Abstract
Background
Current literature shows no consensus for the technique of laparoscopic total mesorectal excision (LTME). This study aimed to assess the current practice of LTME.
Methods
From January to March 2008, members of the European Association for Endoscopic Surgery (EAES), the Indian Association of Gastrointestinal Endo-Surgeons (IAGES), and the Society of Laparoscopic Surgeons (SLS), together with renowned surgeons in the field of LTME, were invited to fill out an online questionnaire concerning aspects of LTME.
Results
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.
Conclusion
The respondents showed an apparent preference for several aspects of LTME. Differences were related to expertise and still more to continent.
Similar content being viewed by others
References
Heald RJ (1979) A new approach to rectal cancer. Br J Hosp Med 22(3):277–281
Swedish Rectal Cancer Trial (1997) Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med 336(14):980–987
Heald RJ, Ryall RD (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1(8496):1479–1482
Peeters KC (2007) The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg 246(5):693–701
Jacobs M, Verdeja JC, Goldstein HS (1991) Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1(3):144–150
A comparison of laparoscopically assisted and open colectomy for colon cancer (2004) N Engl J Med 350(20):2050–2059
Vukasin P et al (1996) Wound recurrence following laparoscopic colon cancer resection: results of the American Society of Colon and Rectal Surgeons Laparoscopic Registry. Dis Colon Rectum 39(10 Suppl):S20–S23
Lacy AM et al (2002) Laparoscopy-assisted colectomy versus open colectomy for treatment of nonmetastatic colon cancer: a randomised trial. Lancet 359(9325):2224–2229
Veenhof AA et al (2007) Laparoscopic versus open total mesorectal excision: a comparative study on short-term outcomes: a single-institution experience regarding anterior resections and abdominoperineal resections. Dig Surg 24(5):367–374
Leroy J et al (2004) Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term outcomes. Surg Endosc 18(2):281–289
McAnena OJ, Heald RJ, Lockhart-Mummery HE (1990) Operative and functional results of total mesorectal excision with ultra-low anterior resection in the management of carcinoma of the lower one-third of the rectum. Surg Gynecol Obstet 170(6):517–521
Morino M et al (2003) Laparoscopic total mesorectal excision: a consecutive series of 100 patients. Ann Surg 237(3):335–342
Breukink S, Pierie J, Wiggers T (2006) Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database Syst Rev 18(4):CD005200
Bretagnol F et al (2007) Rectal cancer surgery without mechanical bowel preparation. Br J Surg 94(10):1266–1271
Fa-Si-Oen P et al (2005) Mechanical bowel preparation or not? Outcome of a multicenter, randomized trial in elective open colon surgery. Dis Colon Rectum 48(8):1509–1516
Peeters KC et al (2005) Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg 92(2):211–216
Slim K et al (2004) Metaanalysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation. Br J Surg 91(9):1125–1130
Soop M, Nygren J, Ljungqvist O (2006) Optimizing perioperative management of patients undergoing colorectal surgery: what is new? Curr Opin Crit Care 12(2):166–170
Guenaga KF et al (2005) Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 21(1):CD001544
Mantyh CR, Hull TL, Fazio VW (2001) Coloplasty in low colorectal anastomosis: manometric and functional comparison with straight and colonic J-pouch anastomosis. Dis Colon Rectum 44(1):37–42
Ho YH, Seow-Choen F, Tan M (2001) Colonic J-pouch function at six months versus straight coloanal anastomosis at two years: randomized controlled trial. World J Surg 25(7):876–881
Kakodkar R, Gupta S, Nundy S (2006) Low anterior resection with total mesorectal excision for rectal cancer: functional assessment and factors affecting outcome. Colorectal Dis 8(8):650–656
Hall NR et al (1995) High tie of the inferior mesenteric artery in distal colorectal resections: a safe vascular procedure. Int J Colorectal Dis 10(1):29–32
Lange MM et al (2008) Level of arterial ligation in rectal cancer surgery: low tie preferred over high tie: a review. Dis Colon Rectum 51(7):1139–1145
Liang JT, Lai HS, Lee PH (2007) Laparoscopic pelvic autonomic nerve-preserving surgery for patients with lower rectal cancer after chemoradiation therapy. Ann Surg Oncol 14(4):1285–1287
Dulucq JL et al (2005) Laparoscopic rectal resection with anal sphincter preservation for rectal cancer: long-term outcome. Surg Endosc 19(11):1468–1474
Zhou ZG et al (2003) Laparoscopic total mesorectal excision of low rectal cancer with preservation of anal sphincter: a report of 82 cases. World J Gastroenterol 9(7):1477–1481
Matthiessen P et al (2007) Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 246(2):207–214
Shah PR, Joseph A, Haray PN (2005) Laparoscopic colorectal surgery: learning curve and training implications. Postgrad Med J. 81(958):537–540
Moriya Y (2006) Function preservation in rectal cancer surgery. Int J Clin Oncol 11(5):339–343
Author information
Authors and Affiliations
Corresponding author
Electronic supplementary material
Rights and permissions
About this article
Cite this article
Cheung, Y.M., Lange, M.M., Buunen, M. et al. Current technique of laparoscopic total mesorectal excision (TME): an international questionnaire among 368 surgeons. Surg Endosc 23, 2796–2801 (2009). https://doi.org/10.1007/s00464-009-0566-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-009-0566-4