Laparoscopic partial TME for sessile polyp with intraoperative endoscopic control

Total mesorectal excision (TME) was described 20 years ago and is now recognized as the therapeutic gold standard for middle and lower third rectal cancers. This is the case of a 70-year-old man with a BMI of 24 presenting with multiple polyps of the sigmoid colon larger than 3cm at 10 to 30cm from the anal verge. He has no past surgical history and colonoscopy revealed 3 sessile polyps at 15, 20, and 30cm from the anal verge as well as a flat polyp at 10cm from the anal verge. The histological examination concluded in one adenomatous, one adenovillous with high-grade dysplasia and one hyperplastic lesion. A laparoscopic partial TME with intraoperative endoscopic control is performed.

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Laparoscopic partial TME for sessile polyp with intraoperative endoscopic control

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Abstract

Total mesorectal excision (TME) was described 20 years ago and is now recognized as the therapeutic gold standard for middle and lower third rectal cancers.
This is the case of a 70-year-old man with a BMI of 24 presenting with multiple polyps of the sigmoid colon larger than 3cm at 10 to 30cm from the anal verge. He has no past surgical history and colonoscopy revealed 3 sessile polyps at 15, 20, and 30cm from the anal verge as well as a flat polyp at 10cm from the anal verge. The histological examination concluded in one adenomatous, one adenovillous with high-grade dysplasia and one hyperplastic lesion. A laparoscopic partial TME with intraoperative endoscopic control is performed.

Classification

routine cases

Keywords

Laparoscopic partial TME, sessile polyp, intraoperative endoscopic control

Media type

Surgical video

Duration

25'16''

Publication

2009-07

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E-publication

WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2711.htm

Laparoscopic partial TME for sessile polyp with intraoperative endoscopic control

1. Clinical case presentation 00'17''

This is the case of a 70-year-old man with a BMI of 24 presenting with multiple polyps of the sigmoid colon larger than 3cm at 10 to 30cm from the anal verge. He has no past surgical history and colonoscopy revealed 3 sessile polyps at 15, 20, and 30cm from the anal verge as well as a flat polyp at 10cm from the anal verge. The histological examination concluded in one adenomatous, one adenovillous with high-grade dysplasia and one hyperplastic lesion. Here’s the preoperative barium enema for the cartography and here are the endoscopic views of the lesion.

2. Marking of lesions through intraoperative endoscopic assistance 01'03''

We have an intraoperative endoscopy performed by a gastroenterologist. They got a scope up to the proximal sigmoid colon with a clip to mark the highest polyp. Outside where I’m going to mark with a bipolar. The use of endoscopic clip intraluminally. So I don’t know where it is. So in this case, you have to use an intraoperative endoscopy to demonstrate the level with the laparoscope inside. You see the inside tip of the endoscope and I’m going to mark the outside with diathermy. This is the lesion high up in the proximal sigmoid colon. There’s diverticular disease of the colon. This is the diseased segment here. There’s the polyp in the upper rectum. But this patient’s got a lot of polyps. See one more polyp here. But more importantly, this is a sessile lesion. Can you see the flat lesion at 6 o’clock? That’s almost down to lower 5cm. So we’re not going to leave this lesion behind. You’ll need a TME to remove it. This is very important to have intraoperative endoscopy to assess what you’re dealing with.

3. Splenic flexure mobilization 02'22''

I think we’ll need to do the splenic flexure mobilization for this case because it’s very proximal. And at the moment, we’re looking at the bottom end. To do a splenic flexure mobilization, we all have to change our position because we are going to look up to the left upper quadrant. So now we’re going to get the table head down. For this operation, I am currently using 5 trocars, but I’ll need an extra trocar for splenic flexure mobilization. See my hand: this is where the 5th trocar goes in. Now we’re going to get our opposite surgeon to come between the legs. We’re all operating looking towards the head end. And now first of all, what we need to do is to find the DJ flexure. And we have the patient’s head down rotated to right. You take all the small bowel over. This is DJ flexure. That’s the IMV here and I just coagulate, use the Ligasure. This is the plane between the Gerota’s fascia and the mesocolon. And you got to get into the right plane to not get bleeding. Well, you should aim to be at this plane because the help here is going to be at your lower border of your pancreas and here’s the Gerota’s fascia. And of course, you can see this DeBakey’s forceps is very gentle with the vascular tissue or bowel tissue. What we’re going to do now is find the top end. I’m using the right iliac fossa 10mm port and the left upper quadrant 5mm port. And don’t forget because we did intraoperative colonoscopy, the bowel is a bit distended because we’re using air just now. Nowadays, we ought to have CO2 insufflation for endoscopy. Currently, only Olympus does CO2 insufflator, which is adequate for endoscopy. Because really the original design, which they also produced was too slow to insufflate. The highest flow was insufficient for adequate endoscopy. But now the new machine, which is on the market, is good. You can see the stomach on the left. So you see how distended the bowel still is after the endoscopy. This is the Harmonic. I like the Harmonic. It does a lot more mist but it’s also very effective. That’s the Ultrasonic by Covidien. But we have to be very careful about this part of the colon, because this very close to the splenic flexure and this can be very vascular. So I’m going to go through this very slowly. I’m going to use a 5 to 12mm trocar to replace one of my 5mm ports because I cannot get my 10mm Ligasure to get up this area. So I’m going to convert the port to a larger one, just to make life easier because I think we have to use a 10mm Ligasure to do this work. See under the trocar coming in, we approach the splenic flexure with the 10mm Ligasure. Vision is very important because if you don’t see, you cannot operate. So I don’t like the operator’s field to be bloody so I take my time for hemostasis. So you can see this is actually very close to the spleen. The robot is not very good operating around the abdomen. You have to be stationed in one position. So for this part of the operation, the robot does not really come in. I think that the splenic flexure has come down but maybe we need to do a bit more on the lateral. I think now we can start from the reverse position again. We have the table head down.

4. Colorectal dissection 10'13''

I do the lateral approach. That’s the standard that we do. I don’t think that better you do lateral medial really, do what you’re comfortable in your hand, that’s important. It’s also absolutely important that you have an OP table that really does good enough tilting for colorectal work, particularly when you’re going down the pelvis. We’re going to show a little trick: how we’re going to deal with the retraction in the rectum. Now important point, the Harmonic or ultrasonic device does not work well when there’s solution. We’ve got to wipe the area that you’re going to dissect till its dry. If you soak it in water, the ultrasound does not work well. Convenient place rectosigmoid area. Now if we have the retraction, we can see when we come. Left hand.

5. Identification of left ureter 12'16''

Always identify the left ureter. What’s the PP at the moment please? Yes, lateral dissection, see the ureter, once you have identified the ureter, you have done enough. I am going to show you the anatomy in a minute, after I free up this. Ureter laterally, we are trying to find the apex of the sacrum. This is what Bill Heald called the medial package. So you can see, I’ve got the whole pedicle lifted up. That’s the iliac vessels, bifurcation of the aorta and this is the nerve here. We are going to go open this plane up to see a little better. You can see my assistant is really holding up the pedicle for me. In a minute we are going to show you the pre-sacral fascia. When you are down to the perirectum you have done your TME, can you see the perirectum down here? This is the perirectum, there is no fat. So the right side, nerve erigentes. We are going to put a scope up, and then decide where to transect. We are trying to tie it down a little lower for the retraction, but we have just lost the original position so we have to find a way to put it back in again. But you see how useful this tape has been for the whole pelvic dissection. Really, the retraction cephalic has enabled you to do the right side, do the left side, and if you used a grasper, you wouldn’t have this ability without damaging the tissue. So you can go completely through the rectum with the grasper. We are now going to use a scope to look at where the lesion is, see whether it is beyond or not. We are going to go down and put the scope up to have a look. The clip is the lower limit marking the flat polyp. I think we can go further but it’s not going to benefit him if they are going to deal with these very low ones by endoscopic removal. As you can see it’s almost going to the anal verge.

6. Colorectal resection and anastomosis 21'15''

What we are interested in is removing the segment of bowel where the low flat polyp is, so when we are beyond the clips, we are beyond that. But you see there is sphincter here feeling the pelvis.