Anastomotic redo after open subtotal TME for rectal cancer: laparoscopic pelvic resection with coloanal anastomosis

Authors

Abstract

The objective of this film is to demonstrate how to perform a laparoscopic redo of a recurrence after carrying out a low colorectal anastomosis through open surgery to manage a cancer of the mid-upper rectum following radiochemotherapy.

Mots-clés

Anastomotic redo, subtotal TME, rectal cancer, laparoscopic pelvic resection, coloanal anastomosis

Type de vidéo

Durée

23'45''

Publication

2011-09

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Audio

E-publication

WeBSurg.com, Sept 2011;11(09).
URL: http://www.websurg.com/doi-vd01en3381.htm

Anastomotic redo after open subtotal TME for rectal cancer: laparoscopic pelvic resection with coloanal anastomosis

1. Introduction 00'11''

2. Laparoscopic view 00'35''

Surprisingly enough, the laparoscopic approach demonstrates the presence of few adhesions at the level of the anterior abdominal wall and the abdominal cavity. Small bowel adhesions are found only at the level of the pelvis close to the previously operated area and to the anastomotic area. These adhesions are easy to take down by means of the versatile Ligasure Advance® vessel-sealing device, which allows to use bipolar current, to divide adhesions in a hemostatic fashion, and to use monopolar current by means of the electrode placed at the extremity of the instrument.

3. Freeing of adhesions 00'00''

The small bowel is fixed to the pelvis in contact to the anastomotic area. The adhesions are progressively freed. They do not look significant as they are not tumoral but only inflammatory. They will be taken down in contact to the rectal wall and to the lowered sigmoid.

4. Small bowel resection 00'00''

Dissection is completed laterally to the right, laterally to the left, anteriorly and posteriorly until the extremity of the small bowel is freed. The small bowel is fixed on the anastomotic area. The division implies opening the small bowel, so the latter should be resected so as to carry out the anastomosis in a healthy area and to resect the area fixed in contact to the colorectal anastomosis.

5. Small bowel anastomosis 00'00''

Resection is carried out immediately. Both legs of the healthy small bowel are fixed. A side-to-side end anastomosis is achieved by means of the Endo-GIA linear stapler terminated in an anisoperistaltic fashion. The opening in the small bowel is carried out using the monopolar electrode of the Ligasure Advance® device, thus allowing for a perfect division with appropriate coagulation. The anastomosis is achieved by means of a 60mm Endo-GIA linear stapler, white cartridge. The area is then trimmed so as to terminate the stapling area and the side-to-side end anastomosis using a white cartridge. The mesentery is then divided by means of a linear stapler, thus allowing to close the mesenteric window by performing a hemostatic stapling. Once the bowel has been resected and the sticky area in contact to the colorectal anastomosis has been removed, this intestinal segment will be placed in a plastic bag. For the time being, it will be left aside in the abdominal cavity after closing it so as to prevent any potential contamination of the abdominal cavity.

6. Anastomotic area dissection 00'00''

Dissection of the anastomotic area is carried on as no carcinomatosis can be detected on a frozen analysis of peri-anastomotic tissue in this patient and as the recurrence seems purely endoluminal. To do so, the pelvis should be perfectly exposed. After excluding the distal segment of the colon by ligating the lowered sigmoid using extracorporeal knots, the distal portion of the rectal stump is washed by means of a betadine saline solution. Dissection is then started on the posterior surface by opening the fibrotic tissue using the electrode of a monopolar hook so as to trim the presacral and perirectal fibrotic tissue. The trimming is performed using an electric scalpel with coagulating division by means of an aspiration cannula in contact with it. Dissection is pursued in contact to the sacrum. There is still a risk of hemorrhage as the presacral vessels are still present. Dissection is carried out on a very hard fibrous tissue. The Ligasure Advance® device features a very short monopolar electrode and is covered with plastic at the level of the jaws so as to perform a very accurate approach at the level of the extremity of the instrument without any significant risk of collateral damage. The procedure is carried on until the correct cleavage plane is found at the level of the posterior surface of the vagina.

7. Lateral dissection 00'00''

Dissection will be carried on laterally to the right and to the left so as to check the lateral margins of the dissection, which should be far away from the anastomotic area and the fibrotic tissue. A histological frozen section of multiple fragments of perirectal fibrotic tissue has been previously carried out. If the result is positive, decision will be made to carry out an abdominoperineal amputation. However, the frozen sections do not demonstrate the presence of any neoplastic cell but only the mere existence of fibrotic tissue. This allows to envisage an oncologic resection with a coloanal anastomosis. Consequently, dissection of the lowered colon and of the rectum will be carried on till the pelvic floor is reached. The distal portion of the rectal stump previously left in place will now be resected.

8. Sigmoid vascular pedicle dissection 00'00''

Dissection of the sigmoid vascular pedicle can be seen here over the rectal artery, which seems to have been left in place and which will be resected later. Dissection is pursued in contact to the sacrum on the lowered portion of the meso with the sigmoid. This portion will be resected at the same time.

9. Dissection to the pelvic floor 00'00''

Dissection is continued. The monopolar electrode proves efficacious as it allows trimming the fibrotic tissue fixed on the anterior surface of the sacrum. The fibrotic tissue is very thick but will show negative results in the histological study. The Ligasure Advance® device allows to use both monopolar current, with sometimes considerable power gathered on a very thin and short electrode, and bipolar current to coagulate bleeding vessels by grasping them between the jaws of the instrument. The procedure is carried on in contact to the sacrum by means of the monopolar electrode without diffusion at the level of the green and white plastic jaws covering the bipolar forceps. The monopolar electrode associated with Valleylab™ Mode division and coagulation current allows trimming in contact to the sacrum while performing a perfect hemostasis on the sacral wall. The distal portion of the rectum has been opened, as can be seen here. Dissection will be continued till in contact with the sphincter and by completely dividing the distal stump below the anastomotic and the tumoral area, which are situated cephalad, and which are excluded by means of a ligature.

10. Lower rectum division 00'00''

The division of the lower rectum and of the perirectal tissue can be well seen here. As previously explained, the tissue is analyzed and no tumoral cells are found at this level. The division is carried out progressively and will be completed transanally. The lateral left division, which is performed until the pelvic floor, can be seen here. It is carried out while removing the distal rectal wall, which has been excluded and washed using a betadine solution before opening. The distal and posterior portion of the rectum are divided, as can be seen here. The fibrotic tissue can be seen here. It will be removed and analyzed. The specimen removal will be completed transanally so as to carry out a coloanal anastomosis at the level of the pectinate line. The end of the dissection on the posterior portion of the distal rectum in contact to the sacrum can be seen here. The dissection is carried out in order to remove the fibrotic tissue, which could be a neoplastic tissue but turns out to be just a fibrotic tissue after analysis. No local recurrences are evidenced.

11. Completion of division and specimen removal 00'00''

Once the division has been completed, and after checking the hemostasis, the rectal and sigmoid segment can be removed. This will be performed transanally as the rectal stump is open. To do so, the lowered colon must be divided at least 10cm cephalad to the anastomotic area. The intestinal segment previously resected will then be removed transanally through an Endo-Catch™ bag. All devices such as the swab and the bag are removed transanally so as not to make any incision on the abdominal wall as this could cause gas leakage and would therefore be a waste of time.

12. Left transverse colon mobilization 00'00''

The transverse left colon must be mobilized while dividing its lateral attachments, such as the colo-omental ligament. The attachments at the descending colon should also be freed on a lateral plane. The posterior attachments should also be removed using a medial approach by opening the lesser sac through a transmesocolic approach, by dividing the attachments of the transverse mesocolon on the anterior surface of the pancreas, and by preserving the left colic artery, which has been present all along the procedure together with the origin of the inferior mesenteric artery. Only the latter will be divided. Now it is time to check how the colon can be lowered at the level of the pelvic floor. The sigmoid vessels are resected. They were still present in this patient, so a limited segmental resection of the rectum had apparently been performed.

13. Colon lowering, IMA division, and preservation of the left colic artery 00'00''

The sigmoid is exteriorized transanally. Now one can realize that the inferior mesenteric artery had been preserved. It will be divided after a new dissection in contact to the aorta by means of the Ligasure Advance® device while using both monopolar dissection and bipolar division simultaneously. Given that the morphotype is nice, and that the vascular network looks relatively good, the left colic artery will be preserved. The inferior mesenteric artery will be divided underneath the left colic artery. The trunk of the inferior mesenteric artery, which had been preserved, can be seen here. The proximal segment of the inferior mesenteric artery will be preserved so as to resect only the distal portion of the superior rectal vessels. The whole distal inferior mesenteric artery is removed beyond the left colic artery. Attached nodes are also removed. Now it is time to choose where the coloanal anastomotic area will be placed on the proximal colon. A stitch is fixed 5 to 6cm away from the distal extremity of the colon. This landmark stitch will be pulled transanally so as to carry out a side-to-end tension-free anastomosis. The transanal approach can be seen here. The distal rectum is still resected by performing an intersphincteric dissection using the monopolar electrode so as to approach the presacral pelvic space, where the lowered colon can be found.

14. Coloanal anastomosis 00'00''

Now it is time for the coloanal anastomosis. The proximal portion of the colon was not sufficiently well prepared above the recurrence. A coloanal anastomosis will be carried out at the level of the pectinate line by grasping the two total stitches on the portion of the anal canal and on the extramucosal colonic portion. The position of the separated stitches can be well seen here. Polysorb® 3/0 is used. Cardinal stitches will be placed followed by intermediate stitches. The good quality of the anastomosis is now checked through a digital examination. The anastomosis should now be protected but, prior to that, the posterior vaginal wall should be checked, as dissection has caused an injury and an opening on a fibrotic area. Consequently, the vaginal injury will be closed using Monocryl® 3/0 separated stitches. No omental protection will be carried out in this patient. Although this could have been done laparoscopically, the omentum has been left in place without any additional protection. A last evaluation is carried out. The quality of the hemostasis is controlled at the level of the pelvis. A peritoneal washing is performed. Presacral hemorrhagic oozing will be prevented by placing Surgicel® absorbable cellulose meshes to cover the presacral area, which will be drained. The mesenteric defect will be closed through stapling by means of an Endo Hernia™ stapler so as to prevent any internal hernia. A Redon drain will be placed in the pelvis. A protective ileostomy will be carried out in the right flank.

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