Keypoints for nerve preservation during laparoscopic TME for T3 rectal cancer in a male patient

WeBSurg est une université virtuelle accessible mondialement sur Internet. Notre objectif est de fournir aux chirurgiens, aux sociétés savantes et au secteur médical un enseignement médico-chirurgical de pointe en ligne en chirurgie mini-invasive et toute information concernant les dernières avancées en chirurgie laparoscopique, dont notamment la Chirurgie Endoscopique Transluminale par les Voies Naturelles (NOTES) et la chirurgie assistée par robot.

Créer un compte gratuit

l'Université Virtuelle

Google translate

Résumé
Chapitres
Vos Commentaires
Interrogez les Experts

Vous devez vous identifier pour accéder à cette partie du site !

Keypoints for nerve preservation during laparoscopic TME for T3 rectal cancer in a male patient

Authors

Mots-clés

RECTUM,OPERATION

Type de vidéo

Vidéo chirurgicale

Durée

07'00''

Publication

2003-04

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Apr 2003;3(04).
URL: http://www.websurg.com/doi-vd01en1268e_2.htm

Keypoints for nerve preservation during laparoscopic TME for T3 rectal cancer in a male patient

1. Hernia reduction 00'12''

Colic nerve injury during performance of total mesorectal excision for carcinoma carries a significant incidence of subsequent impedance and inability to ejaculate in male patients and urinary tension in patients of both sexes. Demonstrated here is dissection anterior to the aorta for a true oncologic procedure. Initial step of the procedure is the isolation of the inferior mesenteric artery as it exits the aorta. This is then divided at its origin consistent with a true oncologic procedure.

2. Hernia sac reduction into the abdominal cavity 00'57''

As the inferior mesenteric artery is withdrawn, the superior hypogastric plexus can be isolated. The branches of the plexus are demonstrated here. The left colic artery is seen just above the left grasper and the right grasper contains the inferior mesenteric artery. There is noted to be a lymph node in this region and this is sent for intraoperative pathologic analysis. We now see dissection on the left colic artery; here dissection is carried anterior to the plexus, which is freed from the mesentery. The branches of the plexus which extend into the mesentery to feed the bowel itself are divided. We have continued distal dissection; you can see the plexus falling away posterior. We see branches here going into the mesorectum which are divided allowing the superior hypogastric nerve to continue along its course. Traction and counter-traction are used to isolate the plane between the fascia propria of the rectum and the presacral fascia. Here we see a specific branch from the plexus going anterior into the mesorectum. This branch will be divided. The dissection is continued posterior at first, as distal as possible, applying the same principles. The iliac vessels are seen on the right. The plexus trunk is pointed out on the right and now the peritoneum on the right side will be divided to continue the dissection.

3. Repair of hiatus 04'03''

The right lateral approach continues and the beginning of the anterior dissection is initiated. The individual branches as they extend into the rectum are divided here at the surface of the mesorectum. At this point, we see the erigens nerves extending on the right and it is preserved while maintaining an oncologic resection. The lateral anterior dissection is then continued distally behind the seminal vessel on the right.

4. Fundoplication 05'20''

It can be seen here that the urogenital branches of the superior hypogastric nerve have been preserved and that the dissection plane is carried adjacent to the mesorectum. Denonvilliers’ fascia is preserved and anterior as just demonstrated and now the dissection turns to lateral mobilization on the left. The peritoneum is divided and continued distally. At this point again, the lateral anterior dissection is continued; Denonvilliers’ fascia is again preserved anteriorly in the space between seminal vesicles, prostate and Denonvilliers’ fascia is dissected further. At this point, use of Harmonic scissors facilitates the dissection and allows for safe progression.

5. Recreation of superior phrenogastric ligament 06'38''

At this point, the ischio-coccygeal ligament will be divided, which will provide an additional 1 to 2cm of distance. The fascia on the anterior surface of the rectum has been divided again at the distal portion of the Denonvilliers’ fascia. The rectal lesion is now excluded with an extracorporeal suturing device and the rectal stump is washed out. At this point it is divided and the oncologic equivalent of double stapling procedure is accomplished. And at this point, we have a nice demonstration of the nerves fully preserved. Here is the plexus trunk and some more distal branches.