Laparoscopic abdominoperineal excision for T4 rectal cancer

This video demonstrates a laparoscopic abdominoperineal resection in a patient with large distal rectal tumor. The sigmoid colon and rectum down to pelvic floor are mobilized laparoscopically. The IMA is divided at the root. The sigmoid colon in divided in its midpoint and a permanent colostomy is contructed. In this case, the surgeon then closes all the laparoscopic ports and turns the patient into the Jack-knife position and completes the perineal portion with patient prone. The tumor is delivered through the perineal wound after complete mobilization of the distal rectum is achieved.

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Laparoscopic abdominoperineal excision for T4 rectal cancer

Authors

J Leroy, J Marescaux

Abstract

This video demonstrates a laparoscopic abdominoperineal resection in a patient with large distal rectal tumor. The sigmoid colon and rectum down to pelvic floor are mobilized laparoscopically. The IMA is divided at the root. The sigmoid colon in divided in its midpoint and a permanent colostomy is contructed. In this case, the surgeon then closes all the laparoscopic ports and turns the patient into the Jack-knife position and completes the perineal portion with patient prone. The tumor is delivered through the perineal wound after complete mobilization of the distal rectum is achieved.

Classification

complex cases

Keywords

Rectum, cancer, abdominoperineal resection, laparoscopic

Media type

Surgical video

Duration

06'00''

Publication

2005-08

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E-publication

WeBSurg.com, Aug 2005;5(08).
URL: http://www.websurg.com/doi-vd01en1692.htm

Laparoscopic abdominoperineal excision for T4 rectal cancer

1. Trocar placement 00'06''

This is the case of a male patient with a T4 rectal cancer for which abdominal perineal excision is required. This patient as well had preoperative radiotherapy. As you can see here we have 5 operative ports, one in the supra-umbilical region, 2 in the right mid-clavicular line

2. Exposure of small bowel 00'23''

and additional ports in the left clavicular line for a future stoma site, which is being utilized here to retract the small bowel, and then finally one port in the suprapubic region.

3. Aorta 00'40''

We review the anatomy and note the aorta and the approximate site of the inferior mesenteric artery. We begin our medial dissection with monopolar cautery and endo-shears. We will maintain the mesentery in place here as it aids in the retraction of the small bowel during our dissection into the pelvis.

We feel this gains significant time in the overall procedure. Here you can see the inferior mesenteric artery. The IMA is ligated with the Ligasure device 1cm from the aorta in keeping with the oncologic principles of the procedure. Further dissection continues after this is completed.

5. Medial dissection 01'40''

We note the lymph node in the area for which we will dissect and add to the surgical specimen. Maintaining in this avascular plane

6. Genital vessels 01'54''

We can continue our dissection posterior-laterally through the mesentery of the left and sigmoid colon.

7. Left ureter 02'04''

Here we have identified the left ureter. We coagulate the IMV first in keeping with the oncologic principles of the procedure. Continued medial dissection and down to the rectum is then advanced. The Ligasure device is as well used as a blunt dissector. Lateral attachments are now taken down with the monopolar cautery.

8. Lateral dissection 02'38''

We note in a patient such as this with a large T4 lesion an abdominal perineal excision is required. With the use of the laparoscopic technique we feel the patient has benefited in many ways. We have not seen more perineal incisional hernias in these patients versus the open technique. We know from our operative series that significant time-savings can be had not only with other laparoscopic procedures but as well with a laparoscopic procedure compared to the open abdominal perineal excision procedure. As we continue down to the rectum, another benefit of the laparoscopic technique is the better visualization. We have found as well less blood loss with our procedures in the laparoscopic versus open comparison. Continued dissection into the mesentery is now undertaken. We determine the proximal site of the resection here where the GIA device that is utilized.

9. Division of colon 03'42''

This male patient with a narrow pelvis and fatty patient with a large low line rectal tumor, it is prudent to complete the dissection en bloc. We begin with monopolar cautery;

10. Posterior dissection of rectum 03'57''

note that during our dissection we have no manipulation of the rectum or tumor in keeping with the oncologic principles. And we continue in the avascular plane anterior to the sacrum into this intrafascial presacral plane which is anterior to the superior epigastric nerve plexus. We now decrease nerve injuries in the form of impotence and ejaculation disorders. In both a male and female patient, we note significant improvements in urinary retention. The edema that you see here is due to the radiotherapy the patient received preoperatively.

11. Anterior dissection of rectum 04'42''

Now we continue our dissection anteriorly. At this time, we note that we need more tension in our dissection. So we introduce a 5mm retracting device to aid in our retraction to continue our dissection in Denonvilliers’ fascia. We are now at the level of the lateral attachments in the pelvis.

12. Colostomy 05'08''

Here we are preparing the “ostomy” site and it is used from the left mid-clavicular port site.

13. Perineal dissection and specimen extraction 05'19''

Now we begin our transperineal approach. It is described well by Nichols to complete the lower rectal dissection via the perineal approach. Monopolar cautery is used through the initial plane and then maintaining oncologic principles, we include the perirectal fat. Our dissection did not go past the lateral attachments with a laparoscopic approach as well adhering to oncologic principles. The Ligasure device is used once again to continue in our dissection and we note good hemostasis with it. Our specimen is now able to be removed and evacuation of any blood is then done and the site is noted to be hemostatic. Drains are placed in the extraperitoneal rectal space with a trocar. The rectal space is approximated with multilayer suture repair and the procedure is complete.