Laparoscopic TME in a male patient with side-to-end low colorectal anastomosis and peroperative ultrasonography

Local control of rectal cancer and patient survival have improved remarkably with advances in surgical techniques. The objective of this film is to demonstrate a laparoscopic total mesorectal excision for a rectal adenocarcinoma situated in the upper rectum.

Naviguez dans
l'Université Virtuelle
Français ▼

Laparoscopic   TME   in   a   male   patient   with   side-to-end   low   colorectal   anastomosis   and   peroperative   ultrasonography

Authors
J Leroy, J Marescaux
Abstract
Local control of rectal cancer and patient survival have improved remarkably with advances in surgical techniques. The objective of this film is to demonstrate a laparoscopic total mesorectal excision for a rectal adenocarcinoma situated in the upper rectum.
Mots-clés
Laparoscopic TME, male patient, side-to-end low colorectal anastomosis, peroperative ultrasonography
Type de vidéo
Durée
29'30''
Publication
2010-06
Popularité
Favoris
Favorites Media
Audio
en fr
Sous-titres
en
E-publication
WeBSurg.com, Jun 2010;10(06).
URL: http://www.websurg.com/doi-vd01en2981.htm

Laparoscopic   TME   in   a   male   patient   with   side-to-end   low   colorectal   anastomosis   and   peroperative   ultrasonography

5. Mobilization of the descending colon 04'10''
The mobilization is then pursued towards the descending colon by incising the lateral colonic attachments. The sigmoid colon is therefore freed and mobilized. This freeing is completed by a division of the peri-caecal attachments to shelve the caecum in the right iliac fossa and prevent the terminal small bowel from falling into the pelvis. Once the sigmoid colon has been totally freed, it can be maintained by a grasper situated vertically in the left iliac fossa; peanut swabs can be used to complete the traction placed on the tissues and to open the space. This is facilitated by the use of the Ligasure Advance® device, which allows for both monopolar and bipolar current to seal tissues. It is evident that the use of small monopolar electrode is helpful. Combined with the specific shape of the Ligasure Advance® device, it allows for a totally atraumatic dissection of the spaces, in particular in contact to the nerve plexuses situated in a lateral pelvic position and protected by the lateral pelvic aponeurosis. Here the dissection is continued to the left side. The different nerve branches originating from the plexus trunk are visible. These branches will be progressively divided once they have been isolated preserving the plexus trunk at the most. This surgery is based on anatomical and embryological planes that must be found. The use of peanut swabs replacing the surgeon’s fingers in open surgery helps to achieve an appropriate traction and a totally blunt counter-traction.
8. Dissection of the rectal horizontal portion 10'47''
These maneuvers are pursued posteriorly at the level of the rectum’s horizontal portion, back to the Waldeyer’s ligament or fascia, namely the fusion between the fascia propria of the rectum and the presacral fascia. This area may be quite adherent, especially following radiotherapy and, if in doubt, it is preferable to stay in contact to the sacrum rather than in contact to the fascia propria of the rectum. Thanks to the monopolar electrode and to the instrument’s shape, the dissection may be completed by a pressure and by applying the electric current only at the level of the spike without any other contact with the rest of the instrument. This is a very distal, very safe electrode considering the contact area with the tissues. Another advantage lies in the use of bipolar dissection to seal tissues prior to their division, which is essential not only in the presence of vessels but also in the presence of nerve rami. Here nerve branches originating from the plexus trunk can be seen. They will be progressively freed. Thanks to the instrument’s shape, a dissection followed by sealing and division may be carried out: the different planes are progressively opened and the various branches of the plexus trunk are identified. Only the branches heading towards the rectum will be divided. Caution must be exercised when identifying and avoiding the aberrant branches that are accessory trunks in relation to the main trunks. It is sometimes uneasy to find these different dissection planes, and especially after radiotherapy. It is important to persevere and navigate from posterior to anterior and vice versa in order to stay in the correct plane. The easiest solution is to use instruments that seal and divide all the tissues. However, by doing so, major nerve injuries may be induced. The same maneuvers will be performed to the left, to the right, anteriorly and posteriorly. Nerve rami, and particularly in the lower portion, are the most likely structures to be at risk. Most importantly, the dissection should be continued using traction and counter-traction. One may be tempted to use much longer electrodes (seemingly much more efficient) to go faster, however with the risk of local hyperthermia and of too rapid and too extensive a dissection that would induce much more serious hyperthermia-related lesions laterally. Here, the dissection is continued on the left side by sliding on the posterior surface of the lateral parietal aponeurosis, then on its anterior surface – namely posterior to Denonvilliers’ aponeurosis. These maneuvers are pursued always using the Ligasure Advance® device. During median tractions, attention must be paid to avoid any angulation of the plexus trunk as could be the case here. Angulations of the plexus trunk could well occur here. Likewise, at this level, it is clear that it is essential to stay only in contact to the fascia propria of the rectum and to divide only the branches heading towards the rectum whilst avoiding entrance into the fascia propria, into the mesorectum and into the rectal wall. The dissection should be continued in this way until reaching the pelvic floor. It is often uneasy to continue this dissection laterally until the pelvic floor, especially to the left, without finalizing the freeing of the anterior rectal wall. To do so, traction and counter-traction are performed again. Dissection is carried out by staying in contact to Denonvilliers’ aponeurosis. Here the instrument is clearly beneficial in the dissection. Additionally, it is essential to use instruments adapted for the retraction, which should be sufficiently ample to improve the efficacy of the dissecting instrument. Likewise, at this level, it is clear that it is essential to stay only in contact to the fascia propria of the rectum and to divide only the branches heading towards the rectum, while avoiding entrance into the fascia propria, the mesorectum and the rectal wall.
9. Completion of the mesorectal dissection 15'52''
The dissection should be continued this way until reaching the pelvic floor. It is often uneasy to continue this dissection laterally until the pelvic floor, especially to the left, without having finalized the freeing of the anterior rectal wall. To do so, traction and counter-traction are performed again. The dissection is carried out in contact to Denonvilliers’ aponeurosis. The instrument is clearly beneficial in the dissection. Additionally, it is essential to use retraction-adapted instruments, which should be sufficiently ample to improve the efficacy of the dissecting instrument. Here a V-shaped retractor is introduced through a 12mm suprapubic port, allowing for a posterior to anterior traction. The traction effect on the tissues is increased, thus opening up the planes thanks to the pneumodissection and carbon dioxide pressure, and to the counter-pressure on the anterior rectal wall achieved by the surgeon’s left hand. The anterior rectal wall is either grasped by a forceps or is retracted by a peanut swab that is mounted on the forceps. It becomes clear that the space is very small and that other retracting systems should be used to increase the dissection area as well as to increase the possibilities for exposure. Here this H-shaped retractor provides a correct traction and retraction of tissues with an excellent visualization of the lower anterior part of the rectum. The same principles of dissection through monopolar electrode are respected, namely division into the plane by sliding on the posterior surface of Denonvilliers’ aponeurosis. The various nerve branches heading to the rectum are further divided. More caudally, one may found a middle rectal artery originating from the pelvic floor and heading to the mid-portion of the rectum. Rarely the whole dissection is fully carried out in one step anteriorly, or laterally, or posteriorly. Oftentimes, the surgeon should navigate on the distal part while dissecting the anterior, posterior and lateral planes in turn; this allows for the progressive elevation of the rectum by mobilizing it in a stepwise fashion. The efficacy of the electrode is all the more important as a correct traction is obtained and as correct tension is placed on fibrous tracts. Here the danger is to open the planes no longer using the electrode but the cautery division mode. This also happens with ultrasonic scissors, which are effective in dividing tissues rapidly but without dissecting and opening the plane. Here the left-hand side forceps retracting a plexus trunk is visible. A nerve branch heading to the rectum will be retracted after its division. This branch seemed rather voluminous. The procedure is continued to the right as soon as the left part has been finalized. The dissection is delicate and painstaking. Indeed, the patient’s body habitus does not make the dissection easy to perform.
13. Anastomosis 26'15''
The anastomosis is then prepared. To do so, a minimal Pfannenstiel incision is performed suprapubically. The wall is protected by a wound protector through which the Endo-catch II extraction bag will be placed. The operative specimen will be introduced into it prior to its extraction. No enlargement of the incision needs to be done even if a specimen compression has to be performed inside the plastic bag. The proximal colon is searched through the plastic wound protector. The distal colonic extremity is incised close to the stapled area that was formerly carried out distally from the area where the colon will be re-cut. The anvil of a DST PCEEA circular stapler is then introduced prior to re-cutting the distal extremity. The anvil should be situated at least 2cm away from the stapled segment of its distal end, which is buried using absorbable monofilament Maxon 3/0 suture material. A purse-string is fashioned at the level of the anvil’s tip, which comes out at the anti-mesenteric border. Once the purse-string has been created, the anvil is reintroduced into the abdominal cavity through the plastic wound protector. The rectal stump is then perforated. Before doing so, it has been tested with a Betadine solution to rule out the presence of any leakage, which was the case, even if some staples seemed disunited at the level of the mid-portion of the stapling. The anvil is then connected to the stapler’s tip and the side-to-end anastomosis is carried out. This anastomosis is checked. The donuts are controlled and the mesenteric defect is closed to avoid the risk of postoperative internal obstruction. A drain is placed as seems preferable in rectal surgery. No stomy will be performed in this case.