Laparoscopic rectal resection for a large adenovillous tumor

The laparoscopic approach is currently accepted for the treatment of colorectal malignancy. This video demonstrates a laparoscopic rectal resection for a large adenovillous tumor using five trocars. The patient’s right arm is alongside the body. All the team stands to the right, one assistant between the patient’s legs.

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Laparoscopic rectal resection for a large adenovillous tumor

Authors

J Leroy, J Marescaux

Abstract

The laparoscopic approach is currently accepted for the treatment of colorectal malignancy. This video demonstrates a laparoscopic rectal resection for a large adenovillous tumor using five trocars. The patient’s right arm is alongside the body. All the team stands to the right, one assistant between the patient’s legs.

Mots-clés

Laparoscopic rectal resection, large adenovillous tumor

Type de vidéo

Vidéo chirurgicale

Durée

29'09''

Publication

2009-12

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Dec 2009;9(12).
URL: http://www.websurg.com/doi-vd01en2823.htm

Laparoscopic rectal resection for a large adenovillous tumor

1. Operative settings 00'19''

So we have done the laparoscopic exposure using 5 trocars as you can see. I stand on the patient’s right side. The patient’s right arm is alongside the body. All the team stands to the right, one assistant between the patient’s legs. The landmarks are as follows: the pubic symphysis, the xiphisternum, the midline, the anterior superior iliac spine on the left, on the right just behind, and the horizontal line at the level of the umbilicus. I have introduced a 12mm trocar just above the umbilicus, two 5mm trocars at the crossing with the mid-clavicular line and the horizontal line through the umbilicus; another 12mm trocar because I’ll use a stapler, 8 to 10cm lower than trocar number 2.

2. Peritoneal cavity exploration 02'12''

We did a panoramic exploration at the beginning and now we’re exploring if you see the inside view. You have the inside view of the pelvis: see the pelvis is free of adhesions. It’s a good compliant colon, and I think some diverticulum and descending colon that is not bad and easy. It’s not a difficult case. The patient’s BMI is around 24, which is unusual for our country. I’m grasping the mesosigmoid and retracting laterally, not freeing the colon laterally. I’m beginning with monopolar scissors. See my landmark is the promontory that is there. See the iliac vessels, the right ureter is there.

3. Start of dissection 03'17''

We began by a traction on the lateral meso and because I’m doing a counter-traction. See the 3-directional traction and the positive pressure of the pneumoperitoneum and the planes just open by magic. As an open surgeon predominantly I like this technique because it’s exactly the laparoscopic reproduction of what I would do for open; mostly diathermy dissection, monopolar and the traction and counter-traction are the key elements of the team work. We will grasp there to find the plane and then back to the rectal vessels. The best is to find this plane anterior to the promontory where we will find the fascia propria of the rectum, well the beginning of the fascia propria of the rectum. It is embryology, which created these planes because it is a midline structure, which came out in the first 3 months of intrauterine life and went back in again leaving around it planes, which the surgeon can now find to do the perfect oncological job. We can move back. Not too close from the aorta for 2 reasons. We are not sure that it is a cancer and it’s dangerous for the plexus to do a dissection close to the aorta. We see the artery coming. This of course is approaching the origin of the inferior mesenteric artery. That might be a nerve. We believe you are below the nerves. It could be a nerve, don’t you think? The branches of the nerves. But there will be some going into. That is definitely it. See the aorta is there. What we will do is seal using the Ligasure Advance® device. When you do that, you have to reduce the traction on the artery, and not too close from the aorta. It’s a big artery too and arteriosclerosis is sometimes a danger of using all kinds of sealing systems. Don’t tighten too much because you’ll cut the vessels too. Same with the clip. It’s only necessary to secure. I have not divided the branches of the nerves that are heading laterally left to the artery. It’s necessary to dissect very close to the artery to be sure that we are at a distance from the plexus trunk that is now falling. See the plexus trunk there. Now I’m going to the vein. And then the connection upwards is the vein and the ascending left colic artery. It depends how low your anastomosis is going to be and how much you want to descend of the left colon without doing a high ligation of the vein. Sometimes I don’t cut the vein immediately because I keep the descending mesocolon as a retractor, where we’ll have the small bowel retracted. See the right plane is this one, completely free of blood. This is the plane. As soon as it bleeds, you are in the wrong plane. If there’s a small oozing, it’s not the best plane. This is the good one. It’s more difficult in slim patients.

4. Lateral sigmoid dissection 08'39''

The next step is to free the sigmoid laterally once we are sure that we have freed enough medially and posteriorly. See we have to dissect close to the mesosigmoid. I will free now. I’m using the monopolar scissors always using traction and counter-traction anterior to the peritoneum to be sure that we will find the medial posterior plane we have dissected before. I use the monopolar there. I think it’s really important because there’s less lateral damage by using that. See there’s a small blade at the tip, monopolar Valleylab mode, it’s a mix of section and coagulation. It’s not necessary to use a lot of energy because it’s a very small blade so energy is concentrated at the tip and you can use 10 Watts, it’s enough. So very limited lateral thermal diffusion. If you activate the monopolar blade, you cannot use the Ligasure at the same time. This is a hand control for everything, also for power. I’m continuing using this. The danger at this moment is for the genital vessels in women, and the ureter if we are too posterior but as you can see we are not really posterior but not far of the vessels. So this is the first step of TME dissection, the mobilization of the sigmoid with a primary vascular approach. Why? Because if we consider Bill Heald’s technique, it is first division of the sigmoid with primary vascular approach in order to pull on the sigmoid and facilitate the dissection using 3-directional retraction.

5. Mesorectal dissection 11'34''

So the instrument I have introduced in the left trocar in the left hypochondrium is used to do a good traction on the rectum maintaining it vertically. You did not find the middle rectal artery in most people but it is necessary to stay in the right plane to achieve that. See plexus there. There is one on the left. The other if we do an atraumatic traction, it is probably there. So we have to be cautious and do the dissection close to the fascia propria of the rectum having a good atraumatic traction on the nerve as I’m doing the peanut. Notice how he stays rather close to the mesorectum and that it very sensible because if you stay on the mesorectal side of the plane, you are in no danger of opening one of the presacral veins, which can be a real nuisance. And I use the shape as a finger with the nail at the tip, that is doing the dissection. So the shape is used to complete the traction. Using always a good traction, counter-traction is the best technique for the dissection. So Joel, your strategy is first the posterior dissection? It’s the dissection of the posterior vertical part of the rectum. And you try to go as low as possible without modifying your exposure. So the recommendation is to try reproduce what you did during open surgery, and first you dissect the posterior part of the mesorectum. I will change perhaps the technique of retraction, giving this and we’ll use this to retract this way and I’ll do the counter-traction with the other. You notice that he is incising the peritoneum outside. When you are doing the incision, do not do it on the rectal side, but back to the prostate or the urogenital side, you will see why later. See the plexus there, branches of the plexus going to the rectum, we have to divide to continue the traction to stay close to the fascia propria of the rectum. There are several plexus branches. This is an erigent pillar, this is the superior hepatogastric plexus and the branches of nerves. You see the danger, and I suppose people said it was a lateral ligament in the past and you have a lot of branches that are coming from the sacral plexus branches, see the seminal vesicle is there and the posterior side of the Denonvilliers’ fascia. I want to find the posterior aspect of the Denonvilliers’ fascia, I am not far. To progress, it is necessary to divide the branches of nerves. I am dividing the branches of nerves close to the rectum. This is a branch, this is another one of the sacral nerves. I divide a small artery. For me, the mid-rectal artery is lower. When you perform this dissection down there, you are very narrow to the mesorectum. I will continue on the left because I have not freed on the left, I was waiting for you. See the plexus. It is good to begin anteriorly at this moment to have the right plane. Can you tell us your strategy, do you want to go in front of the Denonvilliers’ fascia? No posterior to it, it is a villous tumour, no positivity on the biopsy, this is the prostate I think or perhaps the seminal vesicles. We will change the traction. We have a better view now to continue the dissection. You use curved scissors too. This will improve the possibilities of working. See this yellow part, this is I believe the mesorectum. As you see, we have small veins, small vessels, I will divide them.

6. Inferior limit dissection 21'45''

I am now reaching the inferior limit of the rectum. This is where I have to do the division. I will free the posterior attachment. I will staple because we have enough distance normally. How are you sure? For several reasons, it is an elderly and very fragile patient, it is not good to do a colo-anal anastomosis as for the quality of life it would be riskier than a low colorectal anastomosis. I believe the risk of spillage is present during the procedure. You see when you ligate, you reduce or you maintain the size of the lower rectum. So we will do a colo-supra-anal-anastomosis. We are washing. We would have performed a rectoscopy before doing the ligation.

7. Stapling 24'00''

See we introduce the stapler. It is 30mm in diameter and I use a parnex technique with two cartridges. If you consider that a villous tumor is diffuse, we have to dissect very low and to remove all the rectum. I have removed the specimen in a plastic bag. I have divided the colosigmoid junction. I have freed the splenic flexure laterally and posteriorly, bilateral approach.

8. Specimen view 25'42''

We want to show you the specimen and show you the inferior limit, minimum 1cm, this is the stapling line, and the distal margin is 1cm. We have used a suprapubic incision with a plastic wound protector.

9. Anastomosis 26'07''

As you see, I have introduced the anvil distally, did a new resection and I will do a side-to-end anastomosis with, I hope, tension-free that we have tested before. You see that when we come back in the pelvis, we have the colon falling in the pelvis without too much tension, we can complete the freeing. We will try to do it like this to check it. Move to the left. I can free more there. It is normally better vascularized. Check that there are no twists there: there are none. This is the distal part with all the staples on the rectum, and good on the colon. We have finished doing that, we will close the mesenteric gap. There is a high risk of leak.