Anterior resection with TME for T2 rectal cancer of the upper rectum in a female patient

This detailed video demonstrates Dr. Joel Leroy performing a high anterior resection for a T2 rectal cancer. The surgery commences in the usual fashion with a high ligation of the inferior mesenteric artery, followed by excision of the rectum including the total mesorectal package. All the steps are presented clearly, including the vascular dissection, lateral colonic mobilisation and the laparoscopic approach for total mesorectal excision (TME).

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Anterior   resection   with   TME   for   T2   rectal   cancer   of   the   upper   rectum   in   a   female   patient

Authors
J Leroy
Abstract
This detailed video demonstrates Dr. Joel Leroy performing a high anterior resection for a T2 rectal cancer. The surgery commences in the usual fashion with a high ligation of the inferior mesenteric artery, followed by excision of the rectum including the total mesorectal package. All the steps are presented clearly, including the vascular dissection, lateral colonic mobilisation and the laparoscopic approach for total mesorectal excision (TME).
Keywords
resection, TME, rectal, cancer, mesorectal excision
Media type
Duration
16'50''
Publication
2007-02
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Feb 2007;7(02).
URL: http://www.websurg.com/doi-vd01en2074.htm

Anterior   resection   with   TME   for   T2   rectal   cancer   of   the   upper   rectum   in   a   female   patient

1. High ligation of IMA 00'16''
The patient is placed in the Lloyd-Davies position with the surgeon standing on the right side. For good exposure of the lower abdominal and pelvic organs, it is necessary to tilt the table into a steep Trendelenburg position. This allows the viscera to fall to the superior aspect of the peritoneal cavity by gravity. In addition, a right tilt aids the mobilisation of the small bowel to the right side of the abdomen. Following a full peritoneal exploration, we begin the surgery by incising the sigmoid mesocolon at its base, from the medial side. The peritoneal incision is extended superiorly above the origin of the inferior mesenteric artery and inferiorly towards the right iliac artery. Using scissors connected to electrocautery, gentle dissection is carried out to identify the inferior mesenteric artery. This is the first landmark. Once the IMA is identified, the plane just posterior to this artery is developed. The IMA is retracted anteriorly, and the scissors used to dissect the plane in a sharp fashion. This is an avascular plane and so the use of cautery can be minimised, an important factor in reducing injury to the hypogastric nerves running beneath Toldt’s fascia. The left hypogastric nerve passes close to the left of the IMA, so it is vital to identify it early and sweep it downwards on a broad front so that it is not inadvertently injured. This nerve carries sympathetic fibres and is important for bladder and sexual function. Dissection proceeds on a wide front in order to expose a generous length of the IMA. In the medial vascular approach, the inferior mesenteric artery is always identified early. The IMA is skeletonised at the origin and divided with the LigaSure device, which can seal and divide vessels up to 7mm in diameter. Once the artery is divided, dissection continues posteriorly and laterally on Toldt’s fascia. The inferior mesenteric vein is encountered next, and this is also sealed with the LigaSure. If the plane of dissection is correctly obeyed, Toldt’s fascia will be left intact, enveloping the retroperitoneal structures observed at the bottom of the operative field. As the dissection proceeds, first the ureter, and then the gonadal vessels become visible. This is an avascular plane and if Toldt’s fascia is not breached, then injury to the gonadal vessels and ureter will be avoided. As the dissection continues along Toldt’s fascia, the lateral wall is reached in due course. The retroperitoneal plane in the abdomen is followed into the pelvis. First, the peritoneum is incised along the right pelvic rim in a circumferential fashion. The retroperitoneal plane is found directly behind the IMA and this is dissected by applying traction anteriorly on the rectosigmoid and performing sharp dissection between the visceral fascia of the mesorectum and the parietal fascia of the pelvis. Once the medial dissection is completed and the retroperitoneal plane traced into the pelvis, the lateral attachments are now released. This is different from the open approach which usually commences with lateral exposure first. The advantage of this sequence is that the descending colon and sigmoid are fixed by their lateral attachments, and therefore do not fall into the operative field, obscuring the view during vascular dissection. Furthermore, the retroperitoneal plane is easily developed from the medial side by remaining close to the posterior aspect of the IMA. The pelvic dissection commences at the sacral promontory and continues towards the pelvic floor. This is the correct plane that should be followed to perform a total mesorectal excision, described by Bill Heald as the TME plane. It is avascular and therefore minimal cautery is necessary during dissection, reducing the risk of pelvic nerve injury.
2. TME dissection 05'30''
This patient is a woman with a roomy pelvis, therefore it is not difficult to continue the posterior dissection to the pelvic floor. Observe that when performing laparoscopic TME, we prefer not to divide the rectosigmoid first, but instead leave the bowel intact. The rectosigmoid can then be grasped and retracted freely to provide adequate tension to aid dissection. Therefore, instead of pulling up on the divided rectal stump as recommended in open surgery to discover the TME plane, during laparoscopy we apply gentle traction or pushing of the rectum with atraumatic retractors or graspers. Once the posterior plane is well defined, the dissection proceeds along the lateral side, and then anterior. It is usual to commence with right lateral dissection as this is the natural progression after posterior dissection. Here, neurovascular structures traverse this plane, therefore it is necessary to anticipate and secure haemostasis in order to maintain a clear operative field. Also, strong medial and lateral retraction is essential in order to proceed smoothly between the visceral and parietal fascial layers. The anterior recto-uterine fold is incised, continuing the same plane that was found first posteriorly and then developed laterally. In this way, the mesorectum is maintained in a single, complete package, obeying the oncological principles set down by Bill Heald. Once the dissection along the posterior, right lateral and anterior aspect is well advanced, we turn our attention to the left lateral side. Observe how the left lateral dissection between the visceral and parietal fascia is advanced progressively to meet with the dissection already completed from the other side. Because space is limited in laparoscopic surgery, dividing the recto-sigmoid often causes the sigmoid colon to fall into the operative field. This is an important difference in the laparoscopic technique for TME compared to the open technique. Dissection proceeds distally to at least 2cm below the tumour. Then the rectum is skeletonised in preparation for lavage and subsequent division of the distal rectum.