Total Mesorectal Excision Periprocedural Care

Updated: Sep 05, 2017
  • Author: Nanda Kishore Maroju, MRCS, MS, MBBS, DNB; Chief Editor: Kurt E Roberts, MD  more...
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Periprocedural Care

Patient Education and Consent

The advantages of total mesorectal excision (TME) are better clearance of the tumor and hence lower rates of recurrence and better 5-year survival rates. However, in patients who undergo TME as a part of anterior resection, there is a higher rate of anastomotic dehiscence. In practice, this has lowered the threshold for considering a covering ileostomy. It may be a safer option to consider an ileostomy than to risk an anastomotic leak.

Patients should be informed that they may also experience urgency and incontinence to a higher degree than they would if TME were not performed. However, these issues usually decrease with time. The choice of a colonic pouch may reduce the urgency and incontinence in the early postoperative period. An indwelling catheter may be retained for a week for the bladder to regain its tone, especially in men.

The risks of deep venous thrombosis (DVT), pulmonary embolism (PE), intraoperative bleeding, and postoperative bleeding also must be explained.

The process of consenting should ensure that the patient has a chance to speak to a stoma nurse, a colorectal specialist nurse, or both. This is important not only for helping the patient understand the implications of a stoma but also for ensuring that the patient has access to specialist nursing care and support in the postoperative period.

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Preprocedural Planning

Bowel preparation and stoma-site marking are performed on the day before the procedure. Polyethylene glycol or sodium picosulphate solution is usually chosen for bowel preparation. Adequate care to ensure hydration of the patient during preparation is important. Marking of the site for stoma formation is done by a stoma nurse, which gives an opportunity for the patient to discuss stoma issues.

Patients are scored for the risk of DVT and receive appropriate prophylaxis. Prophylactic antibiotics are administered as per protocol at anesthetic induction.

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Equipment

Equipment for TME includes the following:

  • Standard laparotomy tray
  • Self-retaining retractors
  • Stapling devices (linear staplers, heavy-wire linear stapler with articulating head, circular end-to-end anastomosis stapler)
  • Headlight
  • Diathermy
  • Ultrasonic scalpel (optional)
  • Vessel-sealing system (optional)
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Patient Preparation

Anesthesia

Patients are administered general anesthesia, with or without epidural analgesia. A specific issue that an anesthetist should be aware of is the need for a Trendelenburg position during pelvic dissection. The options for postoperative analgesia include continuous epidural infusions, patient-controlled analgesia, wound catheters with local anesthetic, and conventional parenteral/enteral analgesia.

Positioning

The standard position for TME is an extended Lloyd-Davies position. With this position, a right-handed surgeon would have a good view into the pelvis and wouldn be able to operate comfortably while standing on the left of the patient. The first assistant stands on the right, and a second assistant, if available, is positioned between the patient’s legs.

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