Totally laparoscopic TME for middle rectal cancer with a side-to-end colorectal anastomosis

Over the last decade, the surgical treatment of rectal cancer has witnessed various improvements. Total mesorectal excision (TME) became the standard procedure. The surgical quality of the TME has a high effect on prognosis. This is the case of a 60-year-old woman with a BMI of 38 in whom a totally laparoscopic TME for middle rectal cancer with a side-to-end colorectal anastomosis is performed.

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Totally laparoscopic TME for middle rectal cancer with a side-to-end colorectal anastomosis

Authors

J Leroy, J Marescaux

Abstract

Over the last decade, the surgical treatment of rectal cancer has witnessed various improvements. Total mesorectal excision (TME) became the standard procedure. The surgical quality of the TME has a high effect on prognosis. This is the case of a 60-year-old woman with a BMI of 38 in whom a totally laparoscopic TME for middle rectal cancer with a side-to-end colorectal anastomosis is performed.

Catégorie

complex cases

Mots-clés

Totally laparoscopic TME, middle rectal cancer, side-to-end colorectal anastomosis

Type de vidéo

Vidéo chirurgicale

Durée

29'55''

Publication

2009-05

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, May 2009;9(05).
URL: http://www.websurg.com/doi-vd01en2638.htm

Totally laparoscopic TME for middle rectal cancer with a side-to-end colorectal anastomosis

1. Clinical case presentation 00'10''

This is the case of a 60-year-old woman with a BMI of 38. She was complaining of chronic fatigue and again, on screening there was blood in the stools. Colonoscopy found a stenosis 11cm from the anal verge, which was confirmed in terms of location and aspect at rigid rectoscopy, and the histology showed a well-differentiated adenocarcinoma. The patient underwent a CT-scan and MRI and here you can see that there is infiltration of the perirectal fat but the ureter is not touched. So this is a female patient who has a BMI of 38. It’s no big handicap as usual. It’s mainly subcutaneous obesity and intra-abdominally, we have a good distension of the abdominal cavity. Here’s the inside view. The positioning of the trocars is similar to the one I use for sigmoidectomy. I will use two working trocars on the right side. The other ones are for exposure purposes, and I will use 2 instruments for working, one forceps for grasping and the other will be an instrument for the dissection (monopolar scissors, you’ll see the Ligasure Advance or Ligasure Atlas device).

2. Abdominal cavity exploration 01'45''

Before beginning, we did the panoramic exploration of the abdominal cavity. You have seen no carcinomatosis. We use a maximum of space, and we push the omentum above the transverse colon. I’m pushing the small bowel up and due to the abdominal pressure and muscle relaxation, we obtain this exposure, and even if it’s an obese patient, we can do a beautiful exposure using little tricks as you see, the sigmoid and the tumor visible. Move back and the tumor is not a T4 but a T3. We can see anteriorly a huge tumor of the upper rectum and colorectal junction. After the exposure, the first step is to grasp the root of the sigmoid mesocolon and to dissect the artery with scissors. You do a traction.

3. Peritoneum incision 03'14''

We have the promontory there and we incise the peritoneum not too close from the back but sufficiently at a distance using traction to facilitate the opening of the peritoneum. We continue the dissection using scissors as dissectors. You cut this way. Come back. We continue to use the pressure of the pneumoperitoneum to find the back of the vascular sheet. This is the vascular package, see the vascular plane and we slide back to it.

4. Artery dissection 04'19''

If I enter the vascular sheet, I will see the artery and the trunk of the artery and I’ll dissect the artery like this using monopolar scissors. You can safely do it but you can put a ligature. It’s interesting to see that you had no bleeding despite it’s a pretty big vessel. Now the best is to ask our assistant standing between the patient’s legs to grasp the stump of the artery and we stretch anteriorly and we twist this way. I’m dissecting close to the artery. Don’t do too posterior a dissection. The key is to continue there, because the plexus trunks are not far and sometimes follow the traction and the plane close to the vein we have to skeletonize. This is the IMV trunk. It’s not necessary to dissect more. When we have to do a TME resection, the first step (and it’s also proposed by Bill Heald in open surgery) is to mobilize and free the sigmoid colon. And to do this, it’s necessary to do a medial approach and vascular dissection and then to free the lateral attachments, and this is the key to find the right plane at the back of the rectum. These are genital vessels there, the aorta is there. This is where the ureter is. These are the best landmarks. So if you have the genital vessels visible, be sure that the ureter is between. Now we will free laterally.

5. Sigmoid colon freeing 07'17''

We will do exactly what Bill Heald does in open surgery, that is the freeing of the sigmoid in order to pull on the rectum. The only difference is that we don’t divide the rectum immediately as he’s doing in open surgery. The distal component in any direction to help in the traction, counter-traction process: when Joel tried that laparoscopically, it tended to sort of drop down and get in the way. So we continue the dissection until we reach the medial posterior dissection we did earlier. We have to free further laterally. You notice that he very seldom puts any grabbing instrument on the mesorectum itself. I have to finish to free the sigmoid and I will be able to pull on it more. Remember the forceps are on the left. I remove it and I ask my assistant to put it under the colon to do a first traction. I’m finding the plane slowly. We use a zero degree scope.

6. Rectal dissection 09'58''

We use traction and counter-traction. At this moment, I’m using 5 Watts. I use this instrument as a dissector. Not enough traction to be able to dissect so I’m doing another counter-traction like this. Just lifted to the right there. Because it’s also a huge tumor, we will continue the anterior dissection more rapidly as Eric Rullier suggested. As you see, we have freed posteriorly what I call the vertical segment of the rectum, the upper rectum and we have only posterior attachments normally. We have to do a traction and expose there. We see we have a huge tumor. It’s sometimes useful to suspend the uterus using a transparietal approach. See the plexus trunk there surely. I will use a 10mm Ligasure device. In difficult cases, the best is to use this as a finger as we used to do in order to rapidly divide and find the plane. This is the uterosacral ligament. It’s interesting it doesn’t go on to the sacrum. We are reaching the pelvic floor there. We are underneath the tumor there. I want to free this. The Heald retractor is very good at lifting the whole thing forward. We have to continue on this side. It’s the lateral plane. We call it the uterosacral ligament and we may be confused about why it doesn’t go anywhere near the sacrum. I think it’s the vaginal attachment. We go to the right. Not to pull on the cancer and you can see how cleverly Joel is avoiding doing that. Back to the vagina. This is the pelvic floor there. See I have to free the posterior attachments. This is the lower rectum just under the mesorectum. Do you think that neo-adjuvant chemoradiotherapy could have helped with the dissection by shrinking the tumor? Perhaps, we don’t know. If it’s positive, yes. You can be quite sure it’ll make the function worse afterwards. I have proof of that but I don’t suppose many others do. Would you think that the 30 degree camera would help a little more in this area? Because sometimes you are working where we can’t see you. No I don’t believe so. It depends on your assistant. I will check later but I think the ureter is more anterior and lateral there. We’re not thinking it’s the ureter. It’s really difficult to get access at this level. This is a better plane, more lateral. I think you are now probably rather well beyond the tumor, aren’t you? Now I have exteriorized the tumor outside the pelvis. We have to free the posterior attachments now. This is the lower rectum where we will do the anastomosis. Years ago, after all start with the idea that there is such a thing as evidence that the best way to get cancer cells to implant is to crush the tissue. As Bill Heald said, we will wash the rectal stump with betadine solution. We have ligated under the tumor. It’s not only for exclusion but you will see why I put this. Which trocar do you put the stapler in because you are very low? I have completed the ligation. I’m twisting this and I can pull more on the rectum. I have the stapler now through the RIF port.

7. Rectal division 20'23''

This is the ‘Chinese hat’ stapling technique. I’m reducing my traction. To apply the stapler with an angulation, this is a limiting factor. We have the rectal stump around. We are 2cm above the sphincter. We will do a side-to-end anastomosis. Push the tumor towards the pelvis. I have put the specimen inside the plastic bag introduced through a suprapubic port. See there are stitches. This is the proximal part with a stitch with a loop around to find rapidly and the plastic wound protector suprapubically.

8. Proximal colon division 23'32''

This is the proximal colon, and the plastic bag, and we pull slowly on the sigmoid. We arrive on the rectum. The end of the tumor is approximately there and we are 10cm underneath.

9. Anastomosis 25'14''

This is well-vascularized and we will do a side-to-end anastomosis; and you will see that there is no tension. Before we do the anastomosis, we have to test.