Abstract
Oncological adequacy in rectal cancer surgery mandates not only a clear distal and
circumferential resection margin but also resection of the entire ontogenetic mesorectal
package. Incomplete removal of the mesentery is one of the commonest causes of local
recurrences. The completeness of the resection is not only determined by tumor and
patient related factors but also by the patient-tailored treatment selected by the
multidisciplinary team. This is performed in the context of the technical ability
and experience of the surgeon to ensure an optimal total mesorectal excision (TME).
In TME, popularized by Professor Heald in the early 1980s as a sharp dissection through
the avascular embryologic plane, the midline pedicle of tumor and mesorectum is separated
from the surrounding, mostly paired structures of the retroperitoneum. Although TME
significantly improved the oncological and functional results of rectal cancer surgery,
the difficulty of the procedure is still mainly dependent on and determined by the
dissection of the most distal part of the rectum and mesorectum. To overcome some
of the limitations of working in the narrowest part of the pelvis, robotic and transanal
surgery have been shown to improve the access and quality of resection in minimally
invasive techniques. Whatever technique is chosen to perform a TME, embryologically
derived planes and anatomical points of reference should be identified to guide the
surgery. Standardization of the chosen technique, widespread education, and training
of surgeons, as well as caseloads per surgeon, are important factors to optimize outcomes.
In this article, we discuss the introduction of transanal TME, with emphasis on the
mesentery, relevant anatomy, standard procedural steps, and importance of a training
pathway.
Keywords rectal cancer - mesentery - total mesorectal excision - transanal total mesorectal
excision
