Nerve-oriented mesorectal excision (NOME): autonomic nerves as landmarks for laparoscopic rectal resection

We have developed nerve-oriented mesorectal excision (NOME) as a novel concept in rectal cancer surgery by which autonomic pelvic nerves serve as landmarks for a standardized navigation along fascial planes. This article describes the technique step by step and presents our results from 2008 to 2012. The key steps are: preparation of the splanchnic nerves at the mid-posterior sidewall, the hypogastric nerves at the upper sidewall, and the urogenital nerve branches (Walsh) at the caudal-anterior sidewall. The dissection of the lateral ligament is strictly performed as the last step. NOME was applied in 274 consecutive mesorectal excisions (partial 20.4 %, total 79.6 %); a subgroup of 42 male patients underwent a questionnaire-based interview on sexual activity. The conversion rate was 0.7 %. High (complete) specimen quality and circumferential margin negativity were achieved in 90.1 % and 95.3 %, respectively. Anastomotic leaks occurred in 13 (4.7 %) patients. Mortality was 1.8 %. The frequency of prolonged urinary catheter was 1.8 %. Of 22 sexually active males interviewed, 18 (81.8 %) maintained activity postoperatively. NOME achieves high-quality mesorectal specimens and a high rate of preservation of autonomic nerve function. The concept of using nerves as laparoscopic landmarks may help to standardize and master laparoscopic rectal cancer surgery.