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Laparoscopic total mesorectal excision for rectal cancer

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Laparoscopic   total   mesorectal   excision   for   rectal   cancer

作者群
J Leroy, J Marescaux
關鍵字
TME,mesorectum,rectum,cancer,laparoscopy,excision
媒體類型
期間
20'00''
刊物
2004-11
普通的
最愛
Favorites Media
音訊
en jp
副標題
en
數位出版
WeBSurg.com, Nov 2004;4(11).
URL: http://www.websurg.com/doi-vd01en1598.htm

Laparoscopic   total   mesorectal   excision   for   rectal   cancer

2. Sigmoid mesocolon opening 01'25''
I will not do more. You see the iliac vessels. I do not have enough good traction, so I will change it by asking my assistant to lift the mesentery anteriorly in order to have a better visual plane. There is a small node here. You can use bipolar scissors, I prefer to use them for a lot of reasons, because it is a sharp dissection, very clean dissection with no snow as you have with Harmonic scissors. I use it similar to a hook. I am around the fascia that surrounds the artery, I am cutting it to see the artery better. I have just opened the vascular sheath and it is easier to find the plane around the artery to skeletonize it only. How do you make sure that you are in front of the nerves? Because I dissect close to the artery. Professor Nano from Turin advocates finding the artery behind the sympathetic nerves flush with the aorta, which seems more difficult to me. We always try to go for the artery in front of the nerves, which split around it. I will change retraction now. We lift the artery anteriorly. Here’s the sympathetic trunk. You see the ureter is here. It is not necessary to see it so well, because we are not in the right plane. The good plane is anteriorly to the fascia as we will see soon. I have to divide the branches of nerves while staying close to the artery and due to the traction I want to show you the branches. I am posterior and lateral to the artery. What is probably the left colic artery is here, I have to dissect anteriorly staying behind the vascular fascia to find the right plane. We use traction and counter-traction. Slowly the plane is showing. Now we have a parietalization of the plexus. We try to stay anterior to the Toldt’s fascia. I change the grasping, we grasp the artery more like this to have better traction. You have seen the ureter moving here, we have to separate 2 layers of fascia like this. It’s not the holy plane but it’s how we find the holy plane. This is the key to open the door. I think scissors are the best to create planes.
5. Mesorectal dissection 09'35''
My assistant will use forceps on the left. We can see very nicely the internal iliac artery on the right. See the nerve here, that is the right hypogastric nerve. This is a branch of plexus that goes to the rectum. We change the traction and retraction, we can still move posteriorly but want to complete anteriorly. The best is to use this as a retractor. Once you have divided the bowel, it is perfectly ok to use the bowel as a retractor because it is going to come out anyway. Do you always use a 0° optic? Yes. It is necessary to have a low traction on the rectum because if you have too much traction you have no possibility to retract posteriorly. Once you get through the Waldeyer’s sacral ligament, there is an ever nicer plane, it is easier at the back and this is what you want to build on as you come around the sides. It is a male patient so it is harder to get space but you see that slowly we are going medial to the fascia, we can divide like this, it is dangerous because the trunks are not far so don’t pull medially too much. I am anterior to the Denonvilliers’ fascia, this is it here. This is the right seminal vesicle, I am just behind it. The erigens nerves are not too far from this area. The retraction is the key, isn’t it? I have to do more medially now. I will divide the Denonvilliers’ fascia once again. I want to finish the lateral and posterior mobilization. I am freeing laterally on the left, it is not free that is why I have difficulties to finish my dissection anteriorly. These are branches that go to the rectum too, it is a lateral attachment in the lower third of the rectum. I think this is the Denonvilliers’ fascia, the small lower part. This is just above the sphincter, I can divide here. I will prepare some more laterally, left and posteriorly.