the ‘holy plane’ while performing the the complete mesorectum even for tumors of the
TME helps to lower injury of hypogastric nerves rectosigmoid junction or proximal part of the rec-
and plexuses and pelvic veins simply because they tum. This lead to construction of a very low rectal
remain covered and saved by the presacral fascia. anastomosis and therefore a high anastomotic leak
Despite undeniable oncological benefits, TME rate. Tumor specific mesorectal resection with dis-
carries some important drawbacks. Low and very tal margin of 5 cm below the tumor has showed
low resection with TME is connected with quite the same oncological outcome as the TME in
high rate of anastomotic leak. In order to remove review of 415 patients undergoing a curative sur-
complete mesorectum restoration of large intes- gery at the Mayo clinic [21].
tine continuity requires low anastomosis near the Then, multiple studies have shown that any dis-
pelvic floor. Removal of the complete mesorectum tal intramural spread of carcinoma is almost always
may leave the rectal stump ischemic which leads within 1.5 cm from the primary tumor [22]. With
to overall rate of anastomotic leak of 16% [18]. this knowledge the distal margin of 2 cm is
Another problem of the TME is interpretation of accepted as oncologically sufficient.
its quality. By evaluating 180 specimens after TME With use of neoadjuvant chemoradiotherapy
performed by surgeons trained in this technique even shorter distal margin can be accepted. Park
Nagtegaal et al. [19] reported only 57% of and Kim concluded that the distal margin of 1 cm
‘complete’ TME, 19% of ‘nearly complete’ TME and is oncologically adequate in curative resection
24% of ‘incomplete’ TME. A complete TME means after neoadjuvant chemoradiotherapy [23].
an intact mesorectum in a specimen with only
minor irregularities and no narrowing toward the
distal margin (Figure 2). A nearly complete TME
can have irregularity of the mesorectal surface,
slight conning but no visible muscle layer. An
incomplete TME has defects deep to the muscle
layer and very irregular CRM. There were no signifi-
cant differences in overall recurrence between
‘complete’ and ‘nearly complete’ TME but signifi-
cantly higher risk of overall recurrence in
‘incomplete’ TME [19]. This finding led to design-
ing multicentric studies focusing on parametric
monitoring of the quality of the mesorectal exci-
sion; in Czech Republic, six university surgical
departments participated [20]. This study showed
among other things higher percentage of com-
plete and nearly complete TME in prospective part
of the study which means that the implementation
of predefined and proven procedures lead to
improved results.
Removal of the entire rectum leads to functional
effect termed ‘low anterior resection syndrome’
that consists of frequent, fractured and urgent
stools and is caused by the lack of reservoir and
Figure 1. The extent of the total mesorectal excision.
shortened distal sensory zone within the rectum.
4 J. VOTAVA ET AL.
Figure 2. Specimen of the rectum with tumor after the total mesorectal excision with complete TME.
Modern procedures based on TME
Fast development of minimally invasive techniques
influenced surgery for the rectal carcinoma in past
years. Laparoscopy, robotic surgery and most
recently transanal TME (taTME) represents signifi-
cant advancement.
Laparoscopic rectal resection with the TME
results in reduced perioperative blood loss and
shorter recovery time compared to the open TME
without compromising oncological outcomes. The
COLOR II trial (Laparoscopic versus open rectal
cancer removal) showed no inferiority of laparo-
scopic TME compared to open TME for rectal can-
cer in LR, disease free survival and overall
survival [24].
Robotic surgery offers better visualization and
bigger range of instrument movements than con-
ventional laparoscopy, however, it is much more
expensive. Most studies comparing robotic surgery
to conventional laparoscopy have shown increased
operating time, decreased blood loss, decreased
conversion to open surgery and similar oncological
outcomes [25].
TaTME combines endoscopic transanal rectal
resection with TME and laparoscopic abdominal
high ligation of the inferior mesenteric artery and
complete left colic flexure mobilization. Resected
rectum with tumor can be then removed transa-
nally without any need of minilaparotomy. TaTME
offers more accurate dissection in the distal rectum
and facilitates work in narrow or deep pelvis or in
case of a large tumor. However, TaTME is demand-
ing surgical technique with high learning curve
and need of specific equipment. TaTME showed
similar oncological outcomes as laparoscopic TME
with longer operating time and same morbidity
[26]. Acquisition and benefit of all new procedures
and techniques is better access view and manipu-
lation which lead to more precise TME.
Conclusion
Total mesorectal excision as a standard of surgery
for the rectal cancer led to huge decrease in local
recurrence and increase in overall survival. Modern
procedures as robotic surgery or TaTME allows bet-
ter access, visualization and more precise resection
but with same oncological outcomes as open sur-
gery. This fact shows importance of knowledge of
anatomy and embryology and their application in
surgical procedures.
Acknowledgements
We would like to thank Azzat Al-Redouan for illustration.
Disclosure statement
No potential conflict of interest was reported by
the authors.
ORCID
D. Kachlik http://orcid.org/0000-0002-8150-9663
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