Laparoscopic low anterior resection for rectal cancer

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Laparoscopic low anterior resection for rectal cancer

Authors

J Leroy, J Marescaux

Keywords

résection antérieure basse,iléostomie

Media type

Surgical video

Duration

19'00''

Publication

2004-12

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E-publication

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1597.htm

Laparoscopic low anterior resection for rectal cancer

1. Patient position and trocar placement 00'13''

It’s a patient with a BMI above 34-35. I am on the right side with the team, except for the 2nd assistant standing between the patient’s legs. The patient is placed in a Lloyd-Davis modified position, with the right arm alongside the body, left right angle to the patient and operating table. I have introduced the different trocars. Let’s begin with the trocar that is just above the umbilicus, about 20cm above the pubic bone. I will use a zero degree scope. There are two 5mm trocars at the crossing between the horizontal line through the umbilicus and the mid-clavicular line on the right and on the left. Ten centimetres lower I have introduced trocar B and another trocar, a 12mm one. Then I have another trocar that I will use for specimen extraction in the suprapubic area. I will do the extraction through a Pfannenstiel incision probably just under the rib. This trocar will be used to retract the ileocaecum in cases of difficulty. We have insufflated around 4 or 4.5 liters of CO2.

2. Exposure 01'34''

Slowly the omentum and the bowel fall in this area. This area will be for retraction of structures. You see the small bowel that is completely flat. It was not necessary to use more trocars. Here is the appendix that is fixed. We have a wide space so obesity is not always a handicap. I have retracted and arranged the small bowel. Don’t put all of the small bowel to the right laterally. I slide my instruments this way laterally to the duodenojejunal junction and I make sure to check that I’m not against the small bowel. And I place my instrument this way and the angulation between the posterior abdominal cavity and the instrument is sufficient to maintain it orthostatically. You can see the uterus here. We have a long sigmoid loop. There’s a little diverticulum so it will not be necessary to resect too much probably. We see the tumor here. This is the umbilication. We will fix the uterus anteriorly using a stitch and we can do it since this patient is 60 years old. If it was a young patient, I’d put this around the round ligament. We put it outside.

3. Vascular approach 04'03''

Here is the promontory and I begin anteriorly to do the promontory. I have to find out where the origin of the artery is. Now I ask my assistant to lift anteriorly. We remove the lymph node here. We are using the Ligasure Atlas®. I’m dividing the artery. Now I ask my assistant to grasp the artery and to lift it anteriorly this way. The bipolar probably would be better but I don’t think there is a danger. It’s an elective dissection. I use very low power bipolar. I’m dividing the branches of the trunk, which is here. It goes to the artery laterally. These are nodes. Here’s Toldt’s fascia. So we can ligate the IMV. I seal the vein, I don’t cut it. It is mainly traction that does the dissection. I use scissors. I have to stay anteriorly to Toldt’s fascia. It’s better to find the plane that lies anterior to the sacrum. This is the plexus. We divide only the branch of the plexus that runs to the mesosigmoid.

4. Colon mobilization 08'58''

We stay anteriorly to the plexus. Because I have a long sigmoid loop, I will free laterally beforehand. You pull towards the right hypochondrium for exposure. In this case, won’t you mobilize the splenic flexure? It will depend on the vascularization. I have the plane related to the medial approach.

5. Upper rectum mobilization 10'35''

I will now have more possibilities to pull on the sigmoid to have a better exposure like this one. As you may know, surgery is the science of the plane and it’s particularly true for the rectum. I will change the position of the trocar on the left putting it under that to have a better traction and expose this way and to have a 4-directional retraction as put forward by Bill Heald. By using this technique of anatomical planes, you don’t have to care for your left ureter. No because I’m anterior to Toldt’s fascia and if I have difficulties, I will care. I now have to enter between the presacral fascia that prolongs Toldt’s fascia. This is traction and counter-traction. I have to continue dissection staying close to the presacral fascia and the parietal fascia laterally. Slowly we continue dissection lower down. We only have to divide the nerve that crosses the space. Lower as you will see soon, we have to dissect behind the presacral fascia. I will continue dissection laterally. Posteriorly I try to mobilize the rectum. I will continue anteriorly now because I have freed enough posteriorly. We have the limit of the tumor. We have a good view. This is the uterosacral ligament. Scissors are interesting in this case. Now we can clearly see Douglas’s pouch. I think you can go for a classic anterior resection. Yes indeed if we want to respect oncological principles. The sympathetic trunk is more medially. I use the Ligasure now. These are branches of nerve coming from the plexus and running towards the rectum. It seems that there is a small artery. We will divide the branch. You can also use ultrasound scissors. I’m preparing the rectal stump. What is important is to do a cylindrical dissection of the mesorectum. It’s not a tronconical dissection. 2cm is enough, 5cm is better. But it’s not easy to evaluate the inferior limit of the tumor until now. The best way is to use endoscopic exploration. We can do it close to the rectum because it’s not warming. How can you be sure that the rectal wall is not included in your bites? The difference with a 5mm, you slide against the structures. You don’t create a wrong plane. A long time ago, I recommended a 5mm trying to reduce the size of the instrument but I have discovered the new 10mm instrument working like a finger. I tried it and I agree that you can do a fine dissection, not too aggressive. I can do it close to the rectum. We will be 7cm under the tumor. You can also put a ligature underneath. The advantage is that you can pull on this suture to have a better traction and atraumatic orientation of your rectal stump to apply your stapler.

6. Rectosigmoid division 17'02''

I use a 30mm one, which is better for the rectum as you will see. We’ll use 2 cartridges. I have to divide the vein. You can see the ureter here. To give you a better exposure, I want to get the proper limit. I may resect more afterwards. I use the stapler again. I don’t want to do the specimen extraction without a plastic bag.

7. Extraction 18'35''

I will now do the extraction. I’m putting a wound protector plastic drape and I push it into the abdominal cavity. I want to take the specimen with the forceps on the left. We open the bag and place the specimen into the bag. I will close the bag and remove the specimen. I think that I am 7cm underneath the tumor.

8. Anastomosis 19'48''

Let’s use a Babcock forceps. Now an Allis forceps. Now we reintroduce all into the abdomen. A good trick is also to twist the plastic bag so that you can insufflate again. Routinely I bring the stapler with the right hand by myself. We verify that there is no twist, no tension. As in Japan where we find patients with long compliant loops, it’s easier to do this surgery. We can also control the anastomosis using an airtest. We also control the ring that looks perfect.