Laparoscopic treatment of rectal cancer

This video demonstrates a tumor specific TME resection for a mid-rectal tumor. The surgeon mobilizes the rectum for over 5 cm distal to the tumor margin, in the mesorectal planes. This video demonstrates a beautiful dissection of the pelvic nerves during the mobilization of the mesenteric root. The surgeon carries out an end-to-side anastomosis and protects his anastomosis with a loop ileostomy.

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Laparoscopic treatment of rectal cancer

Authors

J Leroy, J Marescaux

Abstract

This video demonstrates a tumor specific TME resection for a mid-rectal tumor. The surgeon mobilizes the rectum for over 5 cm distal to the tumor margin, in the mesorectal planes. This video demonstrates a beautiful dissection of the pelvic nerves during the mobilization of the mesenteric root. The surgeon carries out an end-to-side anastomosis and protects his anastomosis with a loop ileostomy.

Classification

complex cases

Keywords

Tumor specific TME, rectal resection, laparoscopic, pelvic nerves

Media type

Surgical video

Duration

27'00''

Publication

2005-08

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E-publication

WeBSurg.com, Aug 2005;5(08).
URL: http://www.websurg.com/doi-vd01en1824.htm

Laparoscopic treatment of rectal cancer

1. Case description 00'14''

We’ll do the same approach concerning the oncologic dissection as for TME. This is a TME approach for the dissection but not a TME one for the resection. We have installed the patient in the same position than for a sigmoidectomy. The team is in the same position too. I have added one trocar for a better exposure.

2. Trocar placement 00'40''

This trocar is placed on the right subcostal area under the rib on the mid-clavicular line. It is trocar F. Trocar F is used to mobilize the splenic flexure. It is also used to maintain an orthostatic retraction of the ileo-cecum when the cecum is falling. The first step is to retract the omentum cephalad, hence placing in a free space the greater omentum above the transverse mesocolon. Until now, the patient lies in a normal position. We will place the patient in Trendelenburg position now. I’m catching the small bowel pushing it mainly to the right and pushing different loops above the ones I have previously retracted. Here we have the duodenojejunal junction visible here. Here’s the IMV. I will not push the bowel to the right. I will only use this forceps. The loops are above as you see, maintained by an orthostatic retraction. The danger is to place the tip of this instrument on the bowel because there is a risk of compression and ischemia at a distance. We have a long sigmoid loop, very spastic with a diverticulum, which we need to remove to avoid functional problems postoperatively. We want to check and feel where the tumor is. This is a huge tumor here. I will start dissecting soon. This is the sacral promontory and my objective is to incise the peritoneum. We now see the third duodenum. Once we have reached this area, we continue the incision towards the splenic flexure to find the plane anterior to the vein. Now that I have incised I will change the retraction. I ask my assistant to lift this. Dissection continues plane after plane and using traction and counter-traction to open the plane.

3. Left branch of sympathetic trunk 05'00''

You can see the plexus trunk on the left. This is the left branch of the sympathetic trunk. We have to divide the left branch.

We are using the Ligasure. I will show you the danger of using this instrument when there is an artery with sclerosis. I don’t divide the artery completely. You have to continue the dissection behind the vascular sheath. We will divide the branch of the plexus that gets to the left side of the artery paying attention to stay close to the artery. This is probably the left branch of the left colic vessels. There are nerve branches. The plexus is behind. I will continue to find Toldt’s fascia not dissecting here, but staying close to the vascular sheath. We are anterior to Toldt’s fascia. I can seal. Perhaps it’s not necessary to divide more. I will seal that to maintain the small bowel loops above. When you are in the right plane, it’s completely avascular. You can see that we have some difficulties in exposing better because the sigmoid colon is huge. In this case, we will free the sigmoid colon laterally. We did a primary vascular approach medially. It is the traction with my left hand that creates this. Traction, then action with my electrocautery device staying close to the visceral fascia! I want to free laterally because the sigmoid loop is maintained in the pelvis. Attachments are divided when freeing laterally. You see that these are probably genital vessels. If I see so well, it’s because I’m not in the right plane. I am just behind the fascia and we see that very well here. We are correcting this. Now I have just found the medial dissection done previously. You can see the ureter.

5. Posterior dissection of rectum 11'06''

I try to stay close to the fascia propria of the rectum. Now I change since I can pull the sigmoid cephalad. I have to open the space. This is the lateral fascia. I’m dissecting close to it and not far from the nerve. The tumor lies anteriorly. It is rolling under my peanuts. The hypogastric nerves are here. You can use a medial traction and you see there is a seroma. Mobility is limited. We have to free anteriorly now. We have to stay close to the parietal fascia. I think I have to do a TME too since till now I’m not under the tumor. I will keep a rectal stump; I will not do a colo-anal anastomosis but I’ll do an anterior resection. I have to carry out the dissection medially and on the right. I don’t try to dissect too low.

6. Anterior dissection of rectum 14'07''

Going from right to left, I will free millimetre by millimetre until we find the right plane. In this case, I’ll do it anterior to Denonvilliers’ fascia. The tumor is here. These are nerve branches. I’m dividing branches of nerves. This is a nerve I’m dividing getting to the rectum, then another branch just behind. These are the pillar of the erigentes. We will continue on the left. We don’t want to touch the tumor too much. I’m opening the peritoneum. Once I have divided this, I will be able to enter the prerectal space. This is the Denonvilliers’ fascia. I think that I am several centimetres (6 to 7cm) under the tumor. Anteriorly it is fixed. The pelvic floor is not far from here and I will divide at this level probably. I’m now separating from right to left anteriorly to the rectum. The Denonvilliers’ fascia is just here. This is the rectum. You see the tumor is coming now. We will do a posterior approach because of the volume we cannot put instruments anteriorly. I’m behind dividing anterior to the sacrum. This is the left mid-rectal artery. Now we will have more mobility. The tumor is beginning approximately here and ends there. Now we’ll do a lower dissection. This is the rectum. I have dissected this part of the rectum. I have to check posteriorly. I will divide the sacrorectal ligament that you have here. This will allow us to get 1-2cm in length.

7. Rectal resection 21'00''

I’m introducing a 35mm. Now we’re dividing the IMV and we remove the sigmoid mesocolon. We will keep and do the anastomosis approximately at this level. We’re using the stapler here. We have divided the tumor and the mesorectum. We then have to remove the specimen.

8. Specimen extraction 22'59''

And we will do a suprapubic transverse incision. We have put a plastic drape to protect. I will introduce an Endocatch device and push it into the bag and we will push the tumor in the bag. We’re closing the bag and we will remove it through the plastic drape. Arteries are beating so we have to mobilize the splenic flexure. I will continue the dissection a bit further. We see that we are anterior to Toldt’s fascia. So we lift the mesocolon. We have to stay close and posterior to the mesocolon, not on the pancreas. We have a good plane. I’m not using Ligasure or other thermal devices close to the tail. The lesser sac is open here. Now we will divide the attachments to the pancreas. Here is the pancreatic tail. If we don’t understand the situation medially, we have to continue laterally and we see the lateral attachments. You see a venous stasis here so there is ischemia. So we will do the anastomosis on this part without problems. We will do the extraction now.

9. Anastomosis 26'00''

It’s a side-to-end anastomosis. It’s similar to coloplasty because you divide the fibres of the muscles. We will do an ileostomy and select the bowel loop for the ileostomy.