Laparoscopic TME for T3 upper rectal cancer: end-to-end low colorectal anastomosis

Authors

J Leroy, J Marescaux

Abstract

This video, performed during a live demonstration, shows a laparoscopic TME for upper rectal cancer.

Mots-clés

Laparoscopic TME, T3 upper rectal cancer, end-to-end low colorectal anastomosis

Type de vidéo

Durée

26'00''

Publication

2011-10

Popularité

Favoris

Audio

Sous-titres

E-publication

WeBSurg.com, Oct 2011;11(10).
URL: http://www.websurg.com/doi-vd01en3153.htm

Laparoscopic TME for T3 upper rectal cancer: end-to-end low colorectal anastomosis

1. Clinical case 00'20''

Now we’ll be dealing with a rectal cancer, a total mesorectal excision, also called low anterior resection in the US. The patient is a 55-year-old man. As for the previous medical history, he had an appendectomy as a child with a right lower quadrant incision. He presented to his primary doctor with rectal bleeding, and in the work-up he was found to have an adenocarcinoma located 12cm away from the anal verge. The work-up included a colonoscopy completed to the caecum, which revealed the single lesion. No additional lesions were found. CT-scan revealed no lesions on the liver. The patient did have rectal wall thickening, which was consistent with the endoscopic findings. The pathology was a well-differentiated adenocarcinoma. Look at the CT-scan, just to give you a sense of where the lesion was found. You can see it’s just below the caecal promontory, again consistent with the colonoscopy findings 12cm from the anal verge. You can see the wall thickening. He also underwent MRI. The combination of both MRI and CT-scan did not reveal any lymphadenopathy locally, thus predicting a T2 or T3N0 tumor in this case. He did also finally undergo a barium enema again localizing the lesion just below the caecal promontory.

2. Trocar placement 01'59''

This is the xiphisternum, the rib (left and right), the pubis just under the trocar, the midline, the mid-clavicular line on the left, the anterior axillary line on the right. We introduce a 12mm trocar using a mini-open just above the umbilicus. Two trocars are introduced on the right side, crossing the mid-clavicular line and the horizontal line through the umbilicus, and 8-10cm lower to that, I have introduced a 12mm trocar in the right iliac fossa. I have another 12mm trocar in the suprapubic area, 5 to 10cm above the pubis. On the left side, I have also introduced a 5mm trocar to be able to use the retractor for the proximal bowel to use this trocar as an accessory trocar for mobilization of the splenic flexure. I have freed the omental adhesions in the right iliac fossa. I keep on freeing. As you can see, the sigmoid is fixed to the mesentery, and I have to free it from the latter to have a good view. For that purpose, I use the Ligasure Advance® vessel-sealing device with monopolar probe. You can see this is a strong adhesion following appendectomy. I’m reducing power and limited energy, which I can increase with my hand. I have now 15 Watts, a bit more. Thanks to the shape of the device, I can use the scissors’ shape to dissect. We’ll move the camera above to see if this is a tumor. We don’t have the feeling of the tumor.

3. Small bowel retraction 04'44''

Now we will expose better because we have freed the small bowel. I will retract the small bowel on the right side. If we have some difficulty, I will show you some tricks. We can add one trocar to have a better exposure, even if it’s exceptional, it’s only to show you the forceps under the small bowel using orthostatic retraction, like this. The small bowel is kept retracted.

4. Medial approach 05'48''

My landmarks are the promontory and the opening of the peritoneum, which is performed first. The best thing is to begin the dissection anterior to the promontory to find the vascular sheath and to slide on the back of the vascular sheath. We will enter the presacral space later. The first step of TME is to free the sigmoid. When I have freed this, I will ask my assistant to retract closer to the artery, stretching anteriorly. This is the IMA. I dissect it. It is not a big one. This is not an artery, these are surrounding fibrotic tissues. The artery is behind. If you free the colon first, you will have to do a lot of manipulation of the colon. And to free the posterior attachments, you will have some difficulty if you do it using a lateral approach in my opinion. That’s why it is not only an oncologic problem. If I use a medial approach, particularly in an obese patient, I don’t touch the colon —except in this case where there were adhesions— until we have completely dissected the posterior attachments. In slim patients, the fascias are more stuck. I will put a loop around this.

5. Dissection between Gerota\'s and Toldt\'s fascia 08'06''

I’m performing a sharp dissection and I will dissect between Gerota’s fascia posteriorly and Toldt’s fascia anteriorly. This is a completely avascular plane. You should keep a sufficient length of the artery. Now we have to divide after skeletonization 2cm away from the aorta. I’m freeing the lateral attachments of the descending colon. I finished this. I will show you the ureter. You have the spermatic vessels there. You have the aorta there. There is a big distance. The ureter is probably located there. This is the ureter. Remember the forceps I have introduced on the left. I will use it now to expose. I will push it on the back, like this. The forceps, positioned suprapubically, will expose and maintain the sigmoid loop like this. I’m now ready to begin the dissection.

6. Upper rectum dissection 09'43''

I already began the dissection. I wanted to show you the advantage of the shape of the Ligasure Advance® device. I’m using this shape to slide on the fascia and to be between the two fascias using the white and blue side of the shape to open better. These are the presacral vessels on the back. I’m closer to the sacral vessels. You see the dissection, which will now be performed laterally. Contrarily to the opinion of some authors who say that if you are in the right plane, you don’t see the nerve, we do see the nerve here. We change the technique of exposure. We have freed the posterior attachments of what I call the vertical segment of the rectum. Usually there are no adhesions anteriorly. I use a higher current, 30 Watts, because I want to cut more rapidly. The more power you use, the more smoke you have. I will open that and I will begin the dissection. I have opened the peritoneum, not on the side of the rectum as you can see, but on the side of the back of the bladder prostate. I stay lateral to the fascia propria. These are branches of nerves going to the rectum. We can divide them. These are the sacral branches. On the medial side, you were a little bit behind the fascia. I think that’s not a mistake. We will soon see better using a particular retraction. I have to free the lateral attachments, because you see, when we do this dissection, we have to navigate. So you rely more on this traction that opens the cleavage plane. This is a branch of the nerve. So you have to stay very close to the fascia propria. Right. This is a branch of the nerve. I’m dissecting coming from the inferior hypogastric plexus. I have to cut the branch close to the bowel. Another branch. Prof. Leroy is demonstrating the traction, which is so important because it makes it possible to see this image of the plexus. Without traction, you go straight ahead and you divide it. I think the shape is fantastic to open the plane. I have finished that and now I will do it anteriorly.

7. Dissection of fascia propria of rectum 13'50''

I am using retraction. See the fascia propria of the rectum. The advantage is that we retract anteriorly. Oncologically, we have to remove the mesorectum, so we have to dissect until we have finished the distal dissection of the mesorectum. That means that posteriorly we will not have any fat. We will soon see that when we have reached the distal mesorectum posteriorly, we will have the rectum free.

8. Rectum division 15'34''

We will retract further like this. We will fix. We have washed using a Betadine solution, and now we will introduce a 45mm Endo-GIA linear stapler. We will open first. Thanks to the suture we have there, we can exert traction on the rectal stump. We do a small angulation. It’s not enough, but introducing a 60mm stapler is not easy in a male patient. We apply the second cartridge. I normally use two cartridges, using the Chinese hat technique, the parnex technique. We will perforate where the stapling line is crossing. I have a good retraction. We have the pelvic pelvis dissected, we push back the specimen inside the pelvis, and now we will remove resect proximally the segment of the colon. We’ll choose a compliant segment of colon to do the anastomosis, removing the vascular package in an en bloc fashion.

9. Colon division 17'34''

We now divide the colon to isolate the rectum. This is the new 37cm Ligasure® device. I dissect the splenic flexure from the right iliac fossa, laterally to the duodenojejunal junction. We free the medial attachments. We have finished that.

10. Suprapubic incision and specimen extraction 18'30''

We will make a small suprapubic incision. This is the transverse incision. On the other side, we open the aponeurosis without dividing the rectus muscle. We now use a plastic wound protector that we introduce through the trocar. We pull the trocar back, maintaining the forceps, and we use the instrument as a finger to retract. I slide the ring between my finger and the instrument to go in the right way, that is, inside the abdomen. I can remove the trocar. I introduce the Endo-Catch™. I open it and I ask my assistant to push in the direction of the pelvis using the free space back to open the bag. I close the bag like this and I pull. It is difficult to remove the specimen but we can manipulate inside the bag. Do you have any comment on the size of the anastomosis? It is exceptional to use this size for me. It is mainly 28.

11. Colorectal anastomosis 21'24''

I reintroduce inside the abdomen. I will go slowly. It’s a big stapler. There is no tension. The green mark is visible. Now you can pull without twisting. I’ll use the forceps now and I will show the ring. It’s a distal, rectal one, very thick and completed with the stapling line, and the proximal one, complete and thick. I will perform a digital examination of the anastomosis. It’s 1-2cm above the sphincter.

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