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TME with LigaSure Advance®: coloanal anastomosis on the J-pouch after failed closure of the rectal stump

Authors

Abstract

This video presents a TME with creation of a J-pouch for a coloanal anastomosis. A thorough description of the operative steps is presented. This video is recommended for digestive surgeons.

Classification

basic techniques

Keywords

TME, LigaSure Advance, coloanal anastomosis, J-pouch after failed closure of rectal stump, cancer, rectum

Media type

Duration

24'42''

Publication

2008-09

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Audio

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E-publication

WeBSurg.com, Sept 2008;8(09).
URL: http://www.websurg.com/doi-vd01en2372.htm

TME with LigaSure Advance®: coloanal anastomosis on the J-pouch after failed closure of the rectal stump

1. Exposure 00'11''

We have the promontory there. We keep a maximum of the peritoneum. It is mainly for the end of the procedure when we have to close the gap; if we keep more peritoneum anterior to the aorta, it is easier to close. Seal and cut using bipolar and monopolar as you see now. The main objective at this moment is to divide the IMA at its origin. To do so, we use good traction and counter-traction to expose the root of the mesosigmoid. For the exposure, we have only used the positioning of the patient: Trendelenburg with a right lateral tilt, before we put a pillow.

2. Inferior mesenteric artery dissection 01'31''

You see the vascular sheet here very well and we will dissect by staying close to it. I open the vascular sheet there. We see the plexus trunk very well; if we do a more lateral traction, we are sliding behind, we are dissecting slowly. We can also use monopolar because we are sure that there is no contact except at the tip, this will facilitate the division.

3. Inferior mesenteric artery division 02'26''

The division can be done using a LigaSure without tension at a 2cm distance; the only limit is the quality of the vessels, in elderly patients particularly. We change traction and we will divide only the branch of the plexus. These are the branches that are divided. When we have divided the plexus branch, we have to continue the dissection to go behind the IMV.

4. Identification and dissection of inferior mesenteric vein 03'34''

The IMV is lateral to the duodenojejunal junction, we can see it very well there. See the vein is there, this is the IMV running lateral to the duodenojejunal junction. When we dissect it, we can dissect very high, sometimes have to keep the left colic vessels, the left colic vein, which we will do in this case, I don’t think it is not an oncologic problem. The only problem if we do the dissection is to be close to the vein, particularly back to it because if we don’t, we will be behind the fascia.

5. Division of left colic vessels 04'32''

You see the left colic vessels and we will divide the vein too.

6. Completion medial dissection 04'42''

This is the right plane we have anterior to the Toldt’s fascia, we see that very well, we reduce the power of the monopolar. We see the ureter very well, it is the white structure, this is the ureter crossing.

7. Lateral dissection 05'22''

What we will do now is the lateral freeing of the sigmoid. We unfold this because we have the possibility to pull on the rectum. The lateral freeing is a similar step to the one we do in open procedures when we reproduce Professor Heald’s standards. We change the orientation like this to free now the lateral attachment. The energy used is 10 Watts, so we can place pressure with the head of the device. With more power you cut very fast. We have freed the lateral attachment of the sigmoid and now we have the possibility to grasp with the forceps introduced in the left hypochondrium and with the forceps introduced in the suprapubic area, we will apply posterior traction like this.

8. Rectum: dissection of posterior segment 07'37''

We begin the dissection of the posterior aspect of the vertical segment of the rectum, plexus trunk, but as you see we slide on the propria fascia of the rectum when pushing with the instrument. The main advantage is the shape of the device because we are using the shape to dissect. I am sliding, we are using the plane. It is better to be behind the presacral fascia than inside the propria fascia of the rectum.

9. Uterus dissection 09'49''

We have fixation to the uterus now so we’ll do an ‘en bloc’ resection. This is the uterus. The main difficulty in this case is to identify the main landmarks.

10. Rectum: lateral dissection 11'13''

We have to do the lateral dissection now using the blade like this. We separate the plane. These are nerve branches probably. Now we’re doing the freeing of the horizontal segment.

11. Rectum: anterior dissection 12'31''

We have to find the back of the vagina. I think I’m reaching it. It’s coming. We increase the power. Here’s the vaginal wall. I want to go on this side.

12. Distal rectum and mesocolon division 16'29''

We use the stapler. And we open. We can pull. This is the artery and here’s the vein. I have to divide to remove the vascular package keeping the vascularization of the marginal vessels. It’s only to remove the vascular package with the nodes we can see well. The vascular package is there with artery and vein. I’m dividing now the mesentery probably lower than where I will divide the colon to keep a better vascularization of the segment I’ll use for doing the J pouch.

13. Proximal rectum division 17'57''

Stapler again. I will take down this segment.

14. Specimen extraction and creation of the J-pouch 19'05''

I use 2 Kelly forceps. This is well vascularized. This is a beautiful reservoir. We will do a hand-made anastomosis and will close this before doing it. It is a temporary closure, not a long suture, only 2 or 3 stitches, not too much tightened. It’s only to maintain the closure and have an easy access.

15. J-pouch anastomosis 21'49''

We first have to finish the dissection trans-anally. We put this thread trans-anally.

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