Total Mesorectal Excision (TME)

Procedure Snapshot

• Indication: Mid-to-low rectal cancer; cornerstone of oncologic rectal surgery.
• Expected duration: ___
• Special instruments: Curved stapler, energy device, pelvic retractors.

Step Workflow

1. Mobilize rectum circumferentially in avascular plane of mesorectal fascia.
2. Identify and protect hypogastric nerves laterally.
3. Dissect down to levator ani; divide mesorectum sharply.
4. Transect rectum and perform stapled anastomosis.
5. Optional diverting ileostomy.

Key Pimp Questions

• Q: Why TME critical? Complete en bloc removal reduces local recurrence (Heald 1982).
• Q: CRM significance? Circumferential margin ≤ 1 mm → positive.

Critical Anatomy

• Landmarks: Mesorectal fascia, levator ani.
• Danger zones: Presacral venous plexus.

Informed Consent Highlights

• Bleeding, leak, urinary/sexual dysfunction.

Post-op Considerations

• Foley POD 3–5; early ambulation; ERAS pathway.

References

• Chassin’s, Rectum. Clinical Scenarios, Colorectal.
• Heald 1982; Nagtegaal 2019 (PMID 30764073).