Laparoscopic abdominoperineal resection for T4 distal rectal cancer

Authors

Abstract

This video demonstrates a laparoscopic abdominoperineal resection for T4 ultralow rectal tumor with involvement of the sphincter and limited downstaging with a neo-adjuvant radiochemotherapy.

Catégorie

live recorded

Mots-clés

Laparoscopic abdominoperineal resection, T4 distal rectal cancer

Type de vidéo

Durée

33'31''

Publication

2011-06

Popularité

Favoris

Audio

Sous-titres

E-publication

WeBSurg.com, Jun 2011;11(06).
URL: http://www.websurg.com/doi-vd01en3332.htm

Laparoscopic abdominoperineal resection for T4 distal rectal cancer

1. Clinical case presentation 00'18''

This is the case of a 75-year-old man with a BMI of 25. He presents with rectal bleeding and the subsequent investigation, namely the colonoscopy showed a 5cm lesion 2.5cm from the anal verge. The histology was positive for moderately differentiated adenocarcinoma. As you can see, the MRI showed a sphincteric involvement, a T3N0 one, and the patient had a neo-adjuvant treatment consisting of radiotherapy with a total of 45 Grays in 25 sessions and the post-treatment MRI showed a regression of the lesion but still a sphincteric involvement so we scheduled an abdomino-perineal resection. To summarize, it’s an ultralow rectal tumor with the involvement of the sphincter, limited downstaging with a neo-adjuvant radiochemotherapy. An APR is indicated, removing the sphincter and a laparoscopic approach will be used for the upper rectum and mid- and perhaps lower rectum. The goal is to do a cylindrical resection of the perisphincteric tissue and an en bloc resection of the rectosigmoid.

2. Trocar position 02'02''

Now to the position of the trocars. As you see, we have the patient in a Lloyd-Davis position and the whole team stays on the patient’s right side with the first assistant lateral to the right shoulder. Both arms of the patient are alongside the body to be able to safely stay close to the patient and to manipulate the instruments. I have introduced different trocars, always using the same anatomical landmarks that you know now. The laparoscopic unit is on the patient’s left side in front of the surgeon. First, through a mini-open approach, I have positioned a 12mm trocar just above or in the umbilicus. I will use a 0-degree scope and two working trocars in the mid-clavicular line to the right at the level of the umbilicus (a 5mm one) and a 12mm trocar in the right iliac fossa. I can use a 5mm one because I will use 5mm instruments, and just suprapubically, there is a 5mm trocar there to accommodate the retractor and retract the sigmoid laterally, and in the place of the definitive stoma, medial to the epigastric vessels that are not far from the mid-clavicular line, I have introduced a 5mm trocar. I will do as I normally do in this kind of procedure a preperitoneal definitive stoma to limit the risk of peristomal hernia.

3. Surgical field exposure 03'56''

We have exposed the pelvis using the Trendelenburg position, putting a retracting forceps introduced in the left --see the left trocar, and I will push behind the small bowel as you can see, and lateral to the duodenojejunal junction. This is the duodenum, right iliac fossa – we have used a right lateral tilt, and you can see that the small bowel is staying in place. We have carried out the exploration: there is no carcinomatosis. Here is the urinary bladder, and we will begin the dissection using traction to expose iliac vessels and as we usually do, I’m opening the peritoneum anteriorly to the promontory.

4. Peritoneal incision 05'02''

I’m using monopolar scissors. See I have incised the peritoneum and I have to find all the anatomy at the back. Next step is to change the traction. I will use the pressure of the pneumoperitoneum to do the dissection using this and I will open the plane. Now come back anterior to the promontory, and I will continue the dissection sliding on the back of the mesosigmoid and using counter-traction of the vascular sheet of the inferior mesenteric vessels or superior rectal vessels. Please comment on the assistant’s positioning of trocars. What does he do for you now? My 1st assistant is staying on my left side lateral to the right shoulder. He’s holding the camera only till now. So I can use a camera holder and the other assistant between the legs is only maintaining the mesosigmoid retracted laterally.

5. Medial dissection 06'38''

We see the left iliac vessels, see this is the vascular sheet, this is the right plane we have to find. I don’t see the nerve. It’s not necessary to see the nerve. I continue the dissection. The nerve and the artery lie at the back. I will continue to open the vascular sheet. I want to show that I’m doing the focus. The aorta is just there. I will divide at this level, keeping a minimum of stump. Give me the Ligasure® now.

6. IMA dissection 07'24''

We see the trunk. I do a skeletonization of the artery to be sure that I have no structures between my instrument and the forceps. I will reduce the traction. I ask my assistant to reduce the traction on the artery to avoid breaking it and I will seal and complete the procedure either with clips or a loop as I will do like this. I’m completing the loop like this. See my assistant is now grasping the artery to lift it because all the nerve branches are fixed and I’m continuing the dissection laterally left to the artery and you will see that I have some branches of nerves running laterally to the artery and we will see the plexus trunk falling. We will use traction and counter-traction to open the plane as you see now. So we will complete by a division of the IMV.

7. Ureter identification 08'43''

So you can see the ureter very nicely. I think that it is a lymphatic. I will show you where the ureter is. We reduce the traction like this. It’s a one-end loop. I’m ligating the vascular pedicle. Grasp this and turn for better traction like this. See the ureter. So if you don’t know where it is, it is normally the bisector between the genital vessels and the aorta. I’m doing the parietalization of the spermatic vessels; as you see, these are the genital vessels, the ureter, and the aorta or iliac vessels. TME is a technique of dissection. We are doing a dissection in the plane. Until now, we haven’t seen the nerve. If we are in the right plane, we are not dissecting the nerve. I’m doing a lateral freeing of the sigmoid to the right. I’m changing the position of scissors to have less contact. In the US, it’s very unusual for surgeons to use monopolar cautery. It doesn’t seem to work as well as when you use it. Do you use special settings or. No, I’m using 20 Watts with the Ligasure® Advance LESS, it’s a 10-15 Watt one because it depends on the size of the surface contact. See we are using monopolar dissection and this is a real fascinating technique. In open procedures, Bill Heald is using monopolar cautery. Joel, are you using a 0-degree camera? Yes, indeed. And why is that? Why not an angled scope? I’m using a 0 degree because it’s easier, particularly when you have assistants and you change your assistants regularly. With a 0-degree scope, they don’t use all the possibility of angled scopes. I’m stopping there because it’s not a colo-anal anastomosis. Now I use the forceps. It is a low tumor. What about the preservation of the left colic artery? It’s not a bad question, we can do it but we have to do the skeletonization of the IMA. It’s not because it’s a low tumor, we also have to remove all the nodes if we want to be oncologic for a lot of people. I’m not sure this is true but a lot of people will say you have to remove the nodes around the origin of the IMA, particularly for advanced tumors. Now to the Endo-GIA. I’m doing that in APR. See I’ll divide the rectum rapidly. I’m resecting a maximum. Please tell us what stapler you’re using. This is a regular Endo-GIA. This is to do the stoma so we will put this there, and do the stoma using a preperitoneal approach, pulling and you’ll see later how I do. We change now. Remember the forceps on the left side. I’m removing it to ask the assistant to hold the camera to catch the sigmoid. First I want to complete laterally. What you don’t see, it is the most important thing. It is what my assistant is doing and what I’m doing with my left hand. This is traction, counter-traction and action in between, as I always say. This is the left hand that is doing all the work. Now we’ll use a better approach. Give me the peanuts. When you perform the Miles procedure, do you spare the peritoneum in order to close the pelvic space at the end of the operation? It’s a good comment. We have a big omentum. In this case, we will probably use an omental closure. TME I will use the blade of the Ligasure® Advance and the shape of the instrument to do the dissection as you will see. With my hand, I can reduce the power, and thanks to the shape, you can see that the peanuts are like the fingers of the laparoscopic surgeon. It is important to try to respect the plexus and it is not necessary to use high power. I’m using the shape of the device to complete the opening of the plane. I’m using this instrument sometimes as a finger. See on the blue and white part of the device, there is no electrical, no thermal contact. I’ll do more on this side now. What percentage of your rectal cancers do you do abdominoperineals only these days? About 10%, no more. I’m sliding on the fascia propria. I’ll propose to retract more medially and I’m retracting more laterally or we can do the opposite. My assistant is doing more and I’m in conflict with him so we’ll change. He’ll do laterally and I’ll do medially. See I’m going slowly, sliding and using the shape of the instrument. And because it’s not all the instrument that is doing electrocautery dissection, I’m using the shape as you can see to introduce it and as a finger. Remember it’s an advanced tumor. Now we will do the anterior dissection. These are the plexus trunks but we don’t see them. See this is the right superior hypogastric plexus. So we have to do the peritoneal incision on the back of the prostate. I want to have the anatomy like this. I will ask my assistant to do a better retraction, atraumatic like this, and we will see better. So this is one of the dangers. This is the plexus trunk, the superior hypogastric plexus and one of the dangers is to do an angulation of this plexus at this level. Do you use 10 Watts or 20? 26 here in this case. Give me the Ligasure® now. I’m on the back of Denonvilliers’ fascia, I’m using 10 Watts to start with. I use more the shape of the instrument to do a nice dissection and now I use 15 Watts, it’s different, you see. I’m using the shape of the instrument. We have some edema. It’s not bad but if I want that I dissect some nerves there that are crossing the space. This is what I can show you. Normally we cut all the branches like this but we can free all the branches. I can divide, staying medial to the parietal fascia. See we are sliding on the back of Denonvilliers’ fascia. The prostate lies anteriorly. So we try to respect all the anatomy to have a better result. Normally if we follow the results of Eric Rullier and he says it’s not easy, it’s around 50% of problems. It will depend on what you do, what kind of surgery you do when we compare. See when we’re speaking of TME, rectal anterior resection in our country (for rectum only), but in Asia they use this term for sigmoidectomy because they remove the colorectal junction. But it’s completely different concerning the risk, except the origin of the IMA. So this is a surgery of planes. We have to dissect medially, posteriorly, anteriorly to the parietal fascia. Posteriorly, it is the presacral fascia and lateral to the fascia propria of the rectum. So we introduce a T retractor. This is the retractor I have designed with Karl Storz. It is like a finger at the tip –see, and I’m using this to show you that we can dissect very low to see very well the deep pelvis. This is a T shape. I can complete this using curved scissors like this to have a nice opening of this space. I think that it is very important to have a lot of tools to do an easy exposure, to retract. Afterwards, it’s only a technique of dissection. But the first step if you don’t see what you do, you will have difficulty in doing surgery. So exposure is an essential step. You haven’t seen but we have a holder to maintain this retraction orthostatically fixed on the table. I have finished the dissection of the rectum by laparoscopy so we will do the colostomy – very interesting step because I’ll do a preperitoneal colostomy.

8. Colostomy 24'26''

First, remove the skin. We do the definitive stoma in the transrectal area always. It’s not lateral, never. So the first step is to remove a tunnel of fat till we reach the aponeurosis. I’m reaching the rectus muscle. I’m removing this. I’m incising the preperitoneal. Now I have to find the posterior layer of the rectus muscle. See the posterior layer of the rectus muscle very clearly. I have the aponeurosis and the peritoneum just in front. I’m grasping the aponeurosis. I’m grasping the peritoneum. I’m using it as a finger to dissect anteriorly to the peritoneum. Show inside. We’ll dissect like this. I’m showing that we can use the retraction and open to make a tunnel. I continue till I reach the lateral side. I complete the opening like this. Now, I put a loop at the distal part of the colon. I will change now, because it is not a grasper. I remove this and I put a forceps in the same tunnel. Can you put the suture in the branch of the retractor? No, it could be interesting, I can try it, but it’s not enough. Now you see the colon is coming outside. We can pull more. See the colon is coming outside. We will fix the colon later. Now we have two possibilities: first, doing an omentoplasty to prepare the omentoplasty of the pelvis. Will you close that peritoneum around the colon there? No, I don’t close the peritoneum at this level. You don’t have much lateral defect. Usually, there is no risk of internal hernia at this level. There are different possibilities. First, mobilizing the omentum to do an omentoplasty later. I will keep the vascularization of the left omental vessels and I will free the colon there from the round ligament. I will finish the omentoplasty and I will go down on the peritoneum. This is the plane with the pelvic floor. This is the coccyx. I divide the recto-coccygeal ligament and I will be soon in the presacral space. I open the plane. I dissect laparoscopically. I will finish the dissection posteriorly soon to complete it anteriorly later.

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