Laparoscopic TME for lower rectal cancer: when to convert?

The objective of this film is to demonstrate the limits of laparoscopic surgery in lower rectal cancer. This is the case of a 52-year-old patient in whom a voluminous T3/T4 tumor of the mid-rectum was found in association with liver metastases.

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Laparoscopic TME for lower rectal cancer: when to convert?

Authors

J Leroy, J Marescaux

Abstract

The objective of this film is to demonstrate the limits of laparoscopic surgery in lower rectal cancer. This is the case of a 52-year-old patient in whom a voluminous T3/T4 tumor of the mid-rectum was found in association with liver metastases.

Mots-clés

Laparoscopy, TME, lower rectal cancer, liver mestastasis, conversion

Type de vidéo

Vidéo chirurgicale

Durée

13'47''

Publication

2010-10

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Oct 2010;10(10).
URL: http://www.websurg.com/doi-vd01en3031.htm

Laparoscopic TME for lower rectal cancer: when to convert?

1. Introduction 00'08''

The objective of this film is to demonstrate the limits of laparoscopic surgery in lower rectal cancer. This is the case of a 52-year-old patient in whom a voluminous T3/T4 tumor of the mid-rectum was found in association with liver metastases. A suspicious zone and a laterally fixed sigmoid colon are identified immediately in the left inguinal region. There is no peritoneal carcinosis apart from the nodule fixed in the right inguinal region. It will be treated later.

2. Inferior mesenteric artery dissection 01'03''

Since this patient has a voluminous tumor and liver metastases, a resective procedure is envisaged. To do so, the intervention is begun using a vascular approach at the origin of the inferior mesenteric artery by means of the Ligasure® Advance device. This system has a monopolar electrode on its extremity, which allows for cutting and sealing of the different structures, including vessels such as the inferior mesenteric artery here.

3. Inferior mesenteric vein division and identification of nerve plexuses 01'48''

The dissection of the vascular pedicle is continued by identifying the inferior mesenteric vein and the nerve plexuses. The vein is therefore divided once sealed. The vascular pedicle is grasped to allow for the posterior freeing of the sigmoid mesocolon and of the descending mesocolon. This will help to find the entry plane into the presacral space later on. The freeing is achieved by the Ligasure® Advance device and by using traction and counter-traction. Laterally, I prefer to use monopolar scissors, such as the Roticulator™ Mini-Shears™ instrument. These allow for a nice cut of the tissues to be divided, as can be seen on these images.

4. Freeing of descending colon 03'10''

The descending colon is freed of its lateral attachments once the posterior attachments have been freed using a medial approach. At the level of the secondary root of the sigmoid mesocolon, where there seems to be a nodule, this attachment is freed.

5. Metastatic zone dissection 03'36''

The adjoining ureter can be seen in this seemingly metastatic zone. The dissection is resumed using a medial approach and following the few last centimeters of the ureter in contact to the nodule. The freeing of the ureter can be carried out in a better way using a medial approach as can be seen in these images. However, there are very tight adjoining zones. The dissection is further continued by dividing these structures, which prove to be vascular structures, since the ureter is situated underneath. These were the spermatic vessels in contact to the ureter, which was itself freed progressively by means of the cold blade of scissors. However, a ureteral stenosis is found at this level. It will be resected later on in the intervention once the surgical conversion has been undertaken.

6. Rectal dissection respecting TME principles 05'10''

At this time of the intervention, the rectum is dissected posteriorly according to Professor Heald’s principles – namely dissection in the presacral space in contact to the mesorectum. Laterally, the dissection is commenced since the tumor is situated anteriorly. This is made in compliance with TME dissection principles, that is traction and counter-traction using atraumatic instruments such as the peanut swab, one of the best blunt instruments in my opinion. The peanut swab allows for a retraction of tissues similar to the one performed with the surgeon’s fingers. At this moment of the intervention, it is noticeable that entry is made into fairly rigid, cardboard-like tissues. Anteriorly, the lesion is attached into Douglas’ pouch. The peritoneum, posterior to the bladder, is opened away from the tumoral area in order to be easily grasped later on. Laterally to the left, the lateral rectal space is opened after incision of the peritoneum. The dissection is facilitated by the use of angulated Roticulator™ Mini-Shears™ monopolar scissors.

7. Tumor fixation to Denonvilliers’ aponeurosis 07'17''

The dissection is continued anteriorly. One can realize that the tumor is fixed on Denonvilliers’ aponeurosis. This is in contrast to the preoperative imaging, according to which there was a cleavage plane. Decision is made to perform a dissection anteriorly to Denonvilliers’ aponeurosis. However, even at that level, it is noticeable that the tissue is cardboard-like.

8. Dissection anterior to Denonvilliers’ aponeurosis 07'50''

Dissection is pursued using the cold blade of scissors. The space anterior to Denonvilliers’ aponeurosis is entered. As can be seen here, the tumoral mass is relatively metastatic. The rectal area below the tumor will be reached by means of a lateral, then posterior and anterior dissection, in a stepwise fashion. The dissection of the retroprostatic space can be seen here. The use of adapted retractors, which allows to exert anterior traction on the whole prostatic space, facilitates the opening of different planes. It is obvious that the pelvic floor can be reached to the right of the rectum thanks to these instruments allowing for good plane retraction, and thanks to the Ligasure® device and to the angulated monopolar scissors, which open the dissection plane in better conditions. The anterior dissection of Denonvilliers’ aponeurosis can be seen here. It is carried out in contact to the seminal vesicle and the prostate. A fragment of the tissue is retrieved for the histological study. This will demonstrate whether it is a tumoral tissue or not. However, it looks pretty clear that it actually is. At this time in the procedure, some surgeons consider performing a conversion. However, conversion would not lead to a better dissection of the space; on the contrary, one could hesitate to pursue the surgical procedure, as it would seemingly have no therapeutic effect. Indeed, resection would have to be performed in the tumoral area.

9. Division of right deferent duct 10'17''

Here the right deferens duct is divided in order to perform an “en bloc” removal of the tumoral mass, as the latter is seemingly situated around it. There is some hesitation at this time in the procedure on whether or not pursuing the surgical maneuver. Everything appears to be running smoothly. Before further achieving the surgical maneuver using a perineal approach, the resection of the nodule, which is fixed at the level of the right inguinal region, is envisaged. Dissection is further continued. Here, the right deferens duct is divided by means of the Ligasure® Atlas device. It is quickly noticeable that this nodule is fixed on the vascular branches of the external right iliac vein, which is metastasized. Decision is made to carry out a finer dissection in order to resect this nodule. However, as will be shown on the following images, a significant vascular injury will occur at the level of the external iliac vein. Here this vein can be seen. It is dissected and progressively skeletonized.

10. Conversion 12'21''

Due to this metastasis and to the need for a vascular suture, which could be performed laparoscopically, conversion is decided upon, as we are dealing with a tumoral metastasis of the pelvis, a carcinomatosis nodule, a vascular metastasis and a vascular injury. Control can be performed laparoscopically, as can be seen here. A conversion will be carried out at the level of the pelvis, thus completing the surgical maneuver. In this patient, after conversion, an abdomino-perineal amputation and a terminal colostomy will be performed.