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

Accepted author version posted online: 23

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
Department of Surgery, Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic;
a

Department of Anatomy, Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
b

ABSTRACT ARTICLE HISTORY

Total mesorectal excision (TME) was first described 40 years ago by Richard Heald. The Received 20 August 2019
pur- pose of this article is to point out importance of this surgical procedure. Starting from Accepted 18 March 2020
first attempts to surgically cure rectal carcinoma in the nineteenth century through Miles’
oper- ation at the beginning of the twentieth century results were not satisfactory due to KEYWORDS
Total mesorectal excision;
high number of local recurrences after resections for rectal cancer. Progress in surgical
TME; rectal cancer;
technique and knowledge of anatomy and embryology of the rectum led to development rectal surgery
of TME. 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
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
surgical books, e.g. at the level of the interverte-
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
© 2020 The Royal Belgian Society for Surgery
2 J. VOTAVA ET

sacrum. This provided good access to the importance of circumferential resection margin
posterior aspect of the rectum, possibility of (CRM) and connection between positive
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
 ACTA CHIRURGICA 3
CRM and high rate of LR. CRM is the closest the pelvic floor.
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
Horn´ı 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
4 J. VOTAVA ET

Heald reduced the LR with use of the TME to within the rectum.
3.3% [17]. Such low LR gained after the TME is
a result of removal of all lymphatic tissue that is
pri- marily connected with tumor itself en bloc
with rectum. By performing the TME surgeon
removes complete and embryologically defined
organ as a single unit which means lower
number of resec- tions with positive CRM.
Following the ‘holy plane’ while performing the
TME helps to lower injury of hypogastric nerves
and plexuses and pelvic veins simply because
they remain covered and saved by the presacral
fascia.
Despite undeniable oncological benefits, TME
carries some important drawbacks. Low and very
low resection with TME is connected with quite
high rate of anastomotic leak. In order to remove
complete mesorectum restoration of large intes-
tine continuity requires low anastomosis near the
pelvic floor. Removal of the complete
mesorectum may leave the rectal stump
ischemic which leads to overall rate of
anastomotic leak of 16% [18].
Another problem of the TME is interpretation
of its quality. By evaluating 180 specimens after
TME performed by surgeons trained in this
technique Nagtegaal et al. [19] reported only
57% of ‘complete’ TME, 19% of ‘nearly complete’
TME and 24% of ‘incomplete’ TME. A complete
TME means 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 shortened distal sensory zone
 ACTA CHIRURGICA 5
In case of injury of autonomic nerves in pelvis
problems with sexual function in both sexes,
urin- ation and fecal continence may occur.

Tumor-specific mesorectal excision or partial

mesorectal excision (PME)
Original concept of the TME required a removal
of the complete mesorectum even for tumors of
the rectosigmoid junction or proximal part of the
rec- tum. This lead to construction of a very low
rectal anastomosis and therefore a high
anastomotic leak rate. Tumor specific
mesorectal resection with dis- tal margin of 5 cm
below the tumor has showed the same
oncological outcome as the TME in review of
415 patients undergoing a curative sur- gery at
the Mayo clinic [21].
Then, multiple studies have shown that any
dis- tal intramural spread of carcinoma is almost
always within 1.5 cm from the primary tumor
[22]. With this knowledge the distal margin of 2
cm is accepted as oncologically sufficient.
With use of neoadjuvant chemoradiotherapy
even shorter distal margin can be accepted.
Park and Kim concluded that the distal margin
of 1 cm is oncologically adequate in curative
resection after neoadjuvant chemoradiotherapy
[23].

Figure 1. The extent of the total mesorectal excision.

6 J. VOTAVA ET
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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