Totally laparoscopic TME in a male patient with a side-to-end mechanical anastomosis

Total mesorectal excision (TME) of the rectum has been advocated as the gold surgical treatment of the middle and low third rectal cancer. This video clearly demonstrates a totally laparoscopic TME in a male patient with a side-to-end anastomosis according to the principle of TME as described by Professor Heald in open surgery.

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Totally laparoscopic TME in a male patient with a side-to-end mechanical anastomosis

Authors

J Leroy, J Marescaux

Abstract

Total mesorectal excision (TME) of the rectum has been advocated as the gold surgical treatment of the middle and low third rectal cancer. This video clearly demonstrates a totally laparoscopic TME in a male patient with a side-to-end anastomosis according to the principle of TME as described by Professor Heald in open surgery.

Classification

complex cases

Keywords

Totally laparoscopic TME, male patient, side-to-end mechanical anastomosis

Media type

Surgical video

Duration

19'22''

Publication

2009-04

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E-publication

WeBSurg.com, Apr 2009;9(04).
URL: http://www.websurg.com/doi-vd01en2572.htm

Totally laparoscopic TME in a male patient with a side-to-end mechanical anastomosis

1. Introduction 00'10''

The objective of this film is to show the technique of rectal dissection according to the principle of TME as described by Professor Heald in open surgery. As in open surgery, mobilization of the sigmoid colon is first achieved.

2. Division of the inferior mesenteric vessels 00'24''

To do so, the inferior mesenteric artery is divided close to its origin followed by division of the inferior mesenteric vein although it can be simply clipped or sutured by the Ligasure Atlas device as in our case presentation. This is carried out to maintain the small bowel above the mesocolon.

3. Medial approach for sigmoid colon dissection 00'42''

The freeing of the sigmoid colon is performed using a medial approach. It requires a posterior and lateral dissection of the sigmoid colon attachments through the incision of the parietocolic gutter from caudad to cephalad until the splenic flexure at the level of the phrenocolic ligament. Dissection is then continued caudally; the objective is to free the sigmoid colon in order to grasp it and place traction on the rectum. Some authors offer to free the splenic flexure before. Personally I prefer to do it later to limit the mobilization to no more than what is necessary in order to have a tension-free anastomosis. Once the sigmoid colon has been freed in compliance with oncologic principles (i.e., after a primary vascular approach), traction is placed on the mesorectum and on the rectum. Traction is exerted cephalad and anteriorly thanks to forceps introduced suprapubically and in the right iliac fossa. The surgeon uses both trocars situated in the right iliac fossa to bluntly retract the posterior rectal wall thanks to peanut swabs mounted on the tip of the forceps.

4. Upper mesorectal dissection 02'26''

Here we can see the dissection being performed between the presacral fascia and the fascia propria of the rectum as well as between the lateral pelvic fascia and the fascia propria of the rectum. Traction must be placed atraumatically and the best means to avoid using the surgeon’s fingers in open surgery is to use peanut swabs, which allow to retract the fascia propria of the rectum in a blunt fashion without any risk of tearing it. Such a risk may induce metastasis in the event of mesorectal invasion. Here we can see that the nerve branches originating from the superior hypogastric plexus are well in contact with both the parietal fascia and the fascia propria of the rectum. Thanks to an adequate traction and counter-traction, ensuring a three-directional retraction as described by Professor Heald in open surgery, embryological planes are identified. After freeing of the vertical portion of the mesorectum (i.e., the superior third and middle third of the rectum on its posterior aspect), dissection of the lower rectum is continued.

5. Lower mesorectal dissection 03'33''

The best way is to open the Douglas’ pouch on the posterior aspect of the bladder, which allows to place traction on the peritoneum on the anterior aspect of the rectum. Such traction is exerted posteriorly while the assistant standing between the patient’s legs exerts an anterior traction, thereby allowing both the maintenance and the distal retraction of the genitourinary structures. Here we can clearly see the seminal vesicle to the left as well as to the right, and the best way to stay in the right plane is to place another medial traction and counter-traction before using scissors. The objective is to stay in the embryological plane either on the posterior aspect of Denonvilliers’ aponeurosis, either on the anterior aspect depending on the lesion’s site. Retraction must be completed thanks to a retractor introduced suprapubically. Here we use a 10mm T-retractor, which allows for a posterior to anterior traction in order to increase tension on tissues between the Denonvilliers’ fascia and the perirectal fascia. Here we can see the lateral dissection, which reaches close to the anterior aspect of the rectum. Erectile nerves of the sacral branches of the inferior hypogastric plexus can be clearly seen posteriorly. Dissection is continued by retracting the rectum posteriorly in order to reach a vascular branch, which is here the middle rectal artery. This artery is divided using monopolar cautery scissors, but this can be also carried out with the Ligasure Atlas device. The middle rectal artery can be seen here. Its cauterized stump retracts progressively. A few venous plexuses are bleeding during the dissection and the ideal way is to cauterize using the bipolar forceps or even better using the Ligasure device. This allows to seal and divide the tissues while staying in the proper plane. 5mm instruments such as the Ligasure Advance allow to perform the whole maneuver, using both monopolar dissection and coagulation. Dissection is continued to the left, and thanks to an adequate anterior traction and a posterior retraction, another middle rectal vascular branch is visible here to the left, which is usually rarely found since bilateral middle rectal branches are encountered in 20% of patients. In order to respect oncological principles, once the lower rectum has been dissected, a ligature is performed underneath the mesorectum using an extracorporeal knot. To do so, an EndoSuture System is used and allows to ligate using a 2/0 Ethibond thread, which is kept long. The advantage of this ligature is to exclude the rectal stump, which is washed using a Betadine solution. This lavage allows to eliminate any tumoral cells that would have fallen into the rectal lumen.

6. Division of the rectum 08'52''

This ligature also helps to place an adequate traction on the stump, which is then divided using the Endo-GIA linear stapler, blue cartridge. Often we use 30mm long cartridges, which allow for an easy introduction, especially in male patients with a narrow pelvis. Two stapling applications are generally sufficient, especially if the ligature has been carried out and the rectal extremity has been perfectly dissected from adjacent tissues as it is the case here. Division is achieved by crossing the 2 stapling areas according to the “Chinese hat” principle, which ensures a crossing stapling line without the risk of ischemia. Once the rectum has been divided, hemostasis is controlled. Then the maneuver is continued proximally. The anastomotic area has to be chosen. To do so, this area has to be compliant, diverticular-free, and as can be seen in these pictures, an area situated on the upper portion of the sigmoid colon has been chosen, just above a diverticulum that will be excised. The vascular package including lymph nodes is resected.

7. Mesocolon division 10'15''

The mesocolon is divided slightly beyond the future area of division of the colon in order to preserve the vascularization of the marginal arteries at the anastomotic site. The Ligasure Atlas device is used. It allows for an effective division and for a correct hemostasis of tissues. The proximal colon is divided slightly beyond the future anastomotic area. A portion of colon is kept beyond this area in order to be used later for the introduction of the anvil of the circular stapler. The anastomosis is a side-to-end one. The possibility of a tension-free lowering of the colonic extremity must be checked. Mobilization may be completed if necessary, which is true in more than 90% of patients operated. This mobilization may simply be a lateral freeing as in our case, with freeing of the lateral attachments of the splenic flexure and of the left transverse colon. Attachments between the greater omentum and the descending colon may also be taken down as in this case. But above all the phrenocolic attachments are taken down and the lesser sac is opened using a lateral approach. This allows to free the posterior aspect of the splenic flexure. In most cases, this is sufficient to take down the left colon without too much traction, even without any in the pelvis. But if necessary, larger freeing of the medial portion of the transverse mesocolon can be performed.

8. Colon extraction and anastomosis preparation 13'06''

The diseased colonic segment is introduced into an Endo-catch II plastic bag deployed in the abdominal cavity once it has been introduced through a transverse suprapubic incision covered by a plastic wound protector well visible here. Extraction is generally easy by manipulation of the specimen into the plastic bag. Then the proximal colon is brought externally. This is possible when the abdominal wall is not too thick. In case the wall is too thick, especially in obese patients, one portion only is exteriorized; its extremity, which was kept a bit longer is then opened in order to introduce the anvil of the DST PCEEA 28 circular stapler. The spike of the anvil is introduced into the lumen and brought cephalad into the colon. The spike is exteriorized at the antimesenteric border of the colon, approximately 4cm from its extremity before another division is done using the Endo-GIA linear stapler, blue cartridge. The stapled line is covered by a running suture (Maxon 3/0), ensuring a complete patency of the stapling. All these maneuvers are performed outside the abdominal cavity, but if need be, especially in morbidly obese patients, these can be done intra-abdominally. The anvil is introduced in the colonic lumen. It is partially exteriorized. Laparoscopically, the stapling completes the division of the colon that was maintained externally. Complete patency must be achieved around the shaft of the anvil thanks to a running suture (monofilament 2/0 thread) to avoid rupture of the thread when fastening it. Once the purse-string has been applied, the colonic stump is controlled, and the whole is reintroduced into the abdominal cavity. The patency of the plastic drape is guaranteed by its twist and placement of a forceps. The colon reintroduced inside the abdominal cavity is controlled. Possibilities of lowering it until the anastomotic area are checked. This is done before creation of the anastomosis.

9. Side-to-end anastomosis 16'45''

The anastomosis is created by perforation of the rectal stump thanks to the forceps introduced the anus, followed by connection of the anvil to the spike-perforated stump. The perforation site is situated close to the crossing of the stapling line. We check that there is no twist. The lowered colon is positioned in such a way that the anastomosis forms a J-pouch. Once the anastomosis has been completed, the donuts on both colonic and rectal sides are controlled. These donuts were complete and thick. Control of patency is achieved to rule out any leakage by injecting air into the rectum after a clamp has been placed at the level of the upper segment of colon.

10. Closure of the mesocolic defect 18'01''

Once lavage and control of hemostasis have been achieved, the mesocolic defect is closed.

11. Protective diverting ileostomy 18'28''

A protective diverting ileostomy is performed, especially if the patient has had preoperative radiation therapy. In some rare cases, in young patients, the anastomosis can be carried out without any protection when the vascular supply is adequate. Pelvic drainage is used in the form of a Redon catheter introduced through one of the right iliac fossa port sites. Drainage is left in place for a few days.