Tips and tricks for plexus dissection in laparoscopic TME for rectal cancer in a female patient

This is a detailed demonstration of an anterior resection, specifically highlighting the key steps to prevent nerve injury at various stages.

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Tips   and   tricks   for   plexus   dissection   in   laparoscopic   TME   for   rectal   cancer   in   a   female   patient

Authors
J Leroy
Abstract
This is a detailed demonstration of an anterior resection, specifically highlighting the key steps to prevent nerve injury at various stages.
Classification
tips and tricks
Keywords
anterior resection, nerve injury prevention
Media type
Duration
09'15''
Publication
2007-03
Popular
Favorites
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Mar 2007;7(03).
URL: http://www.websurg.com/doi-vd01en2093.htm

Tips   and   tricks   for   plexus   dissection   in   laparoscopic   TME   for   rectal   cancer   in   a   female   patient

1. Preservation of the hypogastric trunk during IMA control 00'15''
With a forceps introduced in the suprapubic trocar, we do the exposure and we see iliac vessels; the promontory is not far, lower in this part, and do the incision of the peritoneum. I’m using traction to get an infiltration of gas to the retroperitoneal structures. This is the duodenum. We complete the incision on the left. We will change traction on the meso to get a better exposure. Dissection is performed step by step plane after plane until we see the origin of the IMA that is not far from the 3rd duodenum that we see on the left. The key is to be close to the posterior aspect of the vascular sheath to stay away from the nerves. These are the surrounding tissues around the artery; you see the origin of the artery is behind the 3rd duodenum, but it’s not necessary to do a dissection until we are at the origin. The plexus trunk is not far, but here. It is fixed posteriorly. We have to stay behind the fascia. I’m using monopolar cautery. This is the vessel and I stay posterior to it. The dissection carries on lower down. You see traction exerted on the meso to do the pneumodissection that is an aid for the surgeon to find the right plane. You can see the vessels here, so we have to stay close but at a distance too. Dissection is carried out until we get a skeletonization of the origin of the artery, and we will use the 10mm Ligasure device at sufficient distance from the origin of the aorta if I encounter any problem. Traction is exerted on the artery in order to lift up a bit, because you see that the plexus trunk is not far from here and dissection is performed close to the trunk of the artery. It is because my assistant is doing traction that I will do a good dissection of nerve branches heading to the lateral side. The plexus trunk runs here posteriorly, and lateral to the aorta and we have to find the vein. We will do the opening of the space. This is the left colic artery that we see posteriorly. I use the Ligasure device as a finger to retract. We see Toldt’s fascia. This is a medial approach of the division of the retromesocolic structures. Because we don’t have enough mobility on the meso, so it’s time to free laterally. As you can see, we use traction and counter-traction and we stay in the right plane. At this moment, the danger is to injure the ureter and/or the genital vessels. We have to continue dissection. Mobilization is now done laterally until we reach the medial dissection, and it is just at this moment that we have reached this step. You see the ureter moving, genital vessels. We will change our traction. The forceps is now put posterior to the sigmoid colon. I will do another retraction.
2. Dissection of lateral pelvic nerves during TME 06'20''
My assistant is retracting the rectum anteriorly as you see and we begin the dissection in the presacral space. We continue slowly. When there is no radiation chemotherapy preoperatively, it’s easier to dissect; particularly in women, the nerves are not far from this area, and we have to maintain a good distance between the nerve and the instrument. You can see that my assistant is retracting atraumatically and perhaps posteriorly I prefer to dissect at a distance. We have opened the presacral space. This is the sacrum. So we’re not too posterior. We continue the dissection. We have 3 directions so far. This is the 3-directional retraction proposed by Bill Heald. I use scissors to get more angulation, and continue on the left. We see very well the nerve, the plexus trunk. We will complete the dissection. We do a medial traction, and the danger is to get an angulation of the nerve and injury to them. You see now there is a parietalization of the sacral branch. We will do the same on the other side. This is the anterior dissection. I think that we will put the retractor. I will have to dissect the mesorectum because there are nodes. I have to remove the mesorectum since there are 3 nodes. I have to divide the mesorectum. That’s the sacral branches running here, plexus trunk above, this is the Ligasure device. These are the inferior rectal vessels. So we have kept the vascularization and we will divide at this level.