Laparoscopic TME with intersphincteric dissection and coloanal anastomosis for ultralow rectal cancer

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Laparoscopic TME with intersphincteric dissection and coloanal anastomosis for ultralow rectal cancer

Authors

J Leroy, J Marescaux

Media type

Surgical video

Duration

06'34''

Publication

2006-09

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E-publication

WeBSurg.com, Sept 2006;6(09).
URL: http://www.websurg.com/doi-vd01en1831.htm

Laparoscopic TME with intersphincteric dissection and coloanal anastomosis for ultralow rectal cancer

1. Trocar placement 00'02''

Sphincter preservation is feasible in cases of ultralow rectal cancer eventually, after radiochemotherapy in borderline tumor cases. The technique begins with trocar placement. Five or 6 trocars are needed depending on the degree of difficulty for exposure.

2. Medial dissection 00'29''

The inferior mesenteric artery is dissected at its origin. The medial dissection of the sigmoid mesocolon is carried out after division of the inferior mesenteric vein. The sympathetic nerve plexus is identified and dissected away. The presacral space dissection continues anterior to the presacral fascia and around the fascia propria of the rectum. Dissection into the parietal fascia allows the preservation of the nerve plexus moving them away to the side.

3. Dissection continues 01'09''

Lateral mobilization of the sigmoid colon is performed in order to proceed with dissection further down to the pelvis for better exposure of the pelvic wall laterally. As a result, the ureter, the nerve plexus and the left parietal fascia can be seen. With a good traction and counter-traction of the rectum and mesorectum, dissection is continued using monopolar dissecting scissors. Opening the Douglas’ pouch is necessary to continue the dissection further down. At this stage, the lateral attachments of the middle and lower thirds of the rectum can be easily identified. Here we can see a lateral branch from the sympathetic plexus. The dissection is continued to the left towards the pelvic floor. At this moment, it is not necessary to continue the dissection to the sphincter. To the right, the same maneuvers are performed.

4. Division of sigmoid colon 02'34''

We can clearly see here a sacral branch that is pulled by medial traction on the rectum and mesorectum. The sympathetic plexus is pulled as well describing an angulation. They will be divided by opening of the cleavage plane between the rectum and the parietal fascia all the way down to the pelvic floor. Division of the sigmoid colon follows. The splenic flexure might be dissected free as we would do in open surgery.

5. Anal part of the procedure 03'18''

Next we will do the anal part of the procedure. The anal mucosa is divided at the anorectal junction. We proceed with an intersphincteric dissection proximal to the mucosa between internal and external sphincters. We carry on all the way down to the pelvic cavity where dissection has already been done very low. A simple traction will then allow us to gently pull out the rectosigmoid that has been completely dissected free in the abdominal time.

6. J pouch anastomosis 04'06''

Here we see the surgical specimen and the lesion situated very low partially necrosed, a residual tumor after radiation therapy. Through an incision made over the pubis, we tailor a J-pouch with the mobilized colon. The small J-pouch measures approximately 6 to 8cm long. The incision made over the pubis was previously protected by a plastic drape. We return to the trans-anal region and place another plastic drape. We will twist it close to isolate the abdominal cavity in order to insufflate the pneumoperitoneum. We verify that the colon has been properly mobilized. It should descend to the anus with no tension and come out to the anastomotic site. The anal J-pouch anastomosis is hand-sewn. Four cardinal stitches are placed taking care to include the skin, the sphincter, and the J pouch. An extramucosal stitch is placed in the pouch. Absorbable braided 2/0 polysorb suture is placed. Intermediary stitches will be placed after the cardinal ones in a similar way described for these last ones.

7. Protective ileostomy 06'03''

Once this part of the intervention has been done, a protective ileostomy is performed after a final laparoscopic exploration of the pelvis.