TME for rectal cancer: laparoscopic dissection of the Holy Plane using 3-directional (3D) retraction

This video shows how to perform laparoscopic dissection of the presacral space following the principle of 3-directional retraction as described in open surgery by Bill Heald. Monopolar cautery scissors are used. This video is very suitable for surgeons interested in rectal surgery.

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TME for rectal cancer: laparoscopic dissection of the Holy Plane using 3-directional (3D) retraction

Authors

J Leroy, F Costantino, J Marescaux

Abstract

This video shows how to perform laparoscopic dissection of the presacral space following the principle of 3-directional retraction as described in open surgery by Bill Heald. Monopolar cautery scissors are used. This video is very suitable for surgeons interested in rectal surgery.

Catégorie

tips and tricks

Mots-clés

Laparoscopic TME, rectal cancer, tips and tricks, posterior dissection

Type de vidéo

Vidéo chirurgicale

Durée

03'30''

Publication

2009-03

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Mar 2009;9(03).
URL: http://www.websurg.com/doi-vd01en2590.htm

TME for rectal cancer: laparoscopic dissection of the Holy Plane using 3-directional (3D) retraction

1. Introduction 00'17''

The objective of this video is to show the laparoscopic dissection of the presacral space, also known as the Holy Plane of dissection thanks to Bill Heald.

2. Sigmoid colon dissection 00'31''

The first operative step is to free the sigmoid colon through a primary vascular approach. The sigmoid colon is completely freed in order to exert traction on the rectum, which can be pushed anteriorly and pulled cephalad.

3. Identification of the plane between the presacral fascia and the fascia propria of the rectum 00'59''

Thanks to appropriate counter-traction, the cleavage plane between the presacral fascia and the fascia propria of the rectum is shown, namely the sheath that envelopes all adipose cellular tissues around the rectum. This dissection is carried out progressively and with caution with low voltage monopolar cautery scissors (i.e., 15 to 25 Watts depending on the thickness of the tissues to be divided).

4. Opening of the space between presacral fascia and fascia propria of the rectum 01'38''

Thanks to a gentle traction on the tissues and thanks to the pneumodissection induced by the pneumoperitoneum, the space between the presacral fascia and the fascia propria of the rectum is opened. Pneumodissection of this interfascial space is clearly visible here. An adequate and totally atraumatic traction and counter-traction is exerted in order to avoid perforation of the fascia propria of the rectum, the principle of 3-directional retraction is herewith carried out as described by Bill Heald in open surgery. This 3-directional retraction includes traction of the rectum cranially. Then thanks to atraumatic retractors embodied by peanut swabs, the fascia propria of the rectum is retracted anteriorly and medially. This traction allows to separate the fascia propria of the rectum from the parietal fascias that cover the nerve plexuses. The scissors’ spatulated electrode is used on tissues that have been placed under traction and maintained atraumatically thanks to the peanut swabs. These peanuts replace the fingers of the surgeon, as used in open surgery. Thanks to a gentle traction and counter-traction, the surgeon works with the monopolar electrode and separates the pelvic fascia from the fascia propria of the rectum.

5. Complete freeing of the holy plane 03'40''

This contributes to a complete freeing of the presacral space, also known as the Holy plane.