Laparoscopic low anterior resection with TME and medial mobilization of the splenic flexure in a female patient

This video shows the case of a female patient presenting with a low rectal cancer for which neoadjuvant therapy is used. The author performs a totally laparoscopic TME using a medial approach. A colorectal anastomosis without bowel protection is performed.

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Laparoscopic low anterior resection with TME and medial mobilization of the splenic flexure in a female patient

Authors

Abstract

This video shows the case of a female patient presenting with a low rectal cancer for which neoadjuvant therapy is used. The author performs a totally laparoscopic TME using a medial approach. A colorectal anastomosis without bowel protection is performed.

Mots-clés

TME, laparoscopy, medial approach, anastomosis

Type de vidéo

Vidéo chirurgicale

Durée

25'34''

Publication

2007-03

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Mar 2007;7(03).
URL: http://www.websurg.com/doi-vd01en2076.htm

Laparoscopic low anterior resection with TME and medial mobilization of the splenic flexure in a female patient

1. Case report 00'18''

This is the case of a female patient presenting with a rectal tumor. The inferior pole of the tumor is around 8cm above the anal margin. We will do a rectal resection.

2. Patient position 00'40''

The patient is placed in supine position, with the right arm along the body. The laparoscopic unit is on the left side. The team is located on the right side of the patient in between the legs. Afterwards I place the patient in Trendelenburg position with a right lateral tilt but not too much. I don’t hesitate to put more than 3 ports. In this case and up to now I have placed 5 trocars: one above the umbilicus for the optical port;

3. Exposure 01'15''

the others are on the right side and suprapubic. The 1st step of the procedure is to expose and therefore I put the patient in Trendelenburg position and right lateral tilt and I push the greater omentum above the transverse colon as you see. I don’t try to push all the small bowel on the right side and we will complete the procedure with some more Trendelenburg. The ileum is pushed to the right side. The jejunum is retracted to the left. We complete the exploration to see if we have the tumor in sight and we see that the tumor is just at the limit of the Douglas’ pouch, with perhaps anterior fixation to the vagina or not far from it. With such an exposure of the operative field, we can examine the sigmoid colon to check for its quality with a view to the anastomosis we will perform later on. We have a lot of diverticula and it is a spastic colon. So probably we will do the anastomosis on this part. It will be necessary to mobilize the splenic flexure in this case. It’s not always necessary when we have a long and compliant sigmoid loop. With the forceps introduced in the suprapubic trocar, we do the exposure and we see iliac vessels, the promontory is not far, lower in this part, and then we do the incision of the peritoneum.

4. Dissection of inferior mesenteric artery (IMA) 03'17''

You see I’m using traction in order to get a gas infiltration of the retroperitoneal structures. This is the duodenum; we complete the incision on the left. We will change traction to get a better exposure. I will change traction on the meso using this technique as you can see up to now. The dissection is carried out step by step, plane after plane until we see the origin of the IMA that is not far from the 3rd duodenum we see on the left. The key is to be close to the posterior aspect of the vascular sheath to keep away from the nerves; these are the surrounding tissues around the artery. You see the origin of the artery, which is behind the 3rd duodenum. But it’s not necessary to do a dissection until we are at the origin of the artery. The plexus trunk is here as you see fixed posteriorly. We have to stay behind the fascia. I’m using monopolar dissection. This is the vessel and I stay posterior to it. We carry on the dissection lower. You can see traction on the meso. Pneumodissection is a tool for the surgeon in order to find the right plane. We see the vessels here. We have to stay close but at a distance too. The dissection is done until we have a skeletonization of the origin of the artery.

5. Division of IMA and IMV 05'58''

We will use the 10mm Ligasure and at enough distance from the origin of the aorta if we face problems. Traction is exerted on the artery, and we will lift but not too much because you see the plexus trunk is not far from here and we do the dissection close to the trunk of the artery. It is because my assistant is exerting traction that I will do a good dissection of the branches of nerves that are running to the lateral side. We have the plexus trunk running here posteriorly lateral to the aorta, and we have to find the vein. And we will do the opening of the space. This is the left colic artery that we see posteriorly. I use the Ligasure device as a finger to retract. You see Toldt’s fascia. So this is a medial approach to the division of the retromesocolic structures because we don’t have enough mobility on the meso,

6. Lateral dissection 08'00''

so it’s time to free laterally. As you see, we use traction, counter-traction; we stay in the right plane. The danger at this stage is to injure the ureter and/or the genital vessels. We then continue the dissection. The mobilization is now done laterally until we reach the medial dissection and it’s just at this moment that we have reached this step. You can see the ureter moving, genital vessels. We will change our traction. The forceps is now put posterior to the sigmoid. I will do another retraction.

7. Presacral space dissection 09'10''

My assistant is retracting the rectum anteriorly, and we begin the dissection in the presacral space. We continue slowly as you see. When there is no radiation chemotherapy preoperatively, it’s easier to dissect, particularly in women. The nerves are not far from this area, and we have to maintain a good distance between the nerve and the instrument. You see that my assistant is retracting atraumatically, and perhaps posteriorly I prefer to dissect more at a distance. We have opened the presacral space. This is the sacrum. So we are not too posterior. We continue the dissection. We have 3 directions. This is a 3-directional retraction as proposed by Bill Heald. I use scissors to get more angulation. We continue on the left. We see very well the nerve, the plexus trunk. We will complete the dissection. We do a medial traction and the danger is to have an angulation of the nerves and injury of them. You see now we have a parietalization of the sacral branch.

8. Anterior dissection 11'10''

Let’s do the same on the other side. This is the anterior dissection. We will now use the retractor. I have to dissect the mesorectum because there are nodes. You see that I have to remove the mesorectum because there are 3 nodes in the meso. I have to divide the meso. These are the sacral branches running here, plexus trunk above. I use the Ligasure. These are the inferior rectal vessels. We have kept this vascularization and we will divide at this level.

9. Division of rectum 12'12''

Now we introduce the stapler to the right iliac fossa trocar. It seems good. We will check the distance. It seems that we have 5cm, 2 it’s enough. But we shall confirm this later. So now we don’t do more. We will choose where we will do the anastomosis. Probably on this part. Now I have to divide this part.

10. Division of sigmoid colon 13'29''

We are doing a nice mobilization of the splenic flexure medially. So we are dividing the mesocolon, and we have a landmark to do the division of the mesocolon. I want to divide inside this meso; it’s particularly important in obese patients but also because I will divide the segment of the colon inside to avoid the manipulation of the rectosigmoid. I do the division now and we will push that in the pelvis.

11. Medial approach 14'31''

We will do the division of the posterior attachments of the transverse mesocolon and splenic flexure using a medial approach. These are the left colic branches, there was the left colic artery running along. The objective is to open the lesser sac anteriorly to the pancreas, and it is open now. We see the pancreas, the kidney, the duodenojejunal junction is here. This is the lesser sac, and the root of the transverse mesocolon. The goal is to stay anterior to Toldt’s fascia. So if you are too posterior, you will go behind the pancreas. As you see, the lifting helps us to do the dissection. The pancreatic tail is here. The danger is to go too anterior towards the mesocolon and in the mesocolon and we will have a risk of vascular injury of the marginal vessels. We do as much as possible, but normally we can’t; we have to complete the dissection laterally. It’s time also to see the vascularization of the colon because sometimes we see the vessels beating here, the color is good. Medially the division of the posterior attachments is carried out. Finally we will reach the posterior dissection we did before after we have opened the lesser sac. In this case, we guess that we will rapidly have the same plane. At this moment, we have also some difficulty to understand where we will go. I prefer to go now between the omentum and we have to free this. We are doing the division of the colo-omental attachment. The omentum is fixed to the colon. It’s not always necessary to do a large mobilization of the splenic flexure, particularly if we do only a sigmoidectomy. And we have to free only laterally this way. Let’s move back. I complete the posterior freeing like this. What are those vessels? These are omental vessels. We have adhesions between the 2 legs of the splenic flexure but if I have enough length, I will do the anastomosis on the compliant part of the colon. At the beginning of my experience, I always began with the freeing of the splenic flexure because I thought if I have to convert, it’d be useful to have a part done by laparoscopy and a part done in open surgery. But our conversion rate is very low. We have less than 3%, all types of colorectal procedures. And when we convert, we do it rapidly because it’s a huge tumor, there’s carcinomatosis or a lot of adhesions. I have to free this. It’s not always necessary to largely free and mobilize the splenic flexure for doing rectal surgery and when I see that people are doing that for sigmoidectomies systematically - I mean large mobilizations, I don’t believe it’s a good and safe idea. We have to free these adhesions. We have enough length. And we have to respect the vascularization, and respect the marginal vessels. Even if I have to do the anastomosis on this part and that’s what I’ll do, it’ll be very good.

12. Suprapubic incision and specimen extraction 21'14''

Now we will remove the rectum through a suprapubic incision. We will protect the incision with a wound protector. I’m now introducing around the forceps, the ring of the plastic wound protector. We now introduce the forceps. We remove this.

13. Anastomosis 22'50''

We have to re-expose the small bowel. There is no tension. Pull now. No it’s not bleeding. The tumor was localized probably at 15cm; with endoscopy it seemed lower because there was a prolapse; radiologically it was higher and it was confirmed because we have the anastomosis around 7cm above the sphincter, and we are at least about 5cm under the tumor removing also the meso. We now have to close the gap. It’s necessary because as you see, the bowel is sliding behind. We’ve had several bowel obstructions due to the non-closure of this.

14. Closure of the gap 24'07''