Laparoscopic coloanal anastomosis for the treatment of anastomotic stricture after partial TME

An anastomotic stricture is a common clinical finding. Its management can be difficult. Major corrective surgery is possible; however, it is technically challenging and not risk-free. The purpose of this video is to show the feasibility of a laparoscopic re-intervention on a stenosis following a colorectal anastomosis performed 2 years previously during the treatment of a PT3N0M0 mid-rectal cancer.

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Laparoscopic coloanal anastomosis for the treatment of anastomotic stricture after partial TME

Authors

J Leroy, J Marescaux

Abstract

An anastomotic stricture is a common clinical finding. Its management can be difficult. Major corrective surgery is possible; however, it is technically challenging and not risk-free. The purpose of this video is to show the feasibility of a laparoscopic re-intervention on a stenosis following a colorectal anastomosis performed 2 years previously during the treatment of a PT3N0M0 mid-rectal cancer.

Catégorie

complex cases

Mots-clés

Laparoscopic coloanal anastomosis, treatment of anastomotic stricture after partial TME

Type de vidéo

Vidéo chirurgicale

Durée

15'47''

Publication

2009-09

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Sept 2009;9(09).
URL: http://www.websurg.com/doi-vd01en2629.htm

Laparoscopic coloanal anastomosis for the treatment of anastomotic stricture after partial TME

1. Introduction 00'09''

The purpose of this video is to show the feasibility of a laparoscopic re-intervention on a stenosis following a colorectal anastomosis performed 2 years ago during the treatment of a PT3N0M0 mid-rectal cancer. The stenosis was the cause of very impeding functional disorders with a poor life quality. After a localized recurrence of the disease had been excluded first, the laparoscopic exploration identifies an abdominal cavity free of carcinomatosis and presenting very few adhesions, as this is often the case following a laparoscopic surgery. Most of the identified adhesions are in contact to the omentum, but there are a few around the small bowel and the abdominal cavity. A few adhesions in contact to the mesenteric breach are easily freed: these are clearly not pathological and suggest a past inflammatory phenomenon.

2. Freeing the colon 01'10''

The fist step is to free the lowered colon, in particular its medial part in order to obtain a view of the mesocolon and of the lowered vascular axis. We continue the dissection towards the pelvis and see that the adhesions on the posterior surface of the bladder and prostate are a little closer to each other without being dense; had it been the case, this could have required a conversion to open surgery. While trying to find the dissection plane, we notice that if the first surgical procedure has been performed within the frame of the oncological principles described by Professor Heald, namely dissection between the various fascias, we can uncover the same planes during the re-intervention, whether it’s on the right lateral aspect or on the left. We just need to apply the same surgical principles used during the first procedure, namely traction and counter-traction, to find the anatomical planes and particularly the posterior planes that are in contact to the fascia propria, presacral fascia and to the Toldt’s fascia laterally. Here we are on the posterior surface of the lowered colon, and posteriorly, on the Toldt’s fascia that covers all the retroperitoneal structures.

3. Pelvic dissection 03'22''

We continue the dissection towards the lesser pelvis on the posterior surface of the lowered colon, as if we were performing a complete resection of the mesocolon. As we can see, it is preferable to perform a complete mobilization of the lowered colon, medially but also laterally as has been done here. With this mobilization performed, we can exert traction on the lowered colon whose vascularization we are trying to preserve, to have enough length to perform a tension-free anastomosis as low as possible, at the level of the anal canal. We continue the dissection in the presacral space. This dissection is made easier by using cold scissors with occasional electrical current to open the planes. The 10mm Ligasure Atlas® is extremely useful as we can use it to divide and connect, but we can also use it as a finger to complete the opening of the operative planes. The freeing is then continued anteriorly on the posterior surface of the prostate and bladder. Here again, by using the traction and counter-traction principles described by Professor Heald, we find the anatomical planes that had been observed during the mesorectal’s total excision. The dissection is continued in contact to the parietal fascia, and here anteriorly, on the posterior surface of the Denonvilliers’ fascia. The benefit of using mounted peanut swabs to push structures out of the way is demonstrated here as it is atraumatic. It is sometimes necessary to complete this dissection by opening the planes with scissors to find a plane with fewer adhesions and continue the dissection, eventually anterior to the Denonvilliers’ fascia if it has been preserved. We can see that it is always possible to find a plane if a good dissection was performed during the first procedure. We now need to find a plane that brings us closer to the zone to anastomose, we see that here there had probably been an anastomotic division with a peri-anastomotic abscess. The fresh-mount study of the skin samples essentially found signs of an inflammatory phenomenon with no tumor recurrence. It was a pouch in contact to the stenotic area that was probably linked to an anastomotic leak. This pouch will be excised and a frozen-section analysis will be able to rule out a local recurrence. The distal end of the rectum now remains to be dissected; this step is difficult via a pelvic approach, we therefore decide to divide the rectal stump and carry out a trans-anal approach. The right anterior lateral division of the lower rectum seems to become increasingly delicate as the plane is hard to uncover. This is why we decide to divide the distal end and excise the rectal stump transanally. Some authors recommend to perform this step before the laparoscopic approach, which would perhaps allow to do the whole procedure laparoscopically. It is the “TATA” technique, described by John Marks, that suggests to free the attachments of the rectum’s distal end transanally after closure of the rectal lumen. Once the exploration stage is over, we should plan for the specimen’s exteriorization to perform the anastomosis in good conditions. To do so, we will mobilize the colon and check the distal colon’s vascularization. This can be delicate, especially if the vascular divisions were performed in an extended fashion during the first procedure.

4. Division of the distal rectum 10'04''

Here we see the division of the distal rectum with the stenotic section that will be taken away. The meso is divided first, then we staple using an Endo-GIA linear stapler: this allows to separate the distal colon and the rectal stump remnant. The descending colon whose mobilization will be completed as mentioned previously before checking the vascularization. The stapling is quite difficult on this stenotic area and the staples did not entirely close on themselves, which is not problematic in this case as a second division will be performed before the anastomosis. Here we see the complementary colon mobilization, in particular the freeing of the mesocolon’s posterior attachments while keeping an eye on the vascular network and the marginal artery, which needs to stay at a safe distance. The medial and lateral approach of the mesocolon’s posterior surface up to the back of the lesser omental sac should be relatively safe for the vascular axis and the marginal artery. Here we see the dissection gradually approaching the pancreas’ inferior border with fibrotic tissue where the gap was closed during the first procedure. The colon is progressively lowered and the lesser sac will be opened at this point of the procedure. The aim is to have a tension-free lowering of the colon so that it can reach up to the anal margin. The lesser sac is now opened, and here we see the freeing of the left transverse colon’s posterior attachments just anterior to the pancreas, the lesser sac is now clearly visible.

5. Transanal approach 12'44''

Once the colon has been mobilized and the rectal stump isolated, we approach the rectum transanally once the appropriate retractors have been set up. We dissect the rectum via a transluminal approach while preserving the sphincter to maintain satisfactory continence. This dissection is performed with cold scissors; the coagulation should be performed carefully with bipolar cautery or the Ligasure®.

6. Colo-anal anastomosis 13'45''

ANASTOMOSIS Following the placement of a Vicryl loop at the level of the proximal colon’s extremity, we exteriorize the colon through the anus by using traction and making sure that there is no twist, until the lowered colon is in a well-vascularized and supple area to perform an end-to-end colo-anal anastomosis. It is performed just above the pectinate line by placing 4 cardinal stitches at 12, 6, 3 and 9 o’clock, an extramucosal stitch on the colon and a full-thickness stitch on the anal canal’s mucosa, and on the sphincter at the level of the cardinal stitches. Intermediate stitches will then be placed until the colon is perfectly fixed. A protective stoma can be prepared, which is the case here in the shape of an ileostomy; the ileostomy is performed at the same level as the one completed during the first procedure. A suction drain going through the left iliac fossa is left in place.