Laparoscopic low anterior resection for rectal cancer in a female patient

This video demonstrates a laparoscopic TME of rectal cancer in a woman. The surgeon carries an extensive mobilization of the sigmoid colon and rectum. The IMA is divided at its root. The ureter, gonadal vessels and the hypogastric nerves are identified. The mesorectal dissection is carried out in the planes down to the pelvic floor. The rectum is divided just proximal to the pelvic floor. The splenic flexure is mobilized before the specimen is exteriorized through a suprapubic incision and a stapled anastomosis is made between the proximal sigmoid and the rectal cuff. A protective stoma is created.

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Laparoscopic   low   anterior   resection   for   rectal   cancer   in   a   female   patient

Authors
J Leroy
Abstract
This video demonstrates a laparoscopic TME of rectal cancer in a woman. The surgeon carries an extensive mobilization of the sigmoid colon and rectum. The IMA is divided at its root. The ureter, gonadal vessels and the hypogastric nerves are identified. The mesorectal dissection is carried out in the planes down to the pelvic floor. The rectum is divided just proximal to the pelvic floor. The splenic flexure is mobilized before the specimen is exteriorized through a suprapubic incision and a stapled anastomosis is made between the proximal sigmoid and the rectal cuff. A protective stoma is created.
Catégorie
complex cases
Mots-clés
operation,total mesorectal excision,TME,female patients,cancer,mesorectum,rectum,laparoscopy
Type de vidéo
Durée
64'00''
Publication
2005-06
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Jun 2005;5(06).
URL: http://www.websurg.com/doi-vd01en0046e.htm

Laparoscopic   low   anterior   resection   for   rectal   cancer   in   a   female   patient

1. Case demonstration 00'14''
As you can see, I have drawn on the patient the ribs, the pubis, the anterior iliac spine and 3 vertical lines: the mid-vertical line, 2 mid-clavicular lines and a horizontal line at the level of the umbilicus. I have placed a lot of ports just above the umbilicus, the umbilicus is not the best landmark, it is 20cm above the pubis so that it depends on the size of the patient. I have introduced a 12mm optical port; the other ports are not always necessary but they are here for a good exposure and to show you the positioning of the ports when it becomes difficult. On the left side is a 5mm port at the junction between the horizontal line of the umbilicus and the left mid-clavicular line. It will be used as a retractor for the small bowel, but also as an operating port to mobilize the splenic flexure if necessary. There is a subpubic port that will be used as a retractor to expose the mesosigmoid and to retract the rectum or as an operating port when necessary such as for the introduction of a stapler. On the right subcostal area, on the mid-clavicular line, we have another port to retract and expose; it will be used as a retractor to retract like this the small bowel when there are difficulties to maintain it in the right iliac fossa. The last 2 ports are used to operate. I am right-handed so I use this port to grasp and the other to dissect. They are also on the right mid-clavicular line at the junction of the horizontal line. As you can see, we have 8 to 10cm between each port, which is necessary to avoid difficulties during the manipulation. The first step is to push the omentum upwards to the subphrenic area, it is a small omentum so it’s not a problem. For this step, we ask that the patient be placed in Trendelenburg position. We then have to arrange the small bowel on the right side of the abdominal cavity, don’t begin at the proximal part of the small bowel but at the middle part and you push it to the right side. I push loop by loop each loop above the previous one. Now I have to expose the small bowel and arrange it on the right side of the abdominal cavity. We have to arrange them loop by loop, placing each one above the previous one. We can eventually fix it like this, not on the vessels or the ureter, to maintain it atraumatically with orthostatic retraction. Another possibility is to use this fat tissue and maintain the grasper. We have another grasper to expose, in this case it is not completely necessary to do that because the sigmoid is fixed laterally, but sometimes it falls medially and it is necessary to maintain it without grasping the colon but the meso that we use as a retractor. The landmark is the sacral promontory and I begin to open with a small incision because there is pressure in the abdominal cavity with the gas. We can incise easily because we open the retroperitoneal space by laparotomy. This is the same when it is an obese patient, even more so. It is only the peritoneum that I incise. I don’t want to see the artery or the nerves immediately, I dissect plane by plane, I could go quicker but it is not our goal, I want to show you that we see very well. At this stage, the key for me is to try and find the shiny back of the visceral package and I am sure that you will do, it is almost there. See the branches of nerves that go to the mesosigmoid, I will divide these branches. I think you’ll just find that holy plane right now behind the shiny package. Hopefully behind that will be some nerves I suppose. The problem with laparoscopy is that we operate on the right side of the patient. I am on the right side. I have to do that later. Now I divide the connection between superior and inferior mesenteric plexus, the branches that go to the mesosigmoid. You see its anastomosis of the right hepatic trunk that gets to the left hepatic trunk. The other trunk is behind here. But when you are speaking of trunks, you are talking of the components of the superior hypogastric plexus? Yes. You see small nodes here. You think that node is inside or outside the fascia of the package? I am behind the fascia. I will show you after. You see the left trunk is here and it is a danger to be behind. The trunk is here and its anastomosis is between right and left. If you take too many of those nerves away by stripping the aorta, the male patient would lose the ability to ejaculate, correct? Yes, that is right. You see I have trouble dissecting now, so my assistant lifts upwards and I change the exposure like this. I take some time because I think it is important to show you where the anatomical structures are. I want to show you that the nerve is behind here. The trunk is falling. In Japan, I think they preserve the left trunk, we also preserve it, it is not just in Japan. Why don’t you cut the artery now? I will divide it but only when I finish my dissection. For lower rectal carcinoma, do you preserve everything as you do, do you cut after? No now I will divide but at this level. I think we can see that you are able to do that and sometimes it may be a good thing but I think the standard method would really be to take it about 1 to 2 centimetres in front of the aorta. One advantage of doing what you have done is that you get a very nice clean route out to the colon just to the right to this artery I think, you can follow it out to the colon sweetly. It is a very constant piece of anatomy that the relationship between the ascending left colic artery and the inferior mesenteric vein. So I will divide the vein at this level, do you agree? If you were going to mobilize the splenic flexure, I would do that, I do agree, but if you do that you might have to take it again higher up above the last tributary. I am just in front of the Toldt’s fascia and it’s an avascular plane, it is only necessary to push between both fascias. Surgery is like this, it is the science of the plane of adhesion. Here is the fascia that covers all the retroperitoneal structures. It is not necessary at this stage to mobilize the sigmoid laterally, we do not touch the sigmoid. Since the beginning of the operation, we have not touched the colon and the rectum. Now is the entrance in the pelvis, in the presacral space. You see the Toldt’s fascia is prolonged by the presacral fascia. You will see the beginning of the posterior dissection. It is the presacral space in front of the presacral fascia that we will dissect. I don’t have the Ligasure device but with it, it is fabulous to dissect this plane. This cord, it’s the trunk of the left one, but I will stay inside the fascia. You see that the right plexus is behind the fascia, there is a cord here. We see the right superior hypogastric nerves here. It is here or perhaps here. I should not dissect too much. I do not need to dissect too much posteriorly for this step of the operation, I complete my dissection anteriorly and I will finish by the lateral ligament. So I have mobilized the sigmoid laterally; through the left port I introduce a grasper to place traction on the rectum but not too much in order not to close the space between the vagina. To better expose, you have to lift the rectum up but not too much. With a grasper introduced in the suprapubic port, I grasp this and open the angle. I never put a retractor in the vagina to lift the vagina forward from outside, I only use traction on this and I will show you that if I place too much traction, I close this angle. So let it fall, and the vertical and horizontal parts of the rectum are respected. It was not difficult, there was a small problem in finding this plane because the patient had had hysterectomy but it was also easier because she did not have too many adhesions. At this time of the operation, have you any idea where the tumor is located? I can feel it behind, it is posterior, I’ll stop to show you where the level is, there were a lot of adhesions so I dissected the sacrum again. When we are too close, we think that we are always dissecting the same thing, I use my grasper to increase the angulation between the vagina but I am not efficient enough so I probably have to change the position of my grasper to have more traction on the vagina; and it is the same in men! We respect the fascia. So I dissect posteriorly, anteriorly, and finally laterally. It is not just laparoscopy, it is the same in laparotomy and we have to dissect the parietal fascia again. See the plexus trunk. I agree, I am waiting with great interest to see the parasympathetic nerve routes, which should be behind there I suppose. I dissect just inside the plexus trunk, it is here, and in men it is just outside the seminal vesicles. I only divide the internal branches of the trunk. I have opened the fascia and I am behind, you probably have sacral branches at this level but it sticks so I prefer to dissect these branches and divide because it is realistic at this level. I do not know if professor Heald would do the same in this case. This is a difficult case but progressively you will see that I am in the good plane; I don’t dissect the rectum, I dissect the fascia and the pelvic wall. That is the middle rectal artery. Sometimes it is not at this level but it is lower. I think it more often comes down lower from the pelvic floor and in a man, it is more often a vessel to the prostate. This is the exception, which proves the rule. How would you know in laparoscopy that the tumor has not extended to other parts such as the prostate, how do you judge the extent of lateral or anterior infiltration? I am performing a total mesorectal excision, so if it is not in the mesorectum, I will not see. We are on the pelvic floor now, you see. I have opened the aponeurosis of the pelvic floor. When you are in a good plane, you only have to unstick 2 planes, on the lateral ligament it is the same, it is not a ligament. When it is a ligament, it is either when the surgeon has gone too far out or too far in. It is our priority to preserve the nerves, and because we preserve the nerves, we know we are in the right plane. The parietal fascia is completely dissected, but it is better to do that than to dissect in the propria fascia of the rectum. I would make the point that if you had a very low tumor, which this isn’t, and you want to get the anastomosis onto the dentate line, taking that bit in the middle which they call the anococcygeal raphy, will give you several extra centimetres, for this one it may not be necessary. We introduce the stapler through the suprapubic port, it’s a green cartridge so when the stapler will be closed, it will be 2mm higher. Your pelvic dissection is beautiful. I progressively introduce the rectum into the stapler and place some traction on it or I can ask my assistant to push, I close the stapler. It is obviously important that you pull only on the bowel beyond the cancer. If you resect now and open up the rectum, you have only 1cm of distance, what would you do in this case? You have to palpate the patient before operating. This is the front of the aorta, as you see we have the vena cava under my grasper, the aorta with the horizontal line, the beginning of the inferior mesenteric artery with the left colic artery behind the inferior mesenteric vein and later on the left side. Here the anastomosis with the branches of the right sympathetic trunks that goes across to the front of the left iliac artery and to the left sympathetic trunk that we have preserved is just here. It is interesting that the whole nerve plexus are often to the left of the aortic bifurcation. We have placed the specimen in an Endocatch II plastic bag, so it’s a big bag and we will remove the specimen. You see the specimen is completely removed. We can see this beautifully emptied pelvis. I have done my dissection from down to up, anteriorly to the Toldt’s fascia while preserving the Toldt’s line because the colon doesn’t fall in this space, so you see I am just in front of the fascia, the pancreas is here. This is a beautiful demonstration of how the laparoscope can be used to mobilize the splenic flexure more easily than in open. Now I can finish mobilizing laterally, so remember what I told you, I preserve this attachment to stop the colon from falling in the operative area. You see why it is important to have the right subcostal port, it is to expose the splenic flexure. When it is easy as in this case, it is not a problem but you have a left subphrenic flexure, it is really interesting to have this disposition, I have changed no ports during this procedure and I can completely dissect with all options in the abdominal cavity. Now it’s the phrenocolic ligament. I want to find the adhesions between the omentum and the colon to open the lesser sac laterally; here is the spleen. This is not exactly the lesser sac. This is Plymouth in the UK, we are watching your technically elegant technical operation, our panel of 4 colorectal surgeons has been very impressed by what we have seen on a technical basis. Can you explain what you are doing at the moment? That is the stomach, you are looking into the lesser sac there. We saw an elegant dissection beginning with the division of the inferior mesenteric vein, followed by a mobilization of the peritoneum. He did a total mesorectal excision in which we had slight differences of opinion about exactly how close to the inferior hypogastric plexus he should go, this is a woman but on the whole he has done the most perfect total mesorectal excision and removed the tumor and he is now mobilizing the splenic flexure prior to the anastomosis. We have the inferior mesenteric artery, left colic artery and we have to mobilize posteriorly to be sure that the left colic artery follows the mesocolon and the transverse mesocolon and the splenic flexure too. If you do not mobilize this, it is impossible. Is this not the point where you have to take the vein again above the last branch? If you wish full mobilization of the splenic flexure, I think it is necessary to take the termination of the vein close to the pancreas. Left colic vein, this is a good plane, it is not behind my vein, you see the renal vein with the genital vein in. The pancreas is here, I think I have dissected enough here. You see the pubis is here and I will divide at this level. The anvil is a 28, it is very low but perhaps we can dilate. I re-introduce the anvil. We have perfect water tightness. Do you think that the diameter of the anastomosis matters low down near the anorectum, ischemia is probably the limiting factor with regards to anastomosis long-term? Would you use a 34 stapler if you could? I use a 28, I think it is possible to use more. You see to manipulate the anvil, I grasp it with a second grasper. Do you not think that you are about to staple a bit of the puborectal sling at the back? Is it not worth pushing that little bit of external sphincter away? Yes, perhaps but I have control when it is introduced. The line is here, we are in the small rectal stump. We have to check that there are no twists. In what cases do you cover with a colostomy because we have read your article about this? We believe that some form of protection is necessary for all anastomosis below 6cm from the anal verge, so most total mesorectal excisions, but we are in fact doing a prospective randomized trial of temporary defunctioning by either ileostomy or colostomy or the use of an intra-anal protective stent, which I would need to show you. I place my finger and the anastomosis is just supra-anal, I have a perfect endo-anal control, it will be controlled by Junji Okuda. You have to be impressed when you look at a beautiful empty pelvis like that, with the anastomosis virtually onto the dentate line, very adequate length, good blood supply, the question of whether you need to defunction this anastomosis is now being raised, I personally would; Professor Ambrosetti would too, Mike Hershman would, what about the audience, raise your hands if you think that temporary stoma is a good idea? I think about two thirds or half. I also think that because this patient has had radiotherapy. Which are you going to use Joel, a colostomy or an ileostomy? Usually in our department, we do colostomies on the right colon. There is no tension, what is important for the functional results is that there is no tension, if you have a reservoir that is straight then you’ll have incontinence because you won’t have a valve that protects and avoids the incontinence. It is not only a problem of reservoir, it is also a problem of good mobilization to have the colon with good curvature behind along the sacral bones and it is more important perhaps than the reservoir. I quite agree with you, the total absence of tension so that the bowel lies in the pelvis. At the moment, it will lie even more posteriorly when you have pushed it down, without gas and the patient is also head down at the moment.