Laparoscopic TME: principles and technique

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Laparoscopic TME: principles and technique

Authors

Mots-clés

rectum,operation,total mesorectal excision,mesorectum,resection,rectum

Type de vidéo

Vidéo chirurgicale

Durée

11'00''

Publication

2004-11

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Nov 2004;4(11).
URL: http://www.websurg.com/doi-vd01en1280e.htm

Laparoscopic TME: principles and technique

1. Vascular approach 00'13''

For this operation, we will use a standard 6 trocar technique. The dissection of the peritoneum will be started at the site of the promontory and we will continue along the right border of the aorta until we reach the 3rd part of the duodenum. The inferior mesenteric artery will be cut between clips and the inferior mesenteric vein will be clipped. You can start the first dissection, which is at the site of the promontory and we will prolonged to the right border of the aorta. In this case, the coagulating scissors are used in the same way as ultrasonic dissection or Ligasure can be used for this dissection. When we reach the inferior mesenteric artery, it will be dissected and freed outside of its bifurcation with the aorta. At this level, we make sure not to damage the inferior mesenteric plexus. When this dissection is completed, we can choose to clip and divide the artery directly or to use other devices as Ligasure, which is performed in this case. Always make sure that you don’t damage the nerves, and therefore the cut-off point is about 1cm from the aorta. Further dissection after this point of the operation will be done along the Toldt’s line and the Toldt’s fascia. This will typically leave behind a very fine tissue layer that covers the ureter and the vessels. This is an embryological plane, which is avascular and is the perfect place to go in this type of operation. You can see the use of the Ligasure to find ourselves exactly in this plane. It is not always very easy to find this plane as you can see. However, once we find it, it’s going to be easy to continue this dissection along this avascular plane.

2. High rectal dissection 03'10''

First part of the dissection towards the pelvic rim will be performed medially as you can see here and will be done to exactly find ourselves in the plane between the fascia propria and the presacral fascia. In this drawing, you can see fascia propria, presacral fascia, and the plane that we need to find between these 2 layers: the holy plane by our colleague, Bill Heald. You can see exactly the part of the operation where we enter this plane and it is at this level that we have to make sure not to damage the superior hypogastric nerve plexus. Further on in this dissection, we will preserve the superior hypogastric nerve, the branches, and the inferior hypogastric nerves. We will continue our dissection now on the lateral side and it will actually be very easy because we will find ourselves exactly in the plane where we finished medially and that’s exactly the place where we will finish this lateral dissection for the moment. This will give us more space and room to move the bowel.

3. Low rectal dissection 04'45''

Further on, we will continue the dissection anteriorly at the level of the Denonvilliers’ fascia where we can either choose to go in front or behind; in this operation, we have done a posterior dissection because the tumor was very high. And at this level, you can see very nicely the posterior view of the Denonvilliers’ fascia. We will continue our dissection posteriorly until we see the level of the pelvic floor and so we’ll finalize the dissection laterally, posteriorly and anteriorly and that will bring us to the next step of the operation, which is dividing the bowel that is performed with a roticulating stapler to make sure that the staple line is not oblique and not too long in order to prevent leakage. This image shows very clearly all the nerves that we tend to preserve, the left and right hypogastric nerves and the inferior hypogastric plexus as well as the sacral nerves. When we dissect laterally, we’ll try to preserve and not damage the nerves by going into the lateral ligament too far away on the lateral side. This dissection is sometimes performed by Japanese colleagues. In this image you can clearly see the nerves preserved and the lateral ligament. We continue the dissection to divide the mesocolon until we reach the point that we chose to divide the bowel.

4. Mobilization of splenic flexure 06'55''

Further dissection for mobilization of the splenic flexure is in this case done by a medial approach on the lateral edge of the inferior mesenteric vein going over the pancreas reaching the lesser sac. It will be finished by dividing the attachment on the omentum and the splenocolic ligaments. Here we can see very nicely the entering of the spleen. We go on the medial edge of the inferior mesenteric vein and we will find ourselves on the pancreas. Make sure not to enter the plane posterior of the pancreas, which can be disastrous in this type of surgery. At this level, we will soon enter the lesser sac by following the plane. If as we can see in this image, we clearly have a view on the anatomy, the risk of damaging the pancreas is small. However, the dissection at this level may be very difficult. You can see a very nice view on the lesser sac and on the pancreas and subsequent dissection along the different planes. This dissection will be continued until we reach nearly the lateral edge of our dissection we performed earlier as you can see in the following images. As I said, we will continue the lateral dissection by dividing the omental attachments and by dividing the splenocolic ligaments, as you can see in this video. It’s always important to ask your assistant to be actively involved in this part of the operation to make a continuous traction and counter-traction to open up the planes. Here we divide the omental colic attachments and we see very nicely that we find the plane that we dissected medially as you can see we can see the stomach at this level. We take down the bowel to make absolutely sure that we had enough dissection and that we don’t have to mobilize any further and this is the case, we don’t have to. We will put the specimen in a retrieval bag and we will use as well a wound protector to make sure there is no diffusion of malignant cells.

5. Colorectal anastomosis 09'51''

The anvil is put in place and the mechanical anastomosis can be prepared by putting the anvil in place and making sure that there is no twist of the bowel and finalizing the anastomosis with the circular stapler. You can see that the bowel is nice and floppy. There’s no twist and it’s the end of the operation.