Total Mesorectal Excision: History and Surgical Outcomes

Abstract

Colorectal cancer is a common malignancy globally, and management of rectal cancer is particularly challenging. Not only should the treatment achieve good local disease control and favorable survival; but the body functions should also be preserved. Since the introduction of abdominoperineal resection by Sir Ernest Miles for rectal cancer resection more than a century ago, the operation had been the gold standard treatment for rectal cancer until the recent 2–3 decades. However, both the oncologic and functional outcomes of conventional abdominoperineal resection have been far from satisfactory.

The introduction of total mesorectal excision by Sir Richard Heald revolutionized the surgical treatment for rectal cancer. He postulated that most of the local recurrence was due to the incomplete excision of the mesorectum. He introduced sharp mesorectal excision along the embryonic plane in rectal resection. Sphincter preservation was achieved by close shave anterior resection. In addition, identification and preservation of the pelvic autonomic nerves could be facilitated with sharp dissection in the relatively bloodless operating field. A very low local recurrence rate and a favorable survival were demonstrated in Heald’s early reports. The technique could be learned and attained by training through workshops and live demonstrations.

Currently total mesorectal excision is regarded as the gold standard surgical technique for rectal cancer. The principles of the operation also form the basis of minimally invasive techniques such as laparoscopic, robotic, and transanal approaches.