Current technique of laparoscopic total mesorectal excision (TME): an international questionnaire among 368 surgeons

The 368 questionnaires showed that 77% of the study participants performed 1–20 LTMEs per year (low volume) and that 33% performed more than 20 LTMEs per year (high volume). Preoperative bowel preparation (PBP), Trendelenburg position, periumbilical insertion of a 30º laparoscope, medial-to-lateral dissection, ultrasonic hemostasis, high-tie ligation, splenic flexure mobilization, left ureteral identification, partial sigmoid resection, extraction of the specimen by a new minilaparotomy and wound protector, end-to-end stapled anastomosis using a 28- to 29-mm anvil with 3.5-mm staples, abdominal lavage, pelvic drainage, and diverting ileostoma were performed by a majority of the surgeons. Less consistency was observed in identification of the right ureter, dissection of Denonvilliers’ fascia, location of the minilaparotomy, and construction of a colonic pouch. There were significant differences between high and low volume and between American and European surgeons. Significantly more low-volume surgeons indicated a preference for an open TME depending on the age and gender of the patient, the presence of comorbidity, previous laparotomy, and locally advanced tumor. More low-volume surgeons applied PBP (83.4% vs. 71.8%; p = 0.017). On the average, high-volume surgeons identified more autonomic pelvic nerves during dissection (2.6 vs. 1.8 nerves). The right ureter was identified by 66% of the American and 31.2% of the European surgeons. In the United States 91.5% and in Europe 61.2% created an end-to-end anastomosis. Pouches were created by 32% of the European and 6.8% of the American surgeons.