Laparoscopic TME for cancer in a male patient treated with a coloanal anastomosis

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Laparoscopic TME for cancer in a male patient treated with a coloanal anastomosis

Authors

J Leroy, J Marescaux

Keywords

laparoscopic resection, résection antérieure du rectum

Media type

Surgical video

Duration

23'15''

Publication

2006-05

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E-publication

WeBSurg.com, May 2006;6(05).
URL: http://www.websurg.com/doi-vd01en1959.htm

Laparoscopic TME for cancer in a male patient treated with a coloanal anastomosis

1. Patient and trocar placement 00'17''

We have installed all the equipment, laparoscopic unit on the left, right arm of the patient alongside the body, one assistant between the patient’s legs who will retract the prostate, another assistant lateral to the right shoulder of the patient. We lift the aponeurosis and we will insufflate.

2. Veress needle for pneumoperitoneum 00'50''

We have placed the patient in a Trendelenburg position, we have a big sigmoid loop with fat tissue. Right lateral tilt, 5mm trocar on the mid-clavicular line at the level of the umbilicus, 10mm trocar in the right iliac fossa on the mid-clavicular line, I will now put a 5mm port on the midline suprapubic. The one on the left mid-clavicular line is placed after insufflation. I am retracting the omentum above the transverse colon.

3. Start of procedure 01'55''

We will begin by opening the peritoneum, we don’t see the aorta, we don’t see the vessels, we will have a strategy to discover them slowly. My goal is now to reach the aorta, you see the IMA coming. This is the right plane, there were adhesions between the mesosigmoid, this is the right plane now. You see the aorta or iliac vessels coming, I dissect more and more deeply. I want to have my landmark, you see the nerve the IMA is behind just here you will see it better soon. This is the origin of the IMA, we will dissect more to find at least 2cm of IMA, I am on the back of the artery.

4. Inferior Mesenteric Artery (IMA) 03'27''

I will seal but from a distance because this is 2cm of the aorta and behind I have a loop ready. What diameter of artery would you be happy taking with the Ligasure? Up to around 7mm, so for the IMA, it’s not bad. You just divide the artery so I ask my assistant to lift anteriorly grasping the artery only to complete the dissection. First the Ligasure, I will seal this, I keep this flap to maintain the retraction of the bowel, I am sure I am not too posterior. I am probably too high for the ureter, which is perhaps here. I think this is the plane of the Toldt’s fascia because we cannot separate like this if we are in the retroperitoneal space. I will seal the IMV, I don’t divide it immediately because as I said I will keep this area to retract the small bowel. My landmark is the vascular sheet of the IMA, I am staying back to it and you can see the vessels. It is a bloodier plane than anteriorly; after we have this plane, we have the key to open the presacral holy plane described by Bill Heald. I will have difficulties dissecting the pelvis if I don’t pull on the sigmoid so I will free the lateral attachments now. It is also faster, we will use the other instrument, I think it is good to have all devices to do this surgery.

5. Lateral mobilization 06'48''

It is important to know what kind of equipment you have, how you use your equipment and if you are at a distance and if you activate the electric arm just like this, we’ll choose the easy way so you have to touch. I always tell my assistant not to use the electrocautery if you haven’t touched beforehand. We will now begin the dissection of the rectum. Can you point out the sacral promontory? It is here. This is the traction that is the main trick. I stay between the fascia propria of the rectum.

6. Beginning of TME 08'00''

I have to complete my retraction to have a better impact on the tissue. But we have a fibrosis and that is why I sometimes have to cut. This is not far from the tumor, we complete anteriorly. We pull on the rectum. This retractor is interesting but not so much because we are pushing on the abdominal wall so we reduce. The problem is to see between the jaws of the retractor, as you see we have a silicon tip so we can also use it as a forceps to retract, grasp atraumatically, particularly to manipulate the mesorectum with my left hand. I am using the Ligasure device because there is very strong and hard fibrotic tissue. We can also use the Harmonic scalpel. We have to free laterally left, we have not freed enough on the left. I am between the parietal fascia, medial traction. It is easier on this side than it is on the other, but without radiotherapy, we don’t have this problem. I am not far from the erigens pillar. My aim is to show you that it is mainly the problem of exposure that is important. So we will change, we complete the anterior section now and I will complete this opening. So this tumor is 6cm? Yes, and it is more posterior than anterior. I try to find the plane posterior to the Denonvilliers’ fascia, the main difficulty is more lateral where we have sometimes nerves coming from here. I will change and use another retractor to show you. This gives the possibility to lift anteriorly as you do with a St Mark’s hospital retractor. So we don’t increase the pressure into the abdomen. Is the tumor invading outside the wall? Outside the fascia propria, no. I know the tumor is 6cm so I will do a total mesorectal excision, I will not touch and try to find where the tumor is. Eventually we will complete trans-anally if it is too difficult. I am not far from the pelvic floor, I will free a bit more posterior to have the possibility to pull the rectum more. You see it is fixed posteriorly. I use a 10mm Ligasure device, I respect the plane around the propria fascia. With a 5mm, we create a plane quicker. I am always behind the Denonvilliers’ fascia. I have dissected very deeply and I introduce a stapler but it’s better in this case, particularly in obese patients to do colo-anal anastomosis; if you have no space to introduce easily a stapler and have a good angulation, you don’t see the end of the mesorectum. The duodenojejunal junction is here, the sealing of the IMV, I complete it and I will divide. We are in the right plane, behind the Toldt’s fascia, we have to stay like this anterior to it to have easy posterior freeing of the descending colon. The kidney is behind my instrument. The target is the forceps, I will ask the assistant to stay here and I will go straight now because it is not easy when we have a fatty mesentery like this to have a good strategy so I will go straight in this direction. I will complete the division of the mesentery outside. We now have to mobilise the splenic flexure, we have different possibilities, one being lateral mobilisation as you see it would be easy in this case, but I want to show you a medial approach. In obese patients what we do when we have difficulties is that. We add a trocar. The key is to find the inferior aspect of the transverse mesocolon like this, not far from the duodenojejunal junction. I will divide anterior to the IMV, now I am opening the lesser sac. The pancreas is probably behind this, I only divide the insertion of the transverse mesocolon, the posterior attachment of the splenic flexure. What is difficult is to free the medial posterior attachment. I ask my assistant to pull down. The key is to open the lesser sac, you open as I did, medial, posterior, trans-mesocolic, you can go as I did lateral from bottom to top or using a superior approach, using a gastro-omental approach outside the marginal vessels of the stomach, or using a colo-omental approach. We have a good compliant colon, there is ischemia at the distal part but as I said, I will cut more distally from where I will do the anastomosis. We will have enough length so we will do a termino-terminal anastomosis. We are using the lone star retractor, it is good to have good exposure. There is a big hemorrhoid so I am dividing the hemorrhoid pedicle. I am between the sphincter and the seromucosal plane.

7. Transanal removal of specimen 20'00''

I will try to remove the specimen trans-anally. We are removing the specimen. As you see, we have completely dissected the mesorectum. We will introduce a drape, you see the exposure is not so bad. We have to be sure that there is no twist. We can pull largely.

8. Colo-anal anastomosis 21'22''

There is a discussion in this case on where to do the anastomosis, removing the fatty tissue around the anal canal. I have 1cm without fatty tissue. Very good tissue, I take the sphincter and I push this. To have very good continence and a good result, it is necessary to mobilise enough, not have a straight direction of the colon in the pelvis, have a colo-anal angle that creates a flap valve and a good water-tightness.