TME for rectal cancer

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TME   for   rectal   cancer

Authors
J Leroy
Mots-clés
operation,rectum,total mesorectal excision,cancer,mesorectum,colorectal surgery
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-vd01en1204e.htm

TME   for   rectal   cancer

1. Case presentation 00'47''
I have introduced the port in nearly the same position as for a sigmoidectomy. Small difference, I introduce the optical port at the level of the umbilicus. I always put a 0 degree scope, the patient is in a right lateral tilt Trendelenburg position, the scope is at the level of the umbilicus except in small patients. It is important to be around 20cm away from the pubis. I use 6 ports, first I introduce the grasper in port D on the left side. I grasp the omentum and push it to the left subphrenic area, as you see we can push all the omentum above or under the liver. With more Trendelenburg and right lateral tilt, I grasp the small bowel with the grasper in port D and I push it laterally to the right at mid-distance between the duodenojejunal junction. Progressively I push the loop to the right more and more cephalad, and push the loop behind the previous one. I can arrange like this the small bowel, I can also maintain it as you have seen laterally to the left as I will do now with my grasper introduced here. Progressively you see we have exposure. I open the peritoneum. The aorta is here, I am trying to find the right aspect of the aorta. This is the left colic artery and I will remove all the fatty tissue with the Ligasure. The superior rectal vessels are here. The key to be anterior to the Toldt’s fascia is to find the plane of the presacral fascia. We will change because I have dissected enough now, I will dissect laterally to have more mobility and better exposure. The dangers at this level are the genital vessels, spermatic vessels in men. It is the same as when doing inguinal hernia repair for example. This is the Toldt’s fascia, I retract progressively and medially the colon and I begin my mobilization. The fascia protects the retroperitoneal structures; we have not seen the ureter, we have not seen the nerves but because I am anterior to the fascia, I am protecting the retroperitoneal structures. I open the plane behind Denonvilliers’ fascia. I am opening the sacrorectal ligament because both fascias are stuck, propria fascia of the rectum and presacral fascia, it is the origin of the sacrorectal ligament. This is the posterior aspect of Denonvilliers’ fascia, this follows the lateral pelvic fascia. I am sliding progressively medially to the lateral fascia. Remember it is a man, I will complete laterally to the left and I change my retraction like this. I am not dissecting the rectum; it will be dissected at the end. Not too much traction on the colon. This is the posterior aspect of Denonvilliers’ fascia; I have completely dissected inside the lateral fascia. I am very close to Denonvilliers’ fascia and I try to preserve it. I have finished laterally to the right and posteriorly I am soon finished, I have to complete anteriorly. My strategy is to divide the sigmoid colon, it is what I usually do, and to mobilize the descending colon and the splenic flexure, I will show you how we can do. This is the first transection, I will not use the Ligasure here. We dissect progressively. There is no oozing after sealing tissues. This is the sealing and usually we cut between. It is now necessary to mobilize the mesentery. I have freed laterally (it’s the lateral approach for the mobilization), I am opening the peritoneum towards the inferior mesenteric artery. This is the superior sheath, this is the colica media artery. I am dissecting the posterior attachments of the left transverse mesocolon. You see the pancreas is here, the colica media vessels are here, I can divide the attachments of the left transverse mesocolon to completely free the posterior attachment of the left transverse mesocolon, so of the splenic flexure too. The left colic artery is here, small sigmoid branch I have divided at the beginning. Now I remove the inferior mesenteric vein, perhaps there will be small branches, I think there is one here coming from the descending colon, I have to divide those branches. I will now complete my dissection using a trans-anal approach. You see the sphincter and the presacral space. It will be more difficult anteriorly. We will now remove the specimen through the anus. Here’s the Douglas’s pouch, we have a small tumor here. It is a total mesorectum because you see there is the part in the anal canal, we have the Douglas’s pouch, and posteriorly the fascia. We introduce this drape with a ring inside the anus, we push it and pull the posterior and lateral part, we have the ring close posteriorly to the sphincter. We apply a clamp and now we insufflate the abdominal cavity, we have perfect patency. First, I must find the top and proximal part of the reservoir. You see the reservoir is in this position, the suture for the landmark is here, so I pull progressively on the reservoir. We pull and remove the drape too. I am careful that there are no twists, there are none here so we pull some more. I fix a little stitch at the end to avoid migration, 4 stitches on the cardinal points. This is a good mobilization, complete mobilization of the transverse colon without twists.