Rectal resection for villous tumor

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Rectal   resection   for   villous   tumor

Authors
J Leroy
Mots-clés
operation,rectum,TME,total mesorectal excision,villous tumor
Type de vidéo
Durée
19'00''
Publication
2004-09
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1161e.htm

Rectal   resection   for   villous   tumor

1. Case presentation 00'15''
Today we will see a rectal resection for an anterior polyp of the rectum just located 10cm above the sphincter. It seems to be a benign polyp but it is not sure because it is a venous polyp 3cm in size and for the gastroenterologists there is a doubt and they don’t want to do a TEM resection or endoscopic resection with a colonoscope. We will perform this operation via laparoscopy, and as you see, this is a 60-year-old male patient, 70kg for 175cm high. As you see in this case, we explore all the abdominal cavity, the liver seems perfect, the preparation of the patient also seems perfect, we have no doubt on the liver. It is not an ultrasonography of the liver but in this case, it does not seem necessary. To expose first, it is necessary to have a good muscle relaxation and in this case good preparation of the bowel and also to arrange all the organs. First of all, we have to push the greater omentum just above the transverse colon and under the diaphragm. Secondly, we have to put the patient in a Trendelenburg position, we also have to perform a right lateral tilt and we will push the small bowel on the right side of the abdomen. We begin at the mid-part of the small bowel and we push each loop above the previous one in order to arrange perfectly the small bowel, not only just to push it to the right side. If we don’t push above the previous one, we will have more difficulties to expose and we don’t occupy completely the space under the right transverse colon. Here is the Treitz’ angle. If we want, we can also introduce under the proximal small bowel the retractor that is introduced through the port E that is on the left side of the abdomen. We maintain the proximal loop above it without traction. We will finish the exposure of the abdomen in the lower part of the abdominal cavity. First, I will ask my assistant to maintain the sigmoid loop, not grasping the colon but you see that we introduce, we push loop by loop of the ileum to the right side of the abdominal cavity. As you see, we use the mesentery to realize a good exposure of the mesosigmoid but also to maintain the sigmoid loop laterally. We also use it as a retractor. You see the exposure at the end after we have completely arranged the small bowel, the omentum and the mesocolon. First, we incise the mesentery, the peritoneum is inside from the promontory to the third duodenum anteriorly and laterally of the aorta on the right side. Progressively when we have finished incising, we will see the origin of the inferior mesenteric artery. I think it’s the left colic artery, I will divide only this branch with the superior rectal artery. It is a big artery, which means that probably there is a very small mid-colic vessel. I have to find the vein first and dissect not too far; in this case, it is probably here. The vein is just behind here. First, I have to find the plane of the vein and the vein is just behind. I use a small anterior traction, I lift the mesorectum anteriorly and I continue to dissect close to the Toldt’s fascia. Now I think it is necessary to change my strategy in order to mobilize laterally, that means here because it would be easier for us to find the distance. Very good, don’t separate laterally completely but it’s only to have more mobility of the rectum. We will now progressively dissect the anterior plane. We will dissect laterally and anteriorly to find the plane of the Denonvilliers’ fascia. The seminal vesicle is here and just behind it, you have the beginning of the Denonvilliers’ fascia. It is not a total mesorectum as usual but I think it is enough in this case. It’s a surgical dissection of the mesorectum. Now I will divide the rectum, we introduce the green stapler. I divide only the mesentery. It seems well vascularized. Now I will introduce the specimen into a bag. There is no traction.