WeBSurg.com, Sept 2004;4(09).
1. Case presentation 00'18''For the first step, we push the omentum upwards, above it is a small omentum so we have no problem. We ask to have the patient placed in Trendelenburg position and after you have to arrange the small bowel on the right side of the abdominal cavity. Don’t begin at the proximal part of the small bowel, but at the mid part. Then you push it on the right side. I push loop by loop above the previous one, not behind. We can eventually fix it like this to maintain this atraumatically with orthostatic retraction. It is the promontory and I begin to open just above, a small incision because there is pressure in the abdominal cavity with the gas, we can incise easily beause we open the retroperitoneal space as we do by laparotomy. It is only the peritoneum that I incise, I don’t want to see immediately the artery or the nerve, I dissect plane by plane. At this stage, the key for me is to try to find the shiny back of the visceral package, you will do too, it is almost there. I will divide the branches of the nerves that go to the mesosigmoid. But I think you just find that holy plane right now behind the shiny package very beautifully. Hopefully behind that will be some nerves I suppose. Yes, the left trunk. Now I divide the connection between the superior and inferior mesenteric plexus, the branches that go to the mesosigmoid. You can see small nodes here. Do you think that node is inside or outside the fascia of the package? I am behind the fascia, I will show you after, see the left trunk is here, it is a danger to be behind. See the trunk is here and its anastomosis between right and left. If you take too many of those nerves away by stripping the aorta, the male patient would lose the ability to ejaculate. Yes, indeed. I’ll divide but I’ll finish my dissection. Do you cut it before or do you always do this step, for lower rectal carcinoma, do you preserve everything as you do? Yes I try, and I will divide at this level. I think we can see you are able to do that, and sometimes maybe it is a good thing but I think the standard method would really be to take it about 1 to 2cm in front of the aorta. One advantage of doing what you have now done is that you get a very nice clean route out to the colon, just south to the right to this artery. You can follow it out to the colon very sweetly. It is a very constant piece of anatomy the relationship between the ascending left colic artery and the inferior mesenteric vein and you’re showing it beautifully. We will divide the vein at this level, do you agree? Well, if you were going to mobilize the splenic flexure, I do agree, but if you are going to mobilize the splenic flexure, you might have to take it again higher up above the last tributary I think. I am just in front of the Toldt’s fascia, it is an avascular plane, it is only necessary to push between both fascias. Here is the fascia that covers all the retroperitoneal structures. It is not necessary at this stage to mobilize the sigmoid laterally. Since the beginning of this operation, we have not touched the colon and the rectum. Now it is the entrance in the pelvis, in the presacral space. It is in front of the presacral fascia that we will dissect, it is not posteriorly to the presacral fascia. You see the right plexus is behind the fascia, there is a cord here, that is the right superior hypogastric nerve. The left one, if I apply some traction, is here. I should not dissect too much. I use my grasper to increase the angulation between the vagina, but since I am not efficient enough so I have to change the position of my grasper to have more traction of the vagina. I dissect posteriorly, anteriorly, and at the end laterally. It is not laparoscopy, it is also the same in laparotomy. And we have to dissect again the parietal fascia. You see the plexus trunk. Yes, I agree the only thing is I am waiting with great interest to see the parasympathetic nerve routes, which will be behind there I suppose. You see it is here, and the main is just outside the seminal vesicles, I only divide the internal branches of the trunk. I have opened the fascia, I am behind and you probably have sacral branches at this level, but I don’t know if it’s nodes so I prefer to dissect these branches and divide because it is realistic at this level. That is the middle rectal artery. It more often comes down lower from the pelvic floor. We are on the pelvic floor now, we have opened the aponeurosis of the pelvic floor. When you are in the good plane, it is like this you only have to unstick two planes. On the lateral ligament, it is the same. It is completely dissected but it is better to do that than to dissect in the propria fascia of the rectum. We introduce the stapler in the suprapubic port, with a green cartridge. I can introduce progressively my rectum into the stapler and place traction on it or I can ask my assistant to push the pelvis to win half a centimetre and I close the stapler. It is obviously important that you pull only on the bowel beyond the cancer. As you see we have the vena cava just under the grasper, the aorta, horizontal line, the beginning of the inferior mesenteric artery with the left colic artery that goes behind the inferior mesenteric vein and on the left side afterwards. Now you have the anastomostic branches of the right sympathetic trunk that goes across in front of the left iliac artery and to the left sympathetic trunk that we have respected just here. It is interesting that the whole nerve plexus often lies slightly to the left of the aortic bifurcation. We have put the specimen in the big plastic bag (Endo-catch number 2) and we will remove the specimen. So I continue my dissection from downwards to upwards anteriorly to Toldt’s fascia, respecting the Toldt’s line because the colon don’t fall in this space, and you see I am just in front of the fascia, perhaps at this level. We follow this dissection posteriorly, it is the Toldt’s line but I respect it and you have the pancreas here. Here is the pancreatic tail. Now I can finish to mobilize laterally. I respect this attachment to avoid the colon from falling in the operative area. You see why it is important to have the right subcostal port, it is to expose and also for the splenic flexure. We have the inferior mesenteric artery, the left colic artery, we have to mobilize posteriorly to be sure that the left colic artery follows the mesocolon, and the transverse mesocolon and the splenic flexure too. If you do not mobilize this, it is impossible. Is this not the point where you have to take the vein again above the last branch? If you wish full mobilization of the splenic flexure, I think it is necessary to take the termination of the vein close to the pancreas to get the full mobilization. This is the left colic vein, the good plane is not behind, this is the renal vein with the genital vein, the pancreas is here. I think I have dissected enough now. I reintroduce the anvil, we have a perfect patency and we can keep this drape. Do you think the diameter of the anastomosis matters this low down, he was putting the point that blood supply was all important, presumably of the upper component of the anastomosis, do you think the diameter is important, would you use a 34 stapler if you could? I am using a 28, I think it is possible in this case to use more. I use a 2nd grasper. Do you not think you are about to staple a bit of the puborectal sling at the back, is it not worth pushing that little part of the external sphincter away? Yes, perhaps, but I have control when it’s introduced. The line is here and we are in the small rectal stump. We believe that some form of protection is necessary for all anastomosis below 6cm from the anal verge, most total mesorectal excisions, but we are in fact doing a prospective randomized trial of temporary defunctioning by either ileostomy or colostomy or the use of an intra-anal protective stent, which I would need to show you. The anastomosis is just supra-anal and I have a perfect endo-anal control. Which are you going to use, colostomy or an ileostomy? Usually in our department, we do colostomy on the right colon. What is important for the functional result is to have no tension; if you have a reservoir with a straight direction, you will have incontinence because you don’t have a flap valve to protect. It is not only a problem of reservoir, it is also a problem of good mobilization to have the colon that will have good curvature behind along the sacral nodes, it is more important perhaps than good reservoir. I quite agree with you, the total absence of tension so that the bowel lies in the pelvis, at the moment it will lie even more posteriorly when you have pushed it down and without gas too and the patient is also head down at the moment.