腹腔镜全直肠系膜切除术（TME）癌症（图文演示）

2. Indications
Rationale
Total “en bloc” resection of the rectum and its mesentery for the treatment of rectal cancer has an anatomical rationale (Hida et al., 1997; Quirke et al., 1986). It should be performed “en bloc” without infraction of the surrounding fascia to avoid local tumor seeding (Enker et al., 1995; Hida et al., 1997). An oncologic resection is done as the local lymph node relays are resected.
The risk of local recurrence correlates with the quality of the excision. This is dependent on the surgeon’s experience (Kockerling et al., 1998).
Lymph node metastases occur in the distal mesorectum in 20% of cases, and depend on the localization and depth of invasion of the tumor. The rate of lymph node metastasis is 10% for the rectosigmoid, 26.3% for the upper rectum, and 19.2% for the lower rectum. The rate is 0% for pT1 and pT2 tumors, 21.9% for pT3 tumors, and 50% for pT4 tumors (Hida et al., 1997).

Indications
Total mesorectal excision is indicated in rectal cancers located 2 to 10 cm above the anal canal. It is recommended in T3 and T4 tumors of the lower rectum. The mesorectum should be excised at least 5 cm below the tumor for T3 and T4 tumors of the upper rectum (Hida et al., 1997).
Preoperative radiation therapy is recommended in T3 and T4 lesions. It does not impair the surgical approach, laparoscopic approach included, provided surgery is done 6 weeks after the end of radiation therapy. Prior to this, massive pelvic edema may complicate dissection.

Contraindications
- contraindications to laparoscopic surgery;
- tumor with invasion of neighboring organs (T4 tumor);
- voluminous tumor;
- multiple abdominal scars.

1. Introduction

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Total mesorectal excision (TME) was thoroughly codified by Heald in 1988.
The procedure helps reduce the risk of local recurrence and the number of permanent colostomies while preserving adjacent anatomical structures (nerve plexuses), as shown by the results published by Heald et al. in 1998.
The authors performed this procedure laparoscopically for the first time in November 1991. The laparoscopic procedure has the major advantage of magnifying anatomical structures (Okuda et al., 1998). The laparoscopic approach does not alter the technical principles described by Heald.
Once the rectum has been excised, continuity of the digestive tract is re-established via low colorectal anastomosis or colo-anal anastomosis. We shall focus on low colorectal anastomosis.