Rectal resection with TME

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Rectal   resection   with   TME

Authors
J Leroy
Mots-clés
operation,rectum,TME,total mesorectal excision
Type de vidéo
Durée
27'00''
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-vd01en1162e.htm

Rectal   resection   with   TME

1. Case presentation 00'14''
I will ask the nurse to put the patient in a steeper Trendelenburg and a steeper right lateral tilt. I will push the small bowel, beginning from the mid part to the right, it is the most important step. After we will slowly push loop by loop, pushing the new loop above the previous one. As you see, I use a lot of ports. I have the jejunum here and the Treitz’ angle. Remember one thing, the mesentery is fixed at the jejunum and at the ileocecal junction and we can move all the small bowel along this axis. We are trying to find the tumor, probably the tumor is here, we are just above the Douglas’ pouch. You see we have adhesions of the sigmoid, I will preserve the adhesions because these will help for the dissection. How do you judge exactly where you start here? First, I start just above the promontory, in front of or above it. I continue my incision, I begin at the level of the promontory, just in front of it and I continue towards the duodenum to incise the peritoneum. At this moment, we do not have enough traction so we cannot dissect easily. We will change traction, I ask my assistant to grasp this and with small traction, I complete the dissection. Will you look for the artery first or will you look for the nerve? Both because when I will have the nerve, I will have the artery. Remember that the artery is sometimes behind the duodenum. You see, the artery is behind. You have the aorta behind and we will see the left sympathetic trunk probably here, very close usually but I will complete my dissection of the artery first and I will show you what I usually do. I will try to keep the left colic artery, it will depend on the level of this left colic artery, if it is very close to the origin of the inferior mesenteric artery, it will be easy to keep it. I take time as you see because I think it is an important step. I lift up to dissect and avoid possible injury due to the Harmonic scissors, I am not against the artery. Here we have the trunk of the superior rectal artery, it is a big artery as you see. I will preserve the left colic artery, at this moment, I don’t know if I will complete this. I will perform the sealing of the vessels, like this. The sympathetic trunk is just behind the left aspect of the artery. I don’t dissect too much, it is not necessary, the trunk is here. I will soon try to find the vein, I don’t dissect too deeply, too posteriorly. If you have a patient who has large lymph nodes, with disease, does it make this part much more difficult or not? It is more difficult than this case, but it is not more difficult than via laparotomy. I am now finding the plane between the mesocolon anteriorly and the Toldt’s fascia posteriorly, and when I am in this plane, I only have to separate both structures. This is the Toldt’s fascia, this is the ureter, when people say do you dissect the ureter, it is not the same. Some teams explain you have to dissect the ureter and isolate it to be sure that you have preserved it. I try to see it but I don’t dissect it except when it is difficult, when there are adhesions, diverticulitis for example, I prefer to find it at this level. I am now in the same plane that I have dissected medially, we have the gonadic vessels, the genital vessels. If we are not in the good plane, it is bleeding, oozing. This is probably not the right plane because I have a patch of the Toldt’s fascia on the mesentery and it is oozing like this. I will correct this by continuing my dissection lower. This is the presacral fascia, I will complete my dissection like this; to find the plane, I only divide the small tractus like this. I am opening this space, I only have to stay in front of the presacral fascia that prolongs the Toldt’s fascia. The promontory is here. I have to open the space slowly. It is coming, I am just behind the fascia propria of the rectum. Remember that the rectum is in the pelvis between the lateral fascia and anterior fascia, that prolongs the lateral fascia, it is the Denonvilliers’ fascia, and posterior fascia, presacral fascia. When the patient has had preoperative radiation therapy, it is like this. We have an edema. It is usually easy to separate the fascia propria of the rectum and the presacral fascia. But progressively both layers will be stuck and it is the beginning of the sacrorectal ligament described by Waldeyer. When they are stuck, we have to make a choice, not in the mesorectum but posteriorly. I have found the good plane. It is sure that it is necessary to have a lot of devices to do this surgery easily. I am very low, I am behind the presacral fascia now, I am dissecting behind, I have to make this choice, I am very low close to the sphincter. But it is not possible to dissect more because I have not mobilized anteriorly, the rectum is free enough to be mobilized by myself. I can feel the tumor posteriorly in the mesentery, I will complete my medialization of the rectum by retracting it medially. You would always go down posteriorly first to continue your dissection downwards and then come back and do the sides. Yes, because I dissect posteriorly the mesosigmoid, I continue to dissect because the path is created by the first dissection. We try to stay close to the fascia propria of the rectum inside the lateral fascia. You see it is the presacral fascia, I complete the section laterally. I am now on the pelvic floor, you will progressively see all the branches of the nerves. These are the parasympathetic branches of nerves, I will divide this branch. You are cutting through the fascia, so now you are going to be behind it again. Yes, it is usually what I do. So you see I dissect close to the pelvic wall and I arrive on the pelvic floor. How low a tumor would you treat with anterior resection as opposed to abdominoperineal resection laparoscopically? It depends on the size of the tumor, the age of the patient, it is necessary to have a good sphincter, so there are a lot of factors, it is not only an anatomical issue but a functional one too. I will do a reservoir if you agree. First, I select this position, but I will probably complete my resection higher. I ask my assistant to maintain the colon like this. We will change the port C because it was a 5mm port and we will change it to put a 12mm one for several reasons: to show you that we can also divide the mesentery using a stapler, the Ligasure, Harmonic scissors. I introduce the stapler like this, it is a white, vascular cartridge Endo-GIA. If we free the lateral attachment, it’s not enough to mobilize the splenic flexure, we also have to free the posterior attachments that fix the transverse colon and the splenic flexure posteriorly. Sometimes, also to mobilize enough, we have to divide the left colic artery but dissecting posteriorly is usually enough to free the splenic flexure without dividing the left colic vessels. We have introduced in the port E and right subcostal area on the mid-clavicular line a grasper to retract medially the colon and as you see, we have finished to mobilize the mesocolon posteriorly. I open just on the right edge of the Treitz’ angle, I am in the lesser sac now. I ask my assistant to change the grasping and maintain this lifted up. The second assistant completes the lifting and I want to dissect posteriorly to the mesocolon to perform progressively the exclusion of the transverse mesocolon far away from the pancreas. And you understand why it seems easy to realize this, we have the pancreas downwards, we divide the mesocolon from medially to laterally and we will have soon finished the posterior mobilization of the splenic flexure. We have the pancreas now here, the stomach, so I will divide the vein but I will keep the artery. Now I am dividing the inferior mesenteric vein slowly. I have to complete posteriorly. Retract this like this. We try to find the sphincter, I retract the mucosa medially. I have the limit between the mucosa and the sphincter, and we dissect between the mucosa and the sphincter until we reach the superior limit of the sphincter. We have to grasp the extremity of the colon that you see here, well vascularized, very pink, to make an exteriorization, and you see we can pull really far because the pubis is here. I am 27cm under the pubis. Now we will do a small reservoir, 6cm in length. I introduce the stapler; another one so we have completed it now. Now we will introduce a grasper through the plastic drape and into the anus. Let the reservoir move, the reservoir is seen in a right position. I have the mucosa here, I fix it like this. We will remove the retractor that we have not introduced in the anus, and we check.