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Laparoscopic TME for rectal cancer in a male patient: an ideal case to start

Authors

Abstract

This video shows Dr. Joel Leroy performing an anterior resection. All the critical steps are described in detail. This video is suitable for surgeons performing laparoscopic colorectal surgery.

Keywords

anterior resection, laparoscopic colorectal surgery

Media type

Duration

15'00''

Publication

2007-10

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E-publication

WeBSurg.com, Oct 2007;7(10).
URL: http://www.websurg.com/doi-vd01en2188.htm

Laparoscopic TME for rectal cancer in a male patient: an ideal case to start

1. Medial vascular approach 00'18''

The main purpose of this film is to show the different steps of a laparoscopic TME in this case in a male patient. First of all, we have to do a perfect exposure of the root of the sigmoid mesocolon to open the peritoneum from the promontory to the duodenum anteriorly to the aorta. After we have opened the peritoneum, we lift and stretch the mesosigmoid anteriorly to find the posterior aspect of the vascular sheet of the inferior mesenteric vessels that we see clearly in this picture. For that, we use a good traction; we use monopolar dissection, and we progressively complete the dissection towards the origin of the IMA. We do a skeletonization staying close to the back of the vascular sheet, and particularly close to the IMA. After we have dissected and done the skeletonization of these vessels, we do a division of it using either clips, or Ligasure. When we use the Ligasure, we can complete after closure of the vessels with a loop or a clip; in this case, we have used the 10mm Ligasure Atlas® about 2cm away from the aorta. When we have finished division of the IMA, we stretch anteriorly the mesosigmoid and we continue the dissection laterally till we reach the IMV that is just divided. When we have finished dividing the vessels and the posterior attachments of the mesosigmoid, we do the lateral freeing of the root of the sigmoid mesocolon enough to free the sigmoid and have the possibility to pull on the rectum.

2. Lateral dissection 02'45''

It is exactly the same principles described by Professor Heald that divide the mesosigmoid and the sigmoid rapidly to have the possibility to pull on the rectum. In laparoscopy, we don’t divide the sigmoid because it’s easier to manipulate and maintain the upper sigmoid and the descending colon above the pelvis. At this moment, we have the possibility to free the lateral attachments of the descending colon and we continue to dissect the attachments of the root of the sigmoid mesocolon laterally and left towards the pelvis.

3. TME dissection : upper rectum 03'56''

At this moment, the sigmoid is completely mobile and we have the possibility to pull on the rectum and to expose the posterior aspect of the mesorectum. This is the 1st step of the pelvic dissection. The vertical segment of the rectum is free on the posterior attachment on the presacral space, the Holy plane described by Professor Heald. Posterior attachments are freed medial lateral using atraumatic traction counter-traction with peanuts. That’s why we use enough trocars to have the possibility to perform traction counter-traction. Here we see the sacral nerve on the right the mid-sacral vessels, and progressively we also free the lateral posterior attachment of the vertical segment of the rectum. The posterior attachments are freed till we reach the junction between vertical and horizontal segments.

4. TME dissection : lower rectum 05'30''

Then we have to dissect and free the mid- and lower rectum anteriorly and posteriorly. This is the horizontal part of the rectum. We open the peritoneum anterior to the Douglas‘ pouch, and we do a dissection anterior to the fascia propria and posterior to the parietal fascia and Denonvilliers’ fascia or in case of anterior tumor, we do this dissection anterior to the Denonvilliers’ fascia. You see the anterior traction, posterior traction to continue the dissection of the horizontal segment of the rectum. For that, we push posteriorly with atraumatic instrument to respect the fascia propria using a peanut. Anteriorly we stretch. Laterally, we do the same dissection using traction counter-traction to have a better exposure and anterior traction, we use a specific retractor. This is an Endo-T retractor with an atraumatic tip that will be used as a finger to retract. We retract anteriorly not pushing on the abdominal wall. It’s why we increase the working space. This is the anterior dissection of the low rectum pushing posteriorly with peanuts and retracting anteriorly with a retractor that opens the retroprostatic space. We do that anteriorly, laterally until we reach the pelvic floor. We check that we have completely freed the rectum anteriorly, posteriorly, and laterally and we see posteriorly on the horizontal part of the low rectum that we have to divide the attachments to the sacrum till we reach the pelvis and till we are close to the external sphincter. We use for the low rectum in this case the 10mm Ligasure Atlas® till we have freed the low rectum underneath the mesorectum.

5. Distal rectal lavage and section 08'31''

This part is without meso and we will do a division of the rectum at this level. Before we will exclude the low rectum under the mesorectum and under the tumor that is located in this case in the mid-rectum, the ligation is done with specific suture and for closure, we are using extracorporeal knots. After we have closed the lumen, we wash the rectal stump using Betadine to clean the rectum, and when we have finished, we apply a stapler to divide the low rectum under the ligation using the Endo-GIA device, a 30mm length that is easier to apply when the instrument is introduced in the right iliac fossa. You can see that we have used 2 cartridges completely and 1cm with a third cartridge.

6. Splenic flexure mobilisation 10'00''

We wash, we control bleeding, and then we have to determine the superior limit of the resection. We routinely do a mobilization of the splenic flexure, particularly for the low rectal resection, it’s not always necessary to do a large mobilization as it will depend on the length of the sigmoid, the compliance of the sigmoid too and of the mobility of the splenic flexure. Doing a lateral freeing is sometimes enough. We have to free lateral and posterior attachments and the descending colon, the splenic flexure will slide.

7. Proximal colon section 11'00''

When we have determined the limit, we remove the vascular package with the mesosigmoid, and we divide the mesosigmoid inside until we reach the limit we have determined, that is located with the forceps, you see in the operative field in the left side of the screen. Then we divide the sigmoid, so we will have the segment of sigmoid with the rectum. We evaluate the length of the descending colon and check that there is no tension when we pull on the extremity of the colon. The rectosigmoid is put into a plastic bag introduced in the suprapubic incision. We introduce the anvil of the circular stapler in the proximal colon through the same incision.

8. Anastomosis 11'57''

We then do in a totally laparoscopic approach an end-to-end circular anastomosis using a circular stapler introduced through the anus. The anastomosis is done under laparoscopic control checking that there is no tension, no devascularization, and we remove the stapler. We do an air test to verify that there is no leak under pressure. We control the donuts that are complete proximally and distally. The mesenteric gap is closed using a stapler, using a running suture. We can put a drainage as in this case and a diverting stoma, particularly when we have preoperative radiation therapy.

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