TME for rectal cancer: transanal total mesorectal dissection (TMD) with single port laparoscopic assistance

Ureteral injuries during laparoscopic procedure are reported in about 1% of cases. In this key lecture, Professor Joël Leroy looks into the prevention, diagnosis and management of this challenging complication.

Background: Rectovaginal fistula is an abnormal connection between the rectum and the vagina, with leakage of rectal contents through the vagina. Different surgeries have been attempted such as direct repair, plug placement, advancement flap, muscle interposition, colostomy, proctectomy or delayed pull-through colo-anal anastomosis. Recently, transanal minimally invasive surgery has been described amongst the surgical options.

Video: The authors present a pure transanal laparoscopic repair of early rectovaginal fistula in a 74-year-old lady, submitted 3 weeks before to a laparoscopic anterior resection of the rectum with ‘en bloc’ hysterectomy for rectal adenocarcinoma (pT4aN0M0). A protective ileostomy was performed at the time of rectal surgery, and the postoperative course was uneventful. After having positioned the patient in a gynecologic position, a new reusable transanal platform according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany) was adopted. The exploration of the lower rectum put in evidence a 2cm rectovaginal fistula, located at a 3 o’clock position and at a 12cm distance from the anal margin. Absorbable figure-of-8 sutures using Vicryl 2/0 were performed to close the defect. Thanks to the curves of the instruments, the surgeon worked under ergonomic positions, without clashing of the instruments’ tips and any conflict of the surgeon’s hands. At the end of the procedure, injection of methylene blue through the vagina did not show any passage of the product into the lower rectum.

Results: The operative time was 120 minutes and intraoperative bleeding was insignificant. The postoperative course was uneventful, and patient discharge was allowed after 6 days. Due to the reusable nature of all the material implemented, no supplementary cost was necessary. The gastrograffin enema after 2 months showed a complete healing of the fistula. As a result, the protective ileostomy was closed.
Conclusion: Rectovaginal fistula can be repaired through a pure transanal laparoscopy, which prevents complicated and demolition surgeries usually performed through the abdomen.

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

This video demonstrates the usefulness of infrared ureteric stents during rectal or colonic resection when there is unusual dense adhesions or mass involving the lateral pelvic wall. In this case, the patient is having a rectal resection due to severe endometriosis and there were dense adhesions between the rectum, uterus and the pelvic wall. The presence of the infrared stents visible by the 3-chip camera allowed the surgeon to mobilize the rectum off the pelvic wall and the uterus without fear of damage to the ureter, which was close by but well outlined.

The authors demonstrate how to perform a transanal total mesorectal excision using the TEO® device (Karl Storz) as well as a hemorrhoid stapler in a stepwise manner.
This pure transanal approach was performed because of a suspicion of a T2 lesion on a large villous rectal tumor at 10/12 cm from the anal verge. The originality of the technique is shown with exceptional quality views during the posterior and lateral mobilization of the root of the sigmoid mesocolon. A mechanical side-to-end pure transanal coloanal anastomosis is also perfectly shown.

Transanal TME for rectal cancer is a new developing surgical approach. Technical aspects of the procedure performed through a TEO™ platform are presented and discussed.

Following Piercarlo Meinero’s original ideas to treat pilonidal sinus using the video-assisted anal fistula treatment (VAAFT) platform which he developed, we successfully performed this approach. This video shows different technical key points, which are essential to manage such chronic fistulas.