Laparoscopic TME 10 weeks after radiochemotherapy for T3N+ rectal cancer

Authors

Abstract

Total mesorectal excision (TME) offers the lowest reported rates of local recurrence and the best survival results in patients with rectal cancer. This video shows a laparoscopic TME 10 weeks after radiochemotherapy for T3N+ rectal cancer.

Catégorie

live recorded

Mots-clés

Laparoscopic TME, radiochemotherapy, T3N+ rectal cancer

Type de vidéo

Durée

27'03''

Publication

2011-07

Popularité

Favoris

Audio

E-publication

WeBSurg.com, Jul 2011;11(07).
URL: http://www.websurg.com/doi-vd01en3373.htm

Laparoscopic TME 10 weeks after radiochemotherapy for T3N+ rectal cancer

1. Introduction 01'25''

You have seen the case. I don’t remember if they said this patient had a diverting stoma on the transverse right colon. So we have a diverting stoma on the right side just under the rib and fixation of the colon on this part of the abdomen. And I introduce different trocars. It’s an usual position. Here’s the pubis, it’s a little lower, midline, vertical line, mid-clavicular line on the left, on the right, the anterior superior iliac spine on the right, then on the left, and the anterior axillary line at this level.

2. Trocar postition 02'23''

This is a 12mm trocar, we’re using a Versa-step® trocar with a sleeve. I have then introduced two 12mm working trocars on the right mid-clavicular line at the level of the umbilicus and the right iliac fossa, another 12mm trocar just suprapubic on the midline for retracting, exposing and removing the specimen at the end through a small incision.

3. Patient position 02'57''

Now to the patient’s position: it’s a Trendelenburg position, not too much, and right lateral tilt, in a Lloyd-Davis position, both arms alongside the body. This is the stoma position.

4. Abdominal cavity exploration 03'15''

I did a panoramic exploration of the abdominal cavity. There’s no carcinomatosis that would be a contraindication to laparoscopy. In the left-side trocar, I put the forceps, which was introduced under the small bowel, lateral to the duodenojejunal junction, and pushed only sliding on the back, and maintained in this position. See I can do that more laterally and if I want, I can push the small bowel around it and above, it is maintained up at distance, and we have the distal small bowel that is pushed on the right side of the abdominal cavity. Then we have a long sigmoid loop that is fixed on this side of the abdominal wall and it is fixed at this level. We have the sigmoid loop there.

5. IMA, IMV dissection and sigmoid mobilization 04'35''

The first step, with the forceps introduced in the suprapubic area, we do a traction on the meso and I will begin the dissection of the IMA. Not too close, we can do at distance, thanks to traction and to the pressure of the pneumoperitoneum. In rectal TME, the first step is always the mobilization of the sigmoid. We’re dividing the artery like this. So we have not seen the nerves, because they are at distance. We see the vasa vasorum and we have to reduce the traction. And when we have fat, we can also close. And the nerves we can see are preserved. We use the Ligasure® device. So I’m not dissecting too posteriorly because I will be in the wrong plane. I have to find the plane. I think it’s the left colic artery. I’m now doing the division of the vein. We have the IMV at this level and the left colic artery above. I think the left colic artery is very constant in its arrangement of coming across anterior to the vein, would you agree with that? Yes. Anterior and lateral. It is crossing in the majority of cases anterior and lateral.

6. Posterior attachements dissection 07'47''

I’m now freeing the posterior attachment to the Toldt’s and Gerota’s fascia. This is Gerota’s fascia and behind and laterally you have the genital vessels and the bisector between the aorta and you will have the ureter. If you are in the right plane, it is always like this. Helped by your 4th dimension too. Each time you get so far, then the gas helps a little more. So we have a long sigmoid loop falling. This can be interesting for the end of the procedure eventually. So the first step, when you do a TME, is the oncologic mobilization of the sigmoid so I prefer to use bipolar cautery. I have the current between the 2 jaws. This is the Ligasure®. This is nice to dissect. You can prepare the peanut swabs. We have adhesions. See I’m not far from the nerve at this level. I see that. I wouldn’t worry too much about the nerve. I’m worried about the cancer. I try to enter around the fascia. We have some nodes visible. I’m entering. I’m perhaps inside the presacral fascia, behind it. I will use this peanut to do an atraumatic retraction. I’m sliding on the bone thanks to the shape. You have a better view by laparoscopy. The best would be to have the same. See I use the shape to slide between the tissues and to retract more and get a better effect. This is the advantage, and I can have a huge contact. The electricity is only on the extremity.

7. TME dissection 12'23''

See the fascia propria of the rectum. We have the plane at this level. This is the fascia propria. We are sliding on the surface. When it presents adhesions, we have seen that it is mainly on the right side that we have problems. I think you are very wise to leave that bit to the very end really. The bit on the right because it’s always easier when the other side has been further done. The extra mobility helps so much. That’s the normal plane. The TME plane, which is beautiful and you see the shiny mesorectal surface. You will push medially like this, and you are retracting this way. I have incised the peritoneum in the rectovesical space. We are on the right side. We can see exactly. This is the inferior rectal artery, and I will continue the dissection. Do you think you can have the electrodes close to this place? Well, it’s difficult to know where they are. I’m passing into the correct plane. We will retract now using a particular retractor to expose —the Endo H. It is the electrode. I think I can cut that above.

8. Rectal division 18'20''

I will do the division approximately at this level. I’m at a sufficient distance. I think it’s enough. There are two electrodes. When we see the pictures, it seems that they are around the tumor. Denonvilliers’ fascia is coming. We will put clips later. We also remove this. I thought it was a node but now I don’t think so. It is a vessel. Aspiration. I have to be sure this is not positive. We are waiting for the frozen analysis. If it is positive, I think I will not do a colorectal or low colo-anal anastomosis. I will do an omentoplasty. You see the tumor is very high. Probably there were nodes. I can continue the dissection further laterally and perform a new frozen analysis.

9. Specimen extraction and anastomosis 23'23''

The tissues are not pushed. This is due to the shape of the cartridge. I have mobilized the splenic flexure. There’s an exclusion here. We are showing the vascular package. I put the specimen into a bag. I am on top of the pelvis. I use the fenestrated grasper. I check with my finger if the anastomosis has been successfully completed.

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