Definition of total mesorectal excision, including the perineal phase: technical considerations.
BACKGROUND
Total mesorectal excision (TME) has contributed to a decline in local recurrence. The operation is difficult because of the complicated anatomy of the pelvis and the narrow spaces in the pelvis. We review the anatomy related to TME and we present our surgical technique.


METHODS
The pelvis can be divided into a parietal compartment and a visceral compartment. Both compartments are covered by a fascial layer: the parietal and the visceral fascia. A space between these fascial layers can be opened by dividing loose areolar tissue. The pelvic autonomic nerves consist of the sympathetic hypogastric nerve and the parasympathetic sacral splanchnic nerve. At the pelvic sidewall these nerves join in the inferior hypogastric plexus.


METHODS
We present our surgical technique based on careful dissection under direct vision and describe our approach to abdominoperineal resection in the knee-chest position. This position enables en bloc resection of the levator ani muscle with the mesorectum, preventing positive circumferential margins in distal rectal tumor.


CONCLUSIONS
TME is a difficult and challenging operation. Continuous attention to surgical technique and anatomy is important to keep up the high standards of contemporary rectal surgery.
Havenga
Klaas
K
Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands. k.havenga@chir.umcg.nl
Grossmann
Irene
I
DeRuiter
Marco
M
Wiggers
Theo
T
D013505:Digestive System Surgical Procedures / Q000379:methods*; D006801:Humans; D010388:Pelvis / Q000033:anatomy & histology / Q000196:embryology; D010502:Perineum / Q000601:surgery*; D012007:Rectum / Q000601:surgery*