Laparoscopic TME with lateral mobilization of the splenic flexure for a T4 low rectal cancer

This case demonstrates the performance of a TME for a 10cm rectal cancer by Prof. Leroy in front of a live audience including Prof. Heald. A number of special technical tricks are displayed for gaining access to the low pelvis while the minimization of cephalad dissection planes is emphasized.

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Laparoscopic TME with lateral mobilization of the splenic flexure for a T4 low rectal cancer

Authors

J Leroy, J Marescaux

Abstract

This case demonstrates the performance of a TME for a 10cm rectal cancer by Prof. Leroy in front of a live audience including Prof. Heald. A number of special technical tricks are displayed for gaining access to the low pelvis while the minimization of cephalad dissection planes is emphasized.

Keywords

TME, Total Mesorectal Excision, lateral mobilization, splenic flexure, T4 low rectal cancer, laparoscopy

Media type

Surgical video

Duration

25'00''

Publication

2008-03

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E-publication

WeBSurg.com, Mar 2008;8(03).
URL: http://www.websurg.com/doi-vd01en2260.htm

Laparoscopic TME with lateral mobilization of the splenic flexure for a T4 low rectal cancer

1. Case commences 00'20''

Surgery seems indicated in this case because there was a stenosis

2. Tumour position displayed 00'26''

and fortunately there is no carcinomatosis. I have exposed and you will see the tumor now. This is the colorectal junction anterior to the promontory, and yesterday I did a rigid rectoscopy and I saw a stenosis at 10cm, you will see that it is really at 10cm because the Douglas’ pouch is invaded and we have a stenosis at this level. So I think it’s partial and perhaps we have some metastasis on the peritoneum at this level, we will remove this.

3. Dissection of retroperitoneum 01'07''

You start beyond the Gruber’s ligament, am I right? You are on the right side of the mesenteric vessel now.

4. Vascular pedicle dissection 01'34''

We have incised the peritoneum, we have to stretch the tissue anteriorly. Grasping like this, see the technique of dissection, we stretch the tissue anteriorly and we go posteriorly using the pneumodissection as a tool. We see the ureter right there. You prefer to use the monopolar now? I prefer this to the Ligasure when I want to do a sharp dissection. We have to slide behind the vascular sheath of the IMA. I leave the small fascia on the plexus. See the plexus trunk and we have to stay just behind the artery, the key is to begin that anteriorly to the promontory. I stay anterior to the aorta, I do not want to dissect too anterior; we also have branches of nerves running. When you lift the artery forward, it is very easy to lift the nerves forward too. We only have to dissect the artery without putting a stapler or Ligasure without dissecting around the artery.

5. Division of Inferior Mesenteric Artery 03'45''

I will divide and seal the artery using Ligasure but I complete the sealing part with a loop. Vascular sheath, the stump. I am cutting very close to the artery, with Ligasure, mechanical cutting or Harmonic if you want, to separate and you will see the peritonization of the plexus coming. Behind you have the ureter, genital vein lateral to the ureter. We see very well in this view all the anatomical details. I have divided the IMV, so I continue to dissect the space and when the right space is completely clean. This is why we want to find the plane, it’s an oncologic problem;

6. Division of posterior sigmoid attachments 04'58''

with the Ligasure, we use traction and counter-traction to separate the plane like this. See the stasis in the venous network and we will continue to free the posterior attachments of the sigmoid. Stay close to the vascular sheath while doing the dissection. Because you are 1.5cm away from the ureter. I don’t dissect the ureter but I localize it during the dissection. For that procedure, Bill Heald, you divide the sigmoid;

7. Lateral and posterolateral rectal dissection 06'45''

I do not divide it but I free it laterally to have the possibility to pull on the rectum and to move laterally the upper part of the rectum when the sigmoid is mobilized. I do not need to touch the splenic flexure now because I do not believe it is necessary in this case. We shall see because if it is a low third anastomosis, it will be necessary, but I will not mobilize the splenic flexure now. I think that’s an argument to take down the splenic flexure first if you are going to take it down, so you don’t have to position the small bowel out of your way, but one time. Now we have freed laterally, medially and posteriorly, we have the possibility to pull on the rectum without touching the tumor.

8. Posterior rectal dissection 07'00''

Do you think that the use of monopolar diathermy to dissect in such a plane is at the moment the most precise way of doing it and is better than for instance a Harmonic scalpel because you continue to be able to see where to go? That’s why Joel uses this technique, it’s exactly what I try to do in open surgery and it’s based entirely on traction, counter-traction and the use of the dissection plane as the principle of the operation. To find the hypogastric nerves at this stage, do you look for them deliberately? So long as you are looking at the shiny back of the mesorectum, it does not matter desperately that you can’t see them immediately. We can see one just there. I personally find that it is helpful to open up in the pararectal sulcus, right and left side before going so deep down here because it helps identify the nerves as you come around laterally and sweep them lateral out of harm’s way but that’s really a matter of taste I think. Certainly it is a bit of a change point in the prognosis and over 20, I think it is death. This is a danger area for the nerve. That’s why we have to open the peritoneum only at the beginning so the nerve, right superior gastric plexus is running there, we are not far from the ureter. The ureter is there. Here is the promontory, the first step in this procedure is to mobilize the sigmoid colon, you also do the ligation of the vessels at their origin and we have deeper the lateral attachment of the vertical segment. After we have the horizontal segment, it’s mainly true in male patients. So you have come around posteriorly first and now you are coming around the right lateral aspect? That’s right but it is only to free the vertical segment. We use 4D retraction, that is that we also use the pressure of the pneumoperitoneum to open the embryological plane. It is at the limit between the white and the yellow. It’s important to appreciate that you do get fat other than mesorectal fat and by getting into this plane, you avoid any risk of tearing those dangerous pre-sacral veins. To complete the dissection, we have to do the anterior part now. Up to now, we have not really touched the colon, the rectum and the tumor.

9. Anterior rectal dissection 11'38''

You see how you can have a plexus injury sometimes, that’s why you have to be incise the peritoneum only. I think it’s easier to damage the nerves in laparoscopic surgery except when you exploit the advantages of magnification. Here are the erigent pillars coming there. This is always one of the trickiest parts of the operation, perhaps you could explain your strategy and why you have incised where you have as you come around laterally to medial or anteriorly? As you know, the danger is to have a nerve stuck to the peritoneum, that is why I incised the peritoneum first. You have very nice traction, would you show us how you lift this rectum now? I have incised the peritoneum not too close to the rectum, more anterior behind same as for prostate and I have the possibility to exert traction like this. I have an assistant pulling on the rectum to maintain it above the pelvis, and sometimes you don’t have to pull too much to have more possibilities to push back the rectum. We have anterior retraction with the peanuts and forceps introduced in the suprapubic trocar. We will remove the uterosacral ligament with the peritoneum. I think that is an important point especially in women who have had episiotomies in the past or trauma from child birth, this plane can be tremendously disrupted. It seems that we have a less clear plane of dissection now. Right, because we have divided the uterosacral ligament and there are vessels in the way. The problem is to know where we will do the resection because we are largely under the tumor. Is it necessary to go deeper? I am reaching the pelvic floor slowly. I am doing the separation with the vagina under the peritoneum. The vagina is there, it was a little bit fixed. Do you think this is a remnant from child birth or something to do with cancer? I think there is a part with the cancer, peritoneal nodule. Nevertheless if there is a small hole in the vaginal fornix, we will close it. Now we are more in the non-pathologic plane, this is why I am having difficulties. You see the vagina is more visible now and the plane will now come very easily. See we can separate like this. I can feel where the tumor is with my instrument. My transection will be done there. I’ll clean my scope. I am just under the mesorectum. I have completely removed the mesorectum. I think he had to get the rectum clearly off the back of the vagina, he wants that anastomosis to have nothing to do with the vagina. I am just above the sphincter, the sphincter is there; you clearly don’t need to do more. When doing a division very low, it is important to have freed completely the low third of the rectum, anterior, lateral, and posterior. I am doing a ligation of the lower rectum to wash the rectal stump before dividing in order to respect the oncological principles stated by Bill Heald.

10. Technical trick to aid rectal retraction 18'17''

A low rectal division will enable me to exert traction on the rectal stump. You can also pull like this. First trick is to have ligation and be able to pull.

11. Transection of distal resection margin 18'30''

I will use a 30mm cartridge. It’s an important point laparoscopically to use a 30mm stapler because as you get very low in the rectum, it gets difficult to get a larger stapler in there if you are going to do a very low anastomosis. What they have shown here with the articulation being further away from where your coming across is a great advantage. However in that case, a 45mm probably would have fit inside. We have seen the pelvic dissection, this is the left colic vein. I am removing the vascular package. Left colic artery, I am dividing the vessels.

12. Further cephalad mesenteric dissection 20'00''

I have the ascending left colic artery crossing the inferior mesenteric vein and left colic vein too. I will divide like this going there. You will not spare these vessels. I am dividing there to keep the network. I think making a pouch will be a good idea because we will do a stoma. If we want to begin chemotherapy rapidly, it is normally necessary to do a stoma.

13. Intracorporeal proximal margin transection 21'26''

I will place the specimen into a plastic bag with double protection to avoid cell spillage. You see it is coming, we will complete the mobilization. I think it’s enough to take down the colon without tension.

14. Extracorporeal specimen delivery and proximal colon preparation for anastomosis 23'33''

We have introduced the specimen in the bag, we close it. In this case, we can do a side-to-end anastomosis, we can do a G-pouch.

15. Intracorporeal re-anastomosis 25'00''

You see it is very well vascularized. OK it’s good, we see you don’t have the other ring. I will close the peritoneum. Beautiful demonstration of the deep pelvis.