Robotic-assisted low anterior resection with total mesorectal excision

This video demonstrates a combined laparoscopic-robotic approach for resection of a low rectal cancer. Mobilization of the colon and mesenteric vascular division are performed laparoscopically. The Da Vinci robot is then utilized to complete the total mesorectal excision (TME). Finally, a laparoscopic stapled colo-anal anastomosis is performed.

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Robotic-assisted low anterior resection with total mesorectal excision

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Abstract

This video demonstrates a combined laparoscopic-robotic approach for resection of a low rectal cancer. Mobilization of the colon and mesenteric vascular division are performed laparoscopically. The Da Vinci robot is then utilized to complete the total mesorectal excision (TME). Finally, a laparoscopic stapled colo-anal anastomosis is performed.

Classification

robotic

Media type

Surgical video

Duration

21'02''

Publication

2006-12

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E-publication

WeBSurg.com, Dec 2006;6(12).
URL: http://www.websurg.com/doi-vd01en2043.htm

Robotic-assisted low anterior resection with total mesorectal excision

1. Trocar placement 00'12''

The procedure begins with six ports. A 12mm right lower quadrant stapling port, two 8mm robotic ports a 10mm camera port and two 5mm assistant ports at the right mid-clavicular line.

2. Exploration 00'27''

This is a 53-year-old gentleman with a low rectal cancer about 6cm from the anal verge. He is 6 weeks status post his neo-adjuvant chemoradiation therapy for what was deemed to be a T3 lesion on preoperative ultrasound. We begin the procedure with a careful inspection for metastatic disease. Next we assess the redundancy of the colon and in this case we deem it necessary to take down the splenic flexure.

3. Mobilization of splenic flexure 01'00''

We first start by packing the small bowel up into the right upper quadrant. As you can see, there are dense adhesions between the small bowel mesentery and the mesentery of the colon. These need to be taken down sharply to expose the root of the descending colonic mesentery as well as the inferior mesenteric vein which are the landmarks to begin the medial to lateral dissection. The medial to lateral dissection is carried out underneath the inferior mesenteric vein, separating the left mesocolon from the underlying Toldt’s fascia. The dissection is carried out laterally toward the left abdominal wall and the white line of Toldt; this is mostly a blunt dissection.

4. Division of IMV 02'14''

Next we proceed with the division of the inferior mesenteric vein near the inferior border of the pancreas. You can see here the left colic artery going up toward the splenic flexure and the part between the left colic artery and the pancreas is the azygos part of the inferior mesenteric vein, which is where we will divide it. Here the inferior mesenteric vein has been prepared and dissected free. It is subsequently clipped and divided with the use of the ultrasonic scalpel. Next we free the attachments of the mesocolon to the inferior border of the pancreas. The attachments of the omentum to the transverse colon are taken down with monopolar cautery as well as with the use of the ultrasonic scalpel. Both the surgeon and the assistant are on the patient’s right side. The patient is in mild Trendelenburg with the left side elevated about 40 degrees. Here you can see we have entered the lesser sac from the medial approach. We will continue freeing the mesentery laterally towards the attachments of the left colon to the abdominal wall. Here we are finally freeing the white line of Toldt. This mobilisation is continued until we meet the medial to lateral plane of dissection, and thus, the take down of the splenic flexure is complete.

5. Division of IMA 05'40''

Here we are elevating the mesocolon and incising the peritoneum over the iliac artery; this will help us to define the origin of the inferior mesenteric artery which will subsequently be divided. Here the inferior mesenteric artery has been skeletonised at its origin from the aorta. We always perform a high ligation of the IMA in cases of cancer. Here the dissection has been completed and the artery has been divided by clips. The mobilisation of the left and sigmoid colon has been completed in a medial to lateral dissection until the entire colon is medialised as you can see here; in this view, you can see the ureter.

6. Robotic set-up 07'50''

Now that we have adequate length, we can bring in the Da Vinci robotic system from in between the patient’s legs. This is a four-armed Da Vinci system you see docking, the three main arms will be above the patient, while the fourth arm is been brought around from the patient’s left side and will be attached to a new trocar on the patient’s left. We find the main advantages to the Da Vinci system, which are a stable camera, three-dimensional vision and rotating instruments allow for a precise dissection during the total mesorectal excision.

7. Right pelvic dissection 08'35''

We begin the procedure on the right pelvic side wall, incising the parietal peritoneum with monopolar cautery. The assistant is now sitting at the patient’s right side and is providing valuable traction anteriorly and cephalad. Here the plane between the visceral and parietal fascia of the mesorectum has been developed. You can begin to appreciate along the pelvic side wall the hypogastric nerve.

8. Posterior pelvic dissection 10'20''

Next we continue the dissection posteriorly towards the coccyx and Waldeyer’s fascia. We can appreciate the stability of the robotic camera as well as the ability of the robotic hook to roticulate and allow the surgeon to very comfortably follow the plane of dissection. The fourth robotic arm is very useful to elevate the redundant peritoneum around the reflection and provide adequate traction.

9. Left pelvic dissection 11'40''

The dissection then continues along the left pelvic side wall. And again, we can appreciate how the robotic arms and the assistant work together to provide adequate traction during the dissection.

10. Anterior pelvic dissection 13'15''

Here we are proceeding anteriorly and we have just identified the left seminal vesicle as shown here. Here we can appreciate the left lateral ligament which will be divided after opening the plane anteriorly and posteriorly. Again here, the dissection proceeds anteriorly behind Denonvilliers’ fascia and the prostate. The posterior view shows the bilobed mesorectum and the Waldeyer’s fascia which is being divided with cautery.

11. Reaching the pelvic floor 15'23''

Here we have reached the pelvic floor and we are freeing the distal most rectum from its muscular attachments. It is important to prepare the distal rectum well to both ensure the adequate distal margin from the tumour as well as to facilitate the division of the bowel with an Endo-GIA stapler. The preparation of the rectum is continued circumferentially. Subsequently, one member of the team performs a very important step, the digital rectal exam in direct vision, to ensure an adequate margin. In this case, we are well below the tumour and we are now preparing for the stapling step.

12. Division of rectum 16'53''

We are using a 30mm roticulating Endo-GIA stapler with a blue cartridge. It is being introduced into the 12mm right lower quadrant port by the assistant while the surgeon at the console retracts the rectum and helps guide the rectum into the stapler’s jaws. After engaging the bowel, the stapler is turned, pushed down to the pelvic floor and fired. It is very important at this point to maintain the bowel in proper orientation before the next firing. And here is our divided rectum with a straight staple line that can be pulled out of the abdominal cavity. The total mesorectal excision is now completed and we can proceed with the extraction of the specimen and the robot is undocked.

13. Specimen extraction 18'58''

We proceed with making a small laparotomy measuring no more than 4cm. This is covered with a wound protector and the specimen is extracted. The proximal mesentery and bowel are divided extracorporeally and here is our final specimen. The specimen is opened and here you can see the tumour with a distal margin of about 3cm. A purse-string suture is placed around the proximal bowel and the anvil is secured.

14. Colo-anal anastomosis 19'45''

Here you can see the stapler coming in from the anus. We are very close as you can see at the level of the pelvic floor and now the anastomosis is completed. After an air-leak test is performed, we usually place a JP drain in the pelvic cavity.

15. Ileostomy creation 20'38''

Finally, a loop of terminal ileum is selected for a diverting loop ileostomy, the 8 mm port is used to mature the ileostomy and the JP drain is brought out through the other 8mm port. This concludes our presentation.