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Laparoscopic total mesorectal excision (TME) for cancer

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Abstract

The description of the laparoscopic total mesorectal excision (TME) for cancer covers all aspects of the surgical procedure used for the management of rectal cancer.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, vascular approach, risk of nerve damage, mobilization of sigmoid colon, mobilization of upper rectum, dissection of lower rectum, splenic flexure, division of rectosigmoid, extraction, direct anastomosis, J-shaped anastomosis.
Consequently, this operating technique is well standardized for the management of this condition.

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Publication

2002-12

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E-publication

WeBSurg.com, Dec 2002;2(12).
URL: http://www.websurg.com/doi-ot02en202.htm

Laparoscopic total mesorectal excision (TME) for cancer

1. Introduction

Total mesorectal excision (TME) was thoroughly codified by Heald in 1988.
The procedure helps reduce the risk of local recurrence and the number of permanent colostomies while preserving adjacent anatomical structures (nerve plexuses), as shown by the results published by Heald et al. in 1998.
The authors performed this procedure laparoscopically for the first time in November 1991. The laparoscopic procedure has the major advantage of magnifying anatomical structures (Okuda et al., 1998). The laparoscopic approach does not alter the technical principles described by Heald.
Once the rectum has been excised, continuity of the digestive tract is re-established via low colorectal anastomosis or colo-anal anastomosis. We shall focus on low colorectal anastomosis.

2. Indications

Rationale
Total “en bloc” resection of the rectum and its mesentery for the treatment of rectal cancer has an anatomical rationale (Hida et al., 1997; Quirke et al., 1986). It should be performed “en bloc” without infraction of the surrounding fascia to avoid local tumor seeding (Enker et al., 1995; Hida et al., 1997). An oncologic resection is done as the local lymph node relays are resected.
The risk of local recurrence correlates with the quality of the excision. This is dependent on the surgeon’s experience (Kockerling et al., 1998).
Lymph node metastases occur in the distal mesorectum in 20% of cases, and depend on the localization and depth of invasion of the tumor. The rate of lymph node metastasis is 10% for the rectosigmoid, 26.3% for the upper rectum, and 19.2% for the lower rectum. The rate is 0% for pT1 and pT2 tumors, 21.9% for pT3 tumors, and 50% for pT4 tumors (Hida et al., 1997).

Indications
Total mesorectal excision is indicated in rectal cancers located 2 to 10 cm above the anal canal. It is recommended in T3 and T4 tumors of the lower rectum. The mesorectum should be excised at least 5 cm below the tumor for T3 and T4 tumors of the upper rectum (Hida et al., 1997).
Preoperative radiation therapy is recommended in T3 and T4 lesions. It does not impair the surgical approach, laparoscopic approach included, provided surgery is done 6 weeks after the end of radiation therapy. Prior to this, massive pelvic edema may complicate dissection.

Contraindications
- contraindications to laparoscopic surgery;
- tumor with invasion of neighboring organs (T4 tumor);
- voluminous tumor;
- multiple abdominal scars.

3. Operating room set-up

• Patient

The patient must be positioned carefully, to avoid complications (nerve and vein compression, injuries of the brachial plexus) and facilitate the procedure and anesthetic monitoring.
The patient can be either secured by supports fixed above the shoulders, or strapped at chest level to prevent slippage.
- Trendelenburg position with a 15° to 25° tilt and a 5° to 10° right tilt;
- moderate lateral decubitus via a sandbag tucked below the left half of the body: this helps lower the organs to the right of the abdominal cavity;
- Lloyd-Davis position, allowing for both abdominal and perineal access: it is essential that the perineum be positioned at the distal edge of the table to facilitate the introduction of a circular stapler during colorectal anastomosis or to perform a colo-anal anastomosis;
- thighs and legs stretched apart with a slight flexure of hips and knees so that positioning of an assistant is easier and instruments can be better handled;
- right arm alongside the body so that an assistant can stand lateral to the right shoulder of the patient;
- left arm at a right angle or preferably alongside the body;
- gastric tube and urinary catheter to drain the bladder and stomach and control diuresis intraoperatively;
- heating device to limit the dissipation of heat.

• Team

Although the procedure can be completed with 1 assistant, it is preferable to have 2 assistants and a scrub nurse, especially at the start of the surgeon’s experience with the technique.
The surgical team remains in the same position throughout the entire procedure.
1. Surgeon
2. First assistant
3. Second assistant
4. Scrub nurse
5. Anesthesiologist

• Equipment

The operating table must allow for both abdominal and perineal access. A table that can be easily tilted by remote control, thereby facilitating perineal exposure, is recommended. The laparoscopic unit is located to the left of the patient. It includes a main monitor, a 3CCD camera (indispensable to perform the procedure in excellent conditions) and a high output (>= 9L/min) insufflator used to monitor pressures electronically. Its inertia should be low to make up for losses in carbon dioxide (induced or not).
The voice-controlled robotic arm or camera-holder is increasingly used to replace the assistant who holds the camera. It offers greater image stability during dissection.
1. Laparoscopic unit
2. Electrosurgical generator
3. Operating table
4. Monitors
5. Ultrasonic generator
6. Instrument table

4. Trocar placement

• Principles

Although a sigmoidectomy is possible with only 3 trocars, in complicated cases and especially when the surgeon’s experience is limited, more trocars are recommended. This improves safety, exposure of the operative field, and mobilization of the splenic flexure.
We prefer to use 6 trocars, with a trend toward reducing the size of trocars. The patient’s body habitus, previous surgical history, and the initial laparoscopic exploration via the supraumbilical trocar help in guiding the introduction of the various operating trocars.
Firm fixation of trocars to the abdominal wall can limit the risk of tumor seeding (Balli et al., 2000). Increased trocar stability also facilitates the procedure, and is achieved by adapting the size of the incision to the trocar, either by fixing the trocar to the skin with a suture or by using orthostatic trocars.

• Optical

Trocar A: 12 mm optical trocar
This first trocar is positioned on the median line above the umbilicus or 20 cm above the pubis in short patients.
This trocar accommodates a 0° optical.

• Operating

• Trocar B

Trocar B is a 5 mm trocar situated on the right midclavicular line, at the level of the umbilicus. It is used as an operating trocar during the dissection of the rectum and sigmoid colon and during the mobilization of the splenic flexure (caudal retraction of the left colon).
This trocar accommodates an atraumatic grasper.

• Trocar C

Trocar C is a 5 mm trocar situated on the right midclavicular line, 8 to 10 cm inferior to trocar B. It is used as an operating trocar during the dissection of the rectosigmoid. It is used as a retracting trocar during the mobilization of the splenic flexure (caudal retraction of the left colon).
At the end of the procedure, it can be replaced by a 12 mm or 15 mm trocar for the introduction of a linear stapler.
This trocar accommodates:
- scissors (monopolar, ultrasonic dissector, clip, staplers), bipolar hook, surgical loop, suction-irrigation device;
- an atraumatic grasper.

• Retractors

• Trocar D

Trocar D is a 5 mm trocar situated on the left midclavicular line, at the level of the umbilicus. It is used as a retracting trocar except during the mobilization of the splenic flexure, when it becomes an operating trocar.
This trocar accommodates:
- an atraumatic grasper;
- scissors (monopolar, ultrasonic dissector, vessel sealing device, clip, staplers), bipolar hook, surgical loop, suction-irrigation device.

• Trocar E

Trocar E is a 5 mm trocar situated 8 to 10 cm above the pubic bone on the median line. It is used as a retractor except during the division of the lower rectum when it can be replaced by a 12 mm or 15 mm trocar to introduce a linear stapler. A grasper is passed through it. It is used to expose the sigmoid mesocolon and the left mesocolon. A flexible retractor is passed through trocar E during the anterior dissection of the rectum.
This trocar accommodates a grasper, a suction-irrigation device, a stapler, and a flexible retractor.

• Trocar F

Trocar F is a 5 mm retracting trocar situated on the right midclavicular line below the costal margin. An atraumatic grasper is passed through it. It is used to retract the terminal portion of the small intestine laterally and to better expose the attachments of the omentum to the transverse colon during mobilization of the splenic flexure.
This trocar accommodates an atraumatic grasper.

5. Instruments

• Optical devices

We prefer to use 0° or 30° angle scopes with a 70° visual field.
Some surgeons use a 45° angle scope; others, like Milsom and Okuda, use a flexible fiberoptic laparoscope that offers multiple scope angulation during dissection.
1. 0° laparoscope
2. 30° laparoscope
3. Flexible laparoscope

• Operating devices

1. Grasper
2. Bipolar forceps
3. Ultrasonic scissors
4. Articulated linear stapler
5. Scissors
6. Circular stapler
7. Vessel sealing device

• Others

1. Suction-irrigation device for lavage and dissection (lysis of adhesions)
2. Traumatic French needle to close trocar openings in obese patients
3. Purse-string applier
4. Clip applier
5. Wound protector
6. Extraction bag
7. Pelvic flexible retractor

6. Exploration

• Generalities

The first step is the exploration of the abdominal cavity, starting with a panoramic exploration to assess the tumoral extension. Visceral organs can be manipulated with atraumatic instruments to complete the exploration.
The length of the sigmoid loop, the quality of the wall of the sigmoid colon and its fixation in the pelvis, and the motility of the descending colon should be assessed.

• Ultrasonography

Recommended by some authors (Milsom et al., 2000), ultrasonography is carried out with a flexible, sterile, and reusable 10 mm probe.

• Tumor marking

Localization of the tumor is indispensable for upper rectal tumors to avoid too large a resection of the middle and lower rectum. If the tumor cannot be visualized, localization is performed via endoscopy by dye-marking (india ink) at the beginning of the procedure or the evening before the procedure (Kim et al., 1997; Okuda et al., 1998).

7. Exposure

• Patient preparation

• Bowel preparation

Exposure depends largely on the space available for retraction of the small bowel loops in the abdominal cavity, and on the positioning of the patient. Complete emptiness of the digestive tract greatly facilitates the layering of bowel loops. Emptying is achieved by a strict, low-residue diet commenced 3 to 8 days prior to surgery. We no longer use polyethylene glycol that was administered 2 days before surgery to complete bowel preparation. The day before, or even on the day of the operation, the patient is placed on a fibre-free diet and undergoes enemas.
Gastric emptying is done by means of a gastric tube.

• Pneumoperitoneum

In addition to the pneumoperitoneal pressure (12 mm Hg), complete relaxation of the muscular wall is essential to create the working space.
1. Muscle relaxation
2. Distension of muscular wall
3. CO2 <= 12 mm Hg

• Arranging intestine loops

The greater omentum and the distal transverse colon are placed in the left subphrenic region and maintained in this position by the Trendelenburg position. An atraumatic retractor, introduced through trocar D, can also be used.

The jejunum is retracted toward the right upper quadrant, below the right transverse mesocolon. The right tilt and Trendelenburg position, along with an atraumatic retractor if needed, maintain the small intestine in this position.

The distal ileum is placed in the right lower quadrant along with the cecum. If the small intestine is too dilated, this operative maneuver may be difficult, notably in obese patients.

1. Retraction of the greater omentum
2. Trendelenburg position
3. Right tilt
4. Retraction of the intestinal loops to the right

• Specific cases

• In the pelvis

The use of specific retractors, eg flexible retractors, is very useful during anterior dissection of the lower rectum. They are introduced in the suprapubic trocar E.
1. Retractor

• Obese patient

Obesity reduces the operating space. Obesity characterized by a flaccid muscular wall (female patients) is not a major handicap as ample working space remains and the mesocolon is longer. When obesity is characterized by a tonic muscular wall (male patients) and short, fatty mesenteries, the surgeon has to progressively layer the intestinal loops to expose the operative field.

• Adhesions

Adhesions, when present, are divided to free the bowel and achieve a better exposure. However, it is sometimes useful to preserve adhesions, notably at the level of the cecum, the sigmoid colon or the splenic flexure.

• Uterus

The uterus can be an obstacle to good exposure of the pelvis. In post-menopausal patients, the uterus can be attached to the anterior abdominal wall by a transparietal suture. This suture is introduced halfway between the umbilicus and the pubis to make the axis of the vagina horizontal, thereby opening the rectovaginal space.

8. Vascular approach

• Generalities

In rectal cancer, the vascular approach is combined with a lymphadenectomy. Perirectal lymph nodes and lymph nodes of the inferior mesenteric chain are removed. However, division of the inferior mesenteric artery (IMA) at its origin and of the inferior mesenteric vein (IMV) at the inferior border of the pancreas is not mandatory to achieve an oncological resection.
The primary vascular approach allows for a medial and posterior dissection of the sigmoid mesocolon, while avoiding manipulation of the colon, rectum, and tumor (Okuda et al., 1998). This helps preserve the working space during the mobilization of the sigmoid colon and rectosigmoid junction.
The IMA should be clipped and divided before the IMV to avoid venous congestion in the mesocolon, which can result in oozing during dissection.
Before these vessels are divided, the sympathetic nerve trunks and the left ureter should be identified and preserved.
1. Sigmoid trunk
2. Superior rectal artery (SRA)
3. Aorta
4. Left colic artery (LCA)
5. Inferior mesenteric artery (IMA)

• Peritoneal incision

The sigmoid mesocolon is retracted anteriorly using a grasper introduced in trocar E. The peritoneum is then opened cephalad, proceeding along the right anterior border of the aorta from the promontory up to the duodenojejunal junction. The incision then crosses to the left toward the splenic flexure to expose the anterior surface of the IMV.
CO2-induced dissection secondary to pneumoperitoneal pressure opens an areolar plane, which makes this step easier.
1. Promontory
2. Right border of the aorta
3. Third portion of duodenum

• Division of the IMA

• Identification of the IMA

Once the peritoneum is opened, the dissection proceeds caudad to cephalad over the whole length of the incision, dividing the fatty and fibrotic tissues.
The aorta and the IMA are progressively identified. Once the right wall of the IMA has been identified, the artery is isolated near its origin below the duodenojejunal junction. The nerve branches that originate from the right para-aortic sympathetic trunk and the intermesenteric plexus and cover the IMA are divided one after the other. During dissection, the IMA is skeletonized while the branches of the periaortic sympathetic plexus are preserved.
The right branches of the superior hypogastric nerve that obliquely cross the aorta anteriorly and inferiorly to the IMA are preserved to avoid functional genitourinary sequelae. This step is crucial as it helps safe dissection of the IMA at its origin.

• Division of the IMA

Division of the IMA near its origin, 1 cm from the aorta, and including the division of the LCA, aims at removing the surrounding lymph node tissue, to achieve an oncological resection. Dividing the IMA at its origin is associated with a risk of injury to the left sympathetic trunk situated on the left border of the IMA. This injury can be avoided if the dissection is carried out close to the IMA. Clips or the use of a vessel-sealing device are more precise and should be preferred to the use of linear staplers to avoid the division of the left sympathetic trunk and ureter.

• Division below the LCA

Division of the IMA after the origin of the LCA combined with a large perivascular dissection also allows an oncological lymphadenectomy.
This technique helps to preserve the vascular supply of the left colon, but it can be an obstacle to splenic flexure mobilization. The sympathetic nerve trunks situated to the left of the IMA should be preserved. Their division can result in urinary dysfunction and ejaculation disorders in men.
1. Left colic artery (LCA)

• Dividing the IMV

The IMV is identified to the left of the IMA, or in case of difficulty, to the left of the duodenojejunal flexure. It is then crossed anteriorly by the LCA, which then runs along its left border.
The IMV is retracted anteriorly with a grasper introduced in trocar E. Before division it is freed from the left sympathetic nerve trunk on its posterior surface. On its left border, it is freed from the LCA.
The IMV is divided between 2 clips below the inferior border of the pancreas, with care taken not to confuse it with the splenomesenteric trunk. The IMV can be divided later to preserve the ''tenting'' effect, which retracts the small bowel during the dissection of the sigmoid mesocolon.
1. Left colic artery
2. Inferior mesenteric vein

9. Risk/nerve damage

• Origin of the IMA

There is a risk of injury to the hypogastric nerves (purely sympathetic) during ligation of the inferior mesenteric artery (IMA) at its origin and during dissection along the left border of the IMA.

• Sacral promontory

There is a risk of injury to the hypogastric nerves (purely sympathetic) during posterior dissection of the rectum in the presacral space.

• Lateral dissection

The inferior hypogastric nerves (mixed sympathetic and parasympathetic) may be exposed to injury if there is excessive lateral traction on the rectum during its lateral dissection.

• Anterior dissection

The cavernous nerves (parasympathetic), located at the postero-lateral border of the apex and base of the prostate, may be injured during the anterior dissection, particularly when it is performed anterior to Denonvilliers’ fascia.

10. Mobilization/sigmoid

• Principles

Mobilization using the medial approach is well adapted for laparoscopy as it preserves the working space and requires minimal handling of the sigmoid colon and rectum.
Mobilization of the sigmoid colon follows the division of vessels. The approach is either medial to free the posterior attachments of the colon or lateral to free the lateral, then posterior attachments. We prefer using the medial approach, except in thin patients, whose sigmoid colon is very mobile, and in whom the lateral approach is more adapted. Using the medial approach, the lateral dissection of the sigmoid colon is done later, when the posterior and right lateral mobilization of the rectum is well advanced. It facilitates the left lateral dissection of the rectum.

• Posterior dissection

A medial approach is used. The posterior freeing of the sigmoid mesocolon is pursued laterally up to Toldt's line. In a medial to lateral order, the left sympathetic nerve trunk, the ureter, and genital vessels, covered with Toldt's fascia, are visualized during the dissection.
Once the inferior mesenteric vessels have been divided, the sigmoid mesocolon is retracted anteriorly (trocar E) to open the posterior space. The plane between Toldt’s fascia and the sigmoid mesocolon can then be identified. This plane is avascular and easily detached. It is exposed when dissection is continued posterior to the sigmoid mesocolon (not on the left lateral border of the aorta).

Laterally
Once the IMA has been divided, its distal portion is retracted anteriorly and to the left to better expose its left surface where the left sympathetic trunk runs, pulled by the traction. The sigmoid nervous rami heading to the left border of the artery are divided. The sympathetic trunk is left behind. Division of the sympathetic trunk at this level can cause retrograde ejaculation in men.
The dissection is continued to the left and anteriorly toward the posterior surface of the sigmoid mesocolon and descending mesocolon, to identify the IMV, which is then divided at the same level as the IMA or more cephalad, below the inferior border of the pancreas.

Caudally
Caudally, dissection is continued medially on the posterior surface of the IMA, then of the SRA posteriorly to its sheath. Nerve branches originating from the hypogastric plexus and running to the sigmoid mesocolon are then divided. The dissection is done anterior to Toldt's fascia and posterior to the sigmoid mesocolon and is followed laterally up to Toldt’s line. The lateral attachments are left undivided at this point to keep the sigmoid colon out of the operative field.
The lateral attachments are usually preserved but they can be divided using a lateral approach if a sigmoid loop impedes access to the pelvis.

1. Toldt's fascia
2. Ureter
3. Left plexic sympathetic trunk

• Lateral freeing

The sigmoid colon is freed laterally after the posterior dissection of the upper rectum.
The sigmoid loop is pulled toward the right upper quadrant (grasper in trocar F) to exert traction on the line of Toldt.
Once the line of Toldt has been opened, the posterior side of the left and sigmoid colon, which have been previously dissected by a medial approach, is accessed. Care must be taken to avoid gonadal vessels and the left ureter as they may be tethered by the medial traction exerted on the mesentery. In case of difficulty, a medial posterior approach should be associated with the lateral dissection. Identification of the ureter with a ureteral catheter (luminous stent or not) can be useful.
1. Ureter
2. Gonadal vessels
3. Base of sigmoid mesocolon

11. Mobilization/upper rectum

• Principles

The rectum and its mesentery should be resected ''en bloc'' without infraction of the surrounding fascia to avoid any risk of local dissemination (Hida et al., 1997). The quality of the resection helps reduce the risk of recurrence (Kockerling et al., 1998).
1. Prostate
2. Seminal vesicles
3. Denonvilliers' fascia
4. Parietal fascia
5. Mesorectum
6. Fascia propria
7. Inferior hypogastric plexus

• Key points

Dissection of the rectum begins on its posterior surface anterior to the presacral fascia. The key to success is the opening of the presacral space between the fascia propria of the rectum and the presacral fascia (Enker et al., 2000). Anterior and lateral dissection follows. There is a major risk of injuries to nerve plexuses at the level of the upper inlet and laterally. These plexuses are medially protected by pelvic fascias. They can be very mobile and drawn medially during traction (especially on the right side), which accounts for the risk of injuries.
1. Presacral fascia
2. Parietal fascia
3. Hypogastric nerve

• Presacral space

The dissection of the presacral space begins anterior to the sacral promontory. Then it is followed caudally anterior to the presacral fascia. To achieve exposure, the rectum is retracted anteriorly and to the left, while maintaining the sigmoid colon in an upward position toward the left lower quadrant. Carbon dioxide helps open the space between the presacral fascia and the fascia propria of the rectum. Mobilization is completed laterally, just medial to the pelvic fascias that cover the right and left branches of pelvic splanchnic nerves.
The dissection is then fairly easily continued caudally down to the level of the fourth sacral vertebra. At this site, the 2 fascias almost fuse. The sacrorectal ligament (Waldeyer’s fascia) originates from here.
1. Presacral fascia

• Lateral rectal dissection

The lateral rectal dissection should be done between the visceral perirectal fascia and the parietal lateral fascia of the pelvis (Enker et al., 2000; Heald et al., 1998). On the right side, the peritoneal incision at the base of the sigmoid mesocolon is lengthened caudally to begin the dissection on the right side of the rectum. The peritoneal incision is extended anteriorly to the rectovesical pouch while a grasper introduced in trocar D holds the rectum and retracts it to the left and anteriorly. This exposes the interfascial space. More caudally, the dissection approaches the superior margin of the lateral ligament, whose existence is subject to debate. The lateral side of the rectum is in closer contact with the lateral fascia at this point. The rectal branches of the pelvic splanchnic plexus that cross this space are divided.
1. Denonvilliers’ fascia

• Anterior rectal space

• Anterior to the fascia

Dissection of the prerectal space can be performed anterior to Denonvilliers' fascia (as described by Heald) or posterior to Denonvilliers' fascia.
In the classical technique described by Heald, Denonvilliers' fascia is transversely opened after the incision of the rectovesical pouch (Heald et al., 1998). Dissection is continued anterior to the fascia. In men, the seminal vesicles and the prostate are exposed. In women, the posterior surface of the vagina is exposed. In male patients, the prostatic and erectile nerves are found in this plane. Dissection is cautiously carried out anterior to Denonvilliers' fascia down to the inferior border of the prostate where dissection is continued posterior to the fascia.
1. Denonvilliers' fascia

• Posterior to the fascia

Dissection posterior to Denonvilliers' fascia is performed between the fascia propria of the rectum and Denonvilliers' fascia in contact with the posterior surface of the fascia. This technique of dissection is not recommended in tumors of the anterior rectal wall. The fascia propria of the rectum directly covers the seromuscular plane, and is not covered by fat, unlike the posterior and lateral surfaces of the rectum.
To find a suitable dissection plane, the rectum is gently retracted anteriorly with a grasper placed on the lower sigmoid colon and introduced through trocar D. Meanwhile the seminal vesicles of the prostate are retracted anteriorly with an instrument introduced through the suprapubic trocar E.
The plane between the fascias is identified once the rectovesical pouch has been opened. The posterior surface of the seminal vesicles is identified laterally, then dissected posterior to the parietal fascia. Dissection is then followed centrally toward the posterior surface of the prostate.
1. Denonvilliers' fascia

12. Dissection/lower rectum

• Introduction

Dissection of the lower rectum is difficult in obese patients or in patients with a narrow and deep pelvis. It is in contact with vascular and nerve structures that must be preserved (Enker et al., 2000; Heald et al., 1998). To preserve genitourinary functions, care must be taken to avoid the middle hemorrhoidal vessels (which are occasionally large) and the parasympathetic nerve branches originating from posterior sacral foramina.
Dissection is performed posteriorly, laterally, then anteriorly to the rectum, alternating the right and left side as the rectum is progressively freed.
Laparoscopic freeing of the lower rectum is facilitated by the use of ultrasonic scissors or a vessel-sealing device.

• Posterior dissection

The posterior dissection is continued caudally on the posterior side of the rectum, anterior to the sacrum, once the sacrorectal ligament (Waldeyer’s fascia) has been opened. Care must be taken to avoid the anterior sacral venous plexus running on the anterior surface of the periosteum of the sacrum. This plexus is formed from posterior branches that lead to large 2-5 mm foramina from the third to the fifth sacral vertebrae before draining into the venous plexus of the intrasacral canal.
Further down the rectum is supported by the rectococcygeal ligament. Sharp division of this structure, using ultrasonic scissors or after coagulation, helps gain 1 to 2 cm over the posterior surface of the rectum, and also assists identification of the anal sphincter.

• Anterior dissection

Dissection is facilitated by the posterior retraction of the rectum, and anterior retraction of the vagina or prostate with the use of an instrument introduced in the suprapubic trocar (trocar E), which grasps Denonvilliers’ fascia.
At this level, dissection of the anterior surface of the lower rectum can only be achieved after lateral rectal dissection (especially in men).
1. Prostate
2. Rectum

• Low lateral dissection

Low division of lateral ligaments exposes the lower pelvic space. This is done on the right side of the rectum, then on the left side. On the left side, the peritoneal reflection of the paracolic gutter should be incised down to the left lateral side of the rectum. One or more branches of the middle hemorrhoidal vessels joining the rectum on its anterior lateral surfaces are usually found on the lower part of lateral ligaments. These branches are infrequent, not always bilateral, and occasionally multiple. They should be controlled by clips or coagulation (bipolar forceps, vessel sealing device or ultrasonic scissors). At this level, the terminal branches of the pelvic nerve plexi run to the bladder, prostate, and genital organs (Enker et al., 1995; Enker et al., 2000).

13. Splenic flexure

• Generalities

Mobilization of the splenic flexure is necessary to allow for a tension-free anastomosis in case of low colorectal or colo-anal anastomosis. The mobilization can take place at the beginning of the surgical procedure, before or after extraction of the rectum. The use of ultrasonic scissors is helpful, but not compulsory.
Except in a few patients with long and compliant sigmoid loops, mobilization of the left colon almost always mandates a large dissection, which combines division of lateral and posterior attachments with vascular divisions while preserving the vascular supply of the mobilized left colon. This vascular supply is sometimes difficult to assess laparoscopically.
1. Lateral approach
2. Medial approach

• Medial mobilization

The medial mobilization of the splenic flexure is perfectly suited to the laparoscopic approach as the surgeon, situated to the patient’s right, has an excellent view of the anterior surface of the pancreas, the base of the left transverse mesocolon, and the posterior surface of the splenic flexure.
Mobilization is performed after the medial posterior freeing of the sigmoid mesocolon, which is then continued cephalad, anterior to Toldt’s fascia, then anterior to the pancreas.
1. IMV
2. Splenic vein
3. Base of the transverse mesocolon
4. Stomach

• Lateral mobilization

The lateral approach is conventional in open surgery. It is used in simple cases when the splenic flexure is mobile. It is completed with the freeing of the lateral and posterior attachments.
1. Attachments of omentum to the transverse colon
2. Phrenicocolic ligament
3. Toldt’s line
4. Toldt’s fascia

14. Division/rectosigmoid

• Strategy

The division of the distal and proximal margins of resection is done prior to extraction. The extraction should be non-traumatic to avoid any risk of tumor cell dissemination (Okuda et al., 1998).
The specimen is isolated before extraction and placed in a plastic, watertight, tightly closed bag. The distal resection is usually performed first but if exposure is difficult, the proximal resection line may well be performed first (Okuda et al., 1998). The division should be done at least 2 cm below the inferior margin of the tumor and 10 cm above it, while removing the whole of the mesorectum.

• Rectal division

Exclusion of lower rectum
The distal part of the dissected rectum is excluded either by ligature or by a clamp, or by a row of staples. The rectum distal to this exclusion is then washed with or without povidone iodine via the introduction of a cannula by the anal canal. This can help avoid the risk of tumor seeding on the division line. Lavage with an antiseptic and tumoricidal solution such as povidone iodine was proposed by Balli et al. (2000).

Rectal division
The lower rectum is exposed by gentle posterior traction. This traction can be performed with the thread used to ligate the rectum below the tumor to exclude the rectal stump. The division is performed with an articulated cutting linear stapler (45 mm, blue or green cartridges).

• Colonic division

In rectal cancer, most surgeons perform the proximal division at the level of the sigmoid colon. The colon is divided on a portion that is healthy, supple, and well vascularized.
The division takes place on the descending colon if the sigmoid colon is affected by a concomitant pathology such as diverticulosis.
The division of the sigmoid mesocolon can be done either with a vessel sealing device, ultrasonic scissors or linear staplers. The complete sigmoid mesocolon is removed.
The division of the colon is done with a cutting linear stapler, which allows for clean division and stapling without opening the digestive tract.
The stapler (blue cartridges) is introduced in trocar C in the right iliac fossa.
1. Marginal arteries
2. Inferior mesenteric vessels

• Rectosigmoid isolation

Once divided, the rectosigmoid is placed in a large, tightly closed plastic retrieval bag. The procedure can thus be continued without manipulation of the tumor in the abdominal cavity. The bag is introduced in trocar E or C. If the specimen is too bulky, it is extracted before completing mobilization of the left colon.

15. Extraction

• Principles

The extraction of the rectum is done through a mini-incision while protecting the abdominal wall with a wound protector. The specimen is isolated and placed into a tightly closed plastic bag before extraction. Certain authors recommend a thorough abdominal lavage after specimen extraction.

• Incision

The incision is generally made in the suprapubic region. Other authors recommend the left lower quadrant. The ability to easily bring the proximal colonic resection line down to the left lower quadrant or to the right lower quadrant helps in the assessment of the mobilization of the colon into the pelvis and thus in the construction of a tension-free anastomosis.
The incision should be adapted to the size of the specimen to be extracted. Care must be taken not to crush the specimen at the time of the extraction.

• Extraction

The specimen is extracted in a tightly closed plastic bag. The abdominal incision is also protected with a wound protector (7 or 11 cm in diameter). This is also used to ensure that the abdominal cavity is airtight during the intracorporeal colorectal anastomosis that follows the extraction.

Wound protector
Once the wound protector is introduced into the abdominal opening, the plastic bag containing the resected sigmoid colon and rectum is brought up to the skin. The bag is then opened to extract the colon, while avoiding abdominal contamination.
1. Plastic bag
2. Plastic drape

16. Direct anastomosis

• Principles

The colorectal anastomosis is a delicate operative step. The rate of fistula, which can be higher in laparoscopic surgery, accounts for the difficulty of this step (Hartley et al., 2001). In our opinion, a diverting stoma to protect the low colorectal or colo-anal anastomosis is necessary, especially after radiation therapy.
A straight anastomosis can be performed, or after a colonic J-pouch has been fashioned.
The anastomosis includes both an extra-abdominal and an intra-abdominal step. The extra-abdominal step takes place after exteriorization of the left colon through the opening covered by the wound protector.

• Preparation

First, the colon is brought outside the abdominal cavity through the incision protected by the plastic drape. The colon should be easily exteriorized beyond the pubis, which helps evaluate the possibilities of lowering it to the pelvic floor for a tension-free anastomosis.
The vascular supply and compliance of the exteriorized colon are evaluated. With a spastic colon, it is recommended to fashion a J-shaped colonic pouch or to perform the anastomosis higher on the more compliant portion of descending colon. The omental appendages in the area of anastomosis are resected.
1. Pubic symphysis

• Placing the anvil

The anvil of the circular stapler (at least 28 mm in diameter) is introduced once a purse-string suture has been fashioned on the distal part of the colon, either manually or with a purse-string device.
The anvil should then be easily introduced in the colonic lumen. Dilatation with bougies is unnecessary as it risks damaging the colonic wall. The quality of the compliance of the colon should allow for an effortless introduction of the anvil.
The purse is tightly closed around the shaft of the anvil. The left colon with the anvil is then pushed into the abdominal cavity.
1. 28 mm in diameter (at least)

• Anastomosis

The anastomosis can be performed under laparoscopic guidance after the reinsufflation of the pneumoperitoneum. The closure of the abdominal incision can be achieved by suturing the peritoneum and muscular planes. To ensure air seal, we prefer to close the previously placed wound protector, which gives the surgeon the possibility of exteriorizing the colon without reopening the abdominal wall.
This intra-abdominal step takes place entirely under laparoscopic guidance. Once the air seal of the abdominal cavity has been obtained with the closure of the plastic drape, the pneumoperitoneum is re-established. The pelvis is again perfectly exposed, with the help of a retractor that can be introduced through trocar D. Anastomosis is carried out with a mechanical circular stapler.
The circular stapler is introduced into the rectal stump by the assistant positioned between the patient’s legs, through the anus, which has previously been gently dilated. The rectal stump is then transfixed with the tip of the head of the circular stapler.
Once the anvil has been clicked onto the proximal part of the circular stapler, it is mandatory to confirm the absence of colon torsion. The posterior side of the mesocolon lies against the sacral concavity. The circular stapler is closed after ensuring no adjacent organs or epiploic appendages are trapped. Stapling is then done in keeping with the manufacturer's recommendations. Once the anastomosis is completed, the colon should mold into the sacral concavity.
The stapler is then loosened and removed through the anus.

17. J-shaped anastomosis

• J-pouch

Anastomosis can be performed on a colonic pouch. This mandates a better mobilization of the left colon, which is exteriorized through the protected opening. In case of suprapubic incision, the superior part of the pouch should be easily drawn beyond the pubis. The colonic J-pouch (6 to 7 cm high) is fashioned with linear staplers or sutures at the level of the antimesenteric tania. The distal end of the pouch is incised to introduce the anvil of the circular stapler.

• Placing the anvil

The anvil of the circular stapler (at least 28 mm in diameter) is introduced after the fashioning of a purse-string suture at the distal end of the pouch. The purse-string is fashioned either manually or with a purse-string device.
The anvil should then be easily introduced into the colonic lumen. The purse is closed tightly around the shaft of the anvil. The left colon with the anvil is then pushed back into the abdominal cavity.

• Anastomosis

18. End of the procedure

• Control of anastomosis

Verification of the anastomosis is mandatory. This includes checking for the circular aspect of the amputated rectal and colon rings, optional air test, and for some authors (Franklin et al., 1996) endoscopic transanal evaluation of the anastomosis. An air test is almost impossible to perform in very low anastomoses.

Air test:
The pelvis is filled with a saline solution so that the anastomosis is largely covered. One clamp is positioned on the colon at the level of the promontory. Air is then injected under low pressure with a syringe introduced in the anal canal. The absence of bubbles confirms the absence of leakage of the anastomosis, but does not mean there is no risk of postoperative fistulas.

Dye test:
The dye test completes the air test if it is positive. Once the pelvis is clean, a betadine solution is injected under low pressure into the rectum with a syringe. This helps identify leaks.
If there is a minimal anterior leak, a suture can be performed. In case of massive leak, the anastomosis should be repeated either transanally, or via the abdominal route (laparoscopy or open surgery). In such cases, a diverting stoma (preferably ileostomy) is often necessary.
Methylene blue test can replace the betadine test. The problem is that it stains the pelvis, which hinders continuation of the exploration. We do not use it.
Drainage of the abdominopelvic cavity is not routine. It is done only if persistent oozing occurs.
1. Air

• Protective stoma

A protective stoma is recommended in low colorectal anastomosis, especially after radiation therapy because of the higher risk of fistula (Heald et al., 1998). It reduces the clinical severity of potential fistulas, which has a rate of 15% in our experience. The loop ileostomy is favored by most authors. It is situated preferably on the terminal ileum to better preserve the vascular supply of the anastomosis. It can also be situated on the right transverse colon. The selected bowel segment is identified under laparoscopic guidance before it is drawn to the skin.
1. Ileostomy
2. Transverse colostomy

• Closure

We conduct moderate lavage of the abdominal cavity before and after the anastomosis.
Exsufflation of the abdominal cavity is recommended before trocar extraction. The risk of incarceration of the omentum or the small bowel is avoided. Tumor seeding can also be avoided. For the same reason, irrigation of trocar incisions with a betadine solution is recommended by some authors (Balli et al., 2000).
The trocar incisions are closed cautiously. Incisions larger than 5 mm should be closed in layers to prevent incisional hernias. In obese patients, instruments such as the traumatic French needle can be very useful.
The gastric tube is not routinely left in place. Many surgeons remove it as soon as the patient awakes. We remove it on POD1.
The patient is mobilized as soon as possible on the operative day. Food intake is resumed as soon as bowel functions are restored. The urinary catheter should be rapidly removed to avoid any infection. Prevention of deep vein thrombosis is routinely performed (low molecular weight heparin).

19. Conclusions

Total mesorectal excision is the total, “en bloc” resection of the rectum and perirectal lymph node tissue (mesorectum) from the pelvic inlet to the pelvic floor. However, this resection presents risks such as hemorrhage, nerve injuries, local recurrences, fistulas, and anastomotic stenoses (Hartley et al., 2001).
The magnification of anatomical structures during pelvic dissection and perfect visualization of the procedure favor the teaching and broadcasting of the surgical technique.
Even though laparoscopy has not demonstrated evidence of better oncological efficacy in the long run, initial results are promising. Our experience shows that this procedure is performed via laparoscopy with similar results to the ones obtained in open surgery. Better preservation of immunity (Nishiguchi et al., 2001) can allow for immediate administration of adjuvant therapy in node positive patients, which will hopefully lead to improved survival outcomes in the future.
Learning should be provided with the help of a surgical team skilled in colorectal and laparoscopic surgery.

20. Reference

Balli JE, Franklin ME, Almeida JA, Glass JL, Diaz JA, Reymond M. How to prevent port-site
metastases in laparoscopic colorectal surgery. Surg Endosc 2000;14:1034-6.
Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision in the operative treatment of
carcinoma of the rectum. J Am Coll Surg 1995;181:335-46.
Enker WE, Kafka NJ, Martz J. Planes of sharp pelvic dissection for primary, locally advanced, or
recurrent rectal cancer. Semin Surg Oncol 2000;18:199-206.
Franklin ME, Jr., Rosenthal D, Abrego-Medina D, Dorman JP, Glass JL, Norem R et al. Prospective
comparison of open vs. laparoscopic colon surgery for carcinoma. Five-year results. Dis Colon
Rectum 1996;39:S35-46.
Hartley JE, Mehigan BJ, Qureshi AE, Duthie GS, Lee PW, Monson JR. Total mesorectal excision:
assessment of the laparoscopic approach. Dis Colon Rectum 2001;44:315-21.
Heald RJ. The 'Holy Plane' of rectal surgery. J R Soc Med 1988;81:503-8.
Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK. Rectal cancer: the Basingstoke experience
of total mesorectal excision, 1978-1997. Arch Surg 1998;133:894-9.
Hida J, Yasutomi M, Maruyama T, Fujimoto K, Uchida T, Okuno K. Lymph node metastases detected
in the mesorectum distal to carcinoma of the rectum by the clearing method: justification of total
mesorectal excision. J Am Coll Surg 1997;184:584-8.
Kim SH, Milsom JW, Church JM, Ludwig KA, Garcia-Ruiz A, Okuda J et al. Perioperative tumor
localization for laparoscopic colorectal surgery. Surg Endosc 1997;11:1013-6.
Kockerling F, Reymond MA, Altendorf-Hofmann A, Dworak O, Hohenberger W. Influence of surgery
on metachronous distant metastases and survival in rectal cancer. J Clin Oncol 1998;16:324-9.
Milsom JW, Jerby BL, Kessler H, Hale JC, Herts BR, O'Malley CM. Prospective, blinded comparison
of laparoscopic ultrasonography vs. contrast-enhanced computerized tomography for liver assessment
in patients undergoing colorectal carcinoma surgery. Dis Colon Rectum 2000;43:44-9.
Nishiguchi K, Okuda J, Toyoda M, Tanaka K, Tanigawa N. Comparative evaluation of surgical stress
of laparoscopic and open surgeries for colorectal carcinoma. Dis Colon Rectum 2001;44:223-30.
Okuda J, Tanigawa N. Colon carcinomas may be adequately treated using laparoscopic methods.
Seminar in Colon & Rectal Surgery 1998; 9:241-6.
Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to
inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision.
Lancet 1986;2:996-9.

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