Laparoscopic TME in a female patient

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摘要

This video shows a TME resection performed live at an EITS Course in Laparoscopic Colorectal Surgery. It shows the technical steps and relevant anatomy in a difficult case as the patient has a past surgical history and is predisposed to bleeding.

分類

complex cases

關鍵字

laparoscopy, TME, female patient, cancer

媒體類型

期間

21'54''

刊物

2008-09

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, Sept 2008;8(09).
URL: http://www.websurg.com/doi-vd01en2406.htm

Laparoscopic TME in a female patient

1. Exploratory laparoscopy 00'14''

The case is a bit tricky. This operation is carried out in a female patient. We are entering the abdomen. The patient had a previous surgical history of appendectomy. There are a lot of adhesions here. I have placed the trocar in the umbilicus. I have created a window in the omentum fixed to the abdomen. You see the adhesions here on the left. This is the small bowel. Adhesions are mainly on the abdominal wall. We have used a right lateral tilt and Trendelenburg position to expose the root of the mesosigmoid. We have the sigmoid fixed to the right iliac fossa. We clean and wash this.

2. Exposure 01'13''

I have exposed the root of the mesosigmoid. There is the promontory there and I will first free the mesosigmoid and the sigmoid in order to manipulate it. I’m now dissecting the vessels. If you are too close from the aorta, there is a danger of injuring the nerves that’s why I’m dissecting with the following landmarks that are the vessels and particularly the IMA.

3. Dissection of the inferior mesenteric artery (IMA) 02'13''

This is the IMA and the vascular sheet and I’ll slide back to the vascular sheet. I’ll continue slowly to reach the IMA at its origin. You see we have the IMA coming. I’m now perforating with the blade.

4. Division of the IMA and base ligation 02'44''

I am at enough distance from the aorta, probably 2cm away from it. We don’t have to dissect too close from the aorta. If you dissect too close, you will be at a higher risk of injuring the plexus. Because I’ve had in one elderly patient postoperative bleeding, because in case of arteriosclerosis in an elderly patient, the risk is to have a bad sealing.

5. Completion medial dissection 03'24''

Now we grasp the vessels close to where we’ve just dissected and we use anterior traction and we’ll dissect close to the artery to divide the branches of nerves that are lateral. And the plexus trunk will fall because if we stay close to the artery, there is no danger. We can continue the dissection in order to reach the posterior side of the vein. This is the fascia and we have to stay anterior to it in order to find the correct plane. This is not a bad plane here but you see there is more oozing anterior to it. We have exactly the plane there. This is the right plane.

6. Lateral dissection 04'54''

We will now free the lateral attachments. I’m now finishing the 1st step that is freeing of the sigmoid. That is the 1st step for the beginning of the TME. The TME will begin after we have freed the sigmoid totally. I’ll see if there is a fixation of the sigmoid. So this is the 1st step of the procedure: vascular division; we can pull on the rectum because we have freed the sigmoid. You see that my assistant is retracting anteriorly. Traction and counter-traction and action, that’s my motto. These are the nerves running there. This is the plexus. You see the shape. We complete the opening before dividing. We use the pressure of the pneumoperitoneum.

7. Presacral space dissection 07'09''

I’m entering the presacral space. So I’ve opened the presacral fascia because I’m at the limit where the fascia and propria fascia of the rectum and sacral fascia are sometimes stuck. This is the sacrorectal ligament of Waldeyer so I’ll complete this higher. This is the dissection of the vertical segment of the rectum, the posterior attachments.

8. Rectum: vertical section dissection 07'36''

First we open the peritoneum slowly like this, using traction and counter-traction, staying close to the propria fascia of the rectum, I have finished to dissect the posterior fixation of the rectum. This is the vertical segment of the rectum. I will now open.

9. Rectum: horizontal section dissection 08'06''

I will dissect the horizontal segment of the rectum. These are the parasympathetic nerves. We don’t have to pull too much on the rectum because we have to keep enough mobility in order to push posteriorly when we pull anteriorly. The danger is to be in the vagina. You see that the white and the blue protect during the dissection because it’s plastic and not metallic so the current is only between the jaws and using monopolar like this at the tip. We will check the inferior limit. These are the posterior attachments of the sacrorectal ligament. This is the posterior tumor and it’s located approximately at this level. So you see that I’ll do the division exactly where I have finished my freeing just under the mesorectum. I’ll do the anastomosis at around 5cm but I think that’s easier than doing a dissection and particularly when we are not far from the tumor in the mesorectum. I’ll do the division approximately at this level when I’ve finished to free the mesorectum.

10. Rectum and proximal colon section 12'08''

I’m trying to reproduce exclusion of the lower rectum during TME in order to wash and apply the stapler more easily and reproduce the triple stapling technique described by Bill Heald. We use betadine to wash and now we’ll apply the stapler. One trocar is above the umbilicus, another one is suprapubic, one in the iliac fossa (see my right hand); the position is also due to the adhesions but normally it’s not far; then I put this to maintain the ileo-caecum retracted and this is used by my assistant holding the camera too in order to maintain the rectum up above the pelvic brim and I’ll use this trocar to mobilize the splenic flexure. We use 3 Kocher clamps.

11. Anastomosis preparation 15'58''

We’re now introducing the circular stapler in the rectal stump. It is done. We maintain this and we’ll perforate more anteriorly. The anvil is introduced laterally and we have a small stump and we push. We now close maintaining the pressure like this. We verify that there is no twist and there is none. You see the splenic flexure that has been mobilized and we complete the anastomosis. I’ll verify the donuts to see if there are very large and complete. That is perfect. You see the colon and the rectum. We will do the same control with my finger. It looks like a reservoir when we do the rectal examination.

12. Mesenteric gap closure 18'46''

We will close the gap because the risk is to have bowel obstruction due to internal hernia. This is an easy closure using a running suture or using staples as we will do now.

13. Ileostomy 19'20''

We’ll determine the site for the ileostomy because we’ll do an ileostomy to protect. I’ll use the segment and I’ll grasp with the forceps preoperatively to determine at around 20-30cm distance from the ileo-caecum. Why so far? To be sure that when we’ll close, we have enough distal bowel for doing the closure without risk. We pull now. You see the proximal one. I put drainage more systematically now than in the past even if there is no bleeding. In this case, it’s particularly necessary because the patient had Plavix®.

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