Laparoscopic TME in a female patient: advantage of using the latest generation of energy source devices, retractors and staplers

Total mesorectal excision (TME) offers the lowest reported rates of local recurrence and the best survival results in patients with rectal cancer. Laparoscopic TME can be performed only by very expert surgeons; the introduction of new devices could help the surgeon during this challening dissection. This video shows a laparoscopic TME in a female patient; the advantage of the latest generation of energy source devices, retractors and staplers is demonstrated.

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Laparoscopic TME in a female patient: advantage of using the latest generation of energy source devices, retractors and staplers

Authors

J Leroy, J Marescaux

Abstract

Total mesorectal excision (TME) offers the lowest reported rates of local recurrence and the best survival results in patients with rectal cancer. Laparoscopic TME can be performed only by very expert surgeons; the introduction of new devices could help the surgeon during this challening dissection. This video shows a laparoscopic TME in a female patient; the advantage of the latest generation of energy source devices, retractors and staplers is demonstrated.

Mots-clés

Laparoscopic TME, female patient, advantage, latest generation, energy source devices, retractors, staplers

Type de vidéo

Vidéo chirurgicale

Durée

09'10''

Publication

2011-02

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Feb 2011;11(02).
URL: http://www.websurg.com/doi-vd01en3178.htm

Laparoscopic TME in a female patient: advantage of using the latest generation of energy source devices, retractors and staplers

1. Pelvis exposure by uterus suspension 00'19''

The first step of the intervention is to expose the pelvis. To do so, the following trick —very common in pelvic surgery for female patients— is used: the uterus is suspended by passing a thread through the abdominal wall using a small needle pushed in the suprapubic region. This needle is used to lift up the round ligaments both to the right and to the left. The pelvis is largely accessible, as can be seen here. This female patient has a BMI of 23, with no excessive adipose tissue.

2. Subperitoneal space opening 01'10''

After pelvic exposure, the subperitoneal space is opened in order to gain access to the inferior mesenteric artery on its posterior surface until its origin. Nerve plexuses should be respected.

3. IMA dissection 01'28''

As can be seen here, the inferior mesenteric artery is dissected and skeletonized, while respecting the adjacent tissues, especially the hypogastric plexus branches.

4. IMA division 01'38''

Division is carried out by means of the Ligasure Advance®, some 2cm away from the insertion on the aorta.

5. Medial to lateral dissection 01'49''

Dissection is carried on from medial to lateral using a medial approach. It is pursued towards the lateral portion of the duodenojejunal flexure, and then towards the posterior portion of the descending colon in order to parietalize all retroperitoneal structures. Dissection should be carried out posterior to Toldt’s fascia and anterior to Gerota’s fascia.

6. Sigmoid lateral dissection 02'43''

Next, the sigmoid colon will be freed from its lateral attachments by dividing all lateral attachments in an elective fashion at the level of the reflection line between the sigmoid mesocolon and the abdominal wall.

7. Mesorectal dissection 02'59''

Once the colon has been mobilized, the posterior aspect of the mesorectum is exposed. Dissection is carried on towards the pelvis until the lower portion of the rectum by exerting traction and counter-traction on the tissues, by removing the whole mesorectum, and by preserving a portion of the lower rectum in this patient presenting with a lesion situated 12 to 15cm away from the anal verge. It is important to remove the whole mesorectum and to preserve the vascularization of the lower rectum in order to carry out the anastomosis in a well-vascularized area.

8. V-shape retractor introduction 04'07''

A V-shaped retractor proves efficacious here, as it allows to retract the pelvis in good conditions, exerting traction from posterior to anterior.

9. Endo-GIA Ultra™ Tri-Staple™application 04'19''

The use of new Endo-GIA Ultra™ Tri-Staple™ staplers allows to carry out the dissection in good conditions using only one single purple 60mm length cartridge —intermediate between blue and green cartridges used in former staplers. The mesocolon is then divided at the junction between the descending colon and the sigmoid colon always using the new generation Endo-GIA Ultra™ Tri-Staple™, which allows for a clean, non-hemorrhagic division of the colon.

10. Splenic flexure mobilization 05'26''

The splenic flexure still needs to be mobilized to achieve a tension-free anastomosis at the lower third of the rectum. The opening of the lesser sac using a lateral approach is visible here. Mobilization is carried out laterally. It allows to lower the colon in excellent conditions in a patient with a very compliant anatomy as can be seen here.

11. Suprapubic incision and specimen extraction 05'58''

The suprapubic incision is carried out at the level of the suprapubic port in order to introduce a small-sized plastic wound protector, 7cm in diameter. The ring is semi-rigid. It is slid between one finger’s and a forceps. This makes it possible to protect the wall and to introduce the Endocatch II plastic bag through which the rectosigmoid, once divided at its upper and lower portion, is placed. Once the bag has been closed and the colonic extremities have been identified —a long suture loop may be used to facilitate the identification of this segment—, the small bowel and the rectum are pulled. Attention must be paid to control that the lesion is situated away from the division margins.

12. Side-to-end anastomosis 07'11''

The next step consists in the preparation of the anastomosis. In this case and in this patient with a very compliant anatomy, it is decided that no reservoir will be made since the intervention takes place at the level of the lower rectum, about 4 to 5cm away from the anal verge. Therefore, a side-to-end anastomosis is decided upon. The anvil of a 28mm PCEEA™ circular stapler is introduced approximately 4 to 5cm away from the extremity in order to preserve at least a 2cm distance between the area stapled with the circular stapler, and the area stapled with the linear stapler at the colonic extremity. The anastomosis should now be performed on the stump and on the colon. Care must be taken to avoid twisting the meso. The connection between the anvil and the stapler placed in the rectum is well visible here. The side-to-end anastomosis is tension-free. After the stapling, the doughnuts must be controlled, both on the rectal and colonic sides.

13. Anastomosis air test 08'41''

An air test may be carried out and the presence of bubbles must be ruled out. An abdominal lavage is then performed.