Laparoscopic partial TME with side-to-end coloanal anastomosis in a female patient

The laparoscopic approach for rectal tumors is a technically demanding procedure, but it is safe and it has the feature of an oncologic procedure. The objective of this video is to demonstrate a standardized technique for the treatment of cancers of the upper rectum in a female patient. The therapeutic strategy includes a partial rectal resection with total mesorectal excision followed by a colorectal anastomosis on the inferior third of the rectum.

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Laparoscopic partial TME with side-to-end coloanal anastomosis in a female patient

Authors

J Leroy, J Marescaux

Abstract

The laparoscopic approach for rectal tumors is a technically demanding procedure, but it is safe and it has the feature of an oncologic procedure. The objective of this video is to demonstrate a standardized technique for the treatment of cancers of the upper rectum in a female patient. The therapeutic strategy includes a partial rectal resection with total mesorectal excision followed by a colorectal anastomosis on the inferior third of the rectum.

Classification

routine cases

Keywords

Laparoscopic partial TME, side-to-end coloanal anastomosis, female patient

Media type

Surgical video

Duration

18'00''

Publication

2009-09

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E-publication

WeBSurg.com, Sept 2009;9(09).
URL: http://www.websurg.com/doi-vd01en2548.htm

Laparoscopic partial TME with side-to-end coloanal anastomosis in a female patient

1. Introduction 00'10''

The objective of this video is to demonstrate a standardized technique for the treatment of cancers of the upper rectum in a female patient. The therapeutic strategy includes a partial rectal resection with total mesorectal excision followed by a colorectal anastomosis of the inferior third of the rectum.

2. Pelvis exposure 00'28''

The first operative step is the perfect exposure of the pelvis. To do so, suspension of the uterus is achieved using transparietal percutaneous threads passed underneath the round ligaments. Then the root of the sigmoid mesocolon is exposed.

3. IMA dissection and division 00'44''

The inferior mesenteric artery is dissected and the sigmoid colon is mobilized: this is the first step of the surgical procedure that aims to reproduce the open technique standardized by Professor Heald. Dissection of the artery is performed using a medial approach; the surgical team is situated to the patient’s right. Dissection is facilitated by an anterior traction placed on the sigmoid mesocolon. The peritoneum is largely opened from the anterior border of the sacral promontory until the external border of the duodenojejunal junction. The artery is skeletonized and attention must be paid to avoid a dissection performed too proximal to the aorta in order to respect the nerve plexuses that are essential even in women with regards not only to sexual but also urinary problems. The nerve structures are parietalized continuing the dissection in contact to the IMA. This artery can be divided either by clip application, ligatures, or also using the Ligasure device as in the present case, but this division is carried out at least 2cm away from the aorta in order to potentially achieve an easier hemostatic control in case of bleeding. This, however, is sufficient oncologically speaking provided the artery has been perfectly skeletonized. Dissection is pursued owing to an adequate anterior traction of the mesentery.

4. IMV dissection and division 02'57''

Dissection towards the duodenojejunal junction is achieved by keeping contact on the posterior aspect of the descending mesocolon until exposing the inferior mesenteric vein just underneath the inferior border of the pancreas. Division is performed using the Ligasure Atlas device along with placement of a Vicryl loop.

5. Colon mobilization 03'45''

Once the vein and the artery have been ligated, the sigmoid colon is mobilized and freed from its lateral attachments. This freeing is achieved using monopolar scissors thanks to a gentle traction on the lateral attachments until the posterior dissection plane is once again identified as it was performed using a medial approach. This posterior plane helped to achieve an anterior dissection of the retroperitoneal structures. Dissection is completed towards the splenic flexure in order to facilitate the lowering of the left colon later on.

6. Mesorectal dissection 04'38''

Dissection of the mesorectum may be started. This dissection is carried out on the posterior aspect of the mesorectum staying within the presacral space and posterior to the fascia propria in order to better preserve the nerve plexuses, and especially the superior hypogastric plexus perfectly visible by transparency in most cases. Since the sigmoid mesocolon has been perfectly freed, an adequate traction can be placed on the rectum and nerve structures, fascias and ligaments can be well exposed. The right uterosacral ligament just divided, dissection in contact to the fascia propria is continued laterally. This fascia propria is retracted using peanut swabs, which allow for blunt traction and avoid opening the fascia propria that would be a mistake oncologically speaking. It is indeed recommended to avoid opening the fascia propria. Dissection of the rectum is carried out between two fascias, the presacral fascia and the fascia propria of the rectum. Dissection is then continued. It is facilitated by tension exerted on the tissues through peanut swabs. As one finger is used in open surgery, the swabs allow for traction without any risk of opening the fascia propria. Tension on the fibrous tracts facilitates the dissection in the appropriate plane by opening the space between the parietal fascia and the fascia propria of the rectum. Dissection of the upper rectum on its posterior aspect is the easiest operative step. Dissection still needs to be pursued laterally thanks to a correct traction and counter-traction. The lateral attachments are further taken down. Here, the left uterosacral ligament has just been divided. The Douglas’ pouch still needs to be opened. Dissection should be performed in contact to the posterior vaginal wall. This is achieved owing to a correct traction and counter-traction that helps to open the spaces using Professor Heald’s technique, namely the 3-directional retraction along with the pressure of the pneumoperitoneum (which I call the “4-directional retraction”). The cellular spaces to be dissected are opened in order to apply low-power voltage with monopolar scissors that will allow for the division of the fibrous tracts. The opening of planes is facilitated only by the technique of traction and counter-traction. We always use a zero degree scope with a high definition camera that allows for a correct visualization of the anatomical structures as had never been better shown before at the time of open surgery.

7. Rectal stump ligation and lavage 09'45''

Once the dissection has been completed, the rectal stump is ligated underneath the tumor and underneath the mesorectum using an extracorporeal ligature system (the EndoSuture System). Closure of the stump is done tightly enough to perform a lavage of the rectal stump with a Betadine solution. This lavage will permit the evacuation of any tumoral cells. It will also facilitate the introduction of the stapler later on. Thanks to the ligature, a 6cm articulated stapler can be used, thus avoiding the use of too many cartridges. The rectal stump is then controlled using the finger and through a Betadine solution lavage to rule out any leakage. Then the vascular package containing all lymph nodes needs to be resected. The sigmoid mesocolon also needs to be divided until the region selected to perform the colorectal anastomosis. In the present case, a side-to-end anastomosis is performed. The portion of colon used here seems well vascularized. A portion of the stump needs to be preserved so that the anvil may be introduced later on before doing another re-cut.

8. Colon division 11'46''

The colon is divided by stapling. Then the proximal end of the bowel segment to be resected is closed by keeping the thread long enough to simply have a landmark in the plastic bag. The bag is introduced through a plastic wound protector that protects the abdominal wall. It is then all introduced through a suprapubic incision.

9. Colon exteriorization 12'50''

Thanks to the thread left in place and coming out of the plastic bag, the exteriorization is then made easier since we have a landmark at bag level, which allows for an easy extraction of the specimen. We check that the tumor is sufficiently distal and the colon is exteriorized through the wound protector itself placed through a small suprapubic Pfannenstiel incision.

10. Introduction of the anvil 13'20''

The anastomosis is prepared outside. The anvil of a DST PCEEA 28 circular stapler is introduced proximally. This anvil is brought out in order to perform a side-to-end anastomosis. The extremity of the colon is divided by one application of staples, which is then buried using a running suture of Maxon 3/0 that secures the stapled area. Closure should be perfect in order to prevent any potential leakage. The stapled area should be located at least 2cm from the circular stapled area to avoid the risk of ischemia of the distal stump.

11. Side-to-end anastomosis 14'56''

The anvil is reintroduced along with the colon into the abdominal cavity, which is re-insufflated before performing the side-to-end anastomosis with the DST PCEEA circular stapler as can be seen on the pictures here. This will recreate a small reservoir, which will avoid an increased frequency of stools and fragmentation phenomena in the first postoperative year.

12. Mesocolic defect closure 15'45''

Then the mesocolic defect should be closed. This closure is performed either by stapling, or by a running suture going through the mesocolic and lateral aortic peritoneal borders, as in the present case. It is recommended to use a monofilament thread, here Maxon 3/0, that slides easily and avoids traction after each stitch, as this is a time-consuming operative step. Therefore monofilament material helps to place traction on the thread after several needle passages, which saves time. No drain will be used and in this case, no protective stomy is necessary.