Low anterior resection in a patient with T3 N0 mid-rectal carcinoma: tips and tricks

The key to an oncologically resection of mid or low rectal cancer is the 'en bloc' resection of the rectum and its enveloping mesentery to the level of the pelvic floor with a negative distal and radial resection margin, the total mesorectal excision (TME). This video illustrates a laparoscopic low anterior resection in a 62-year-old female patient with T3 N0 mid-rectal carcinoma approximately 8 to 9cm from the anal verge.

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Low anterior resection in a patient with T3 N0 mid-rectal carcinoma: tips and tricks

Authors

Abstract

The key to an oncologically resection of mid or low rectal cancer is the 'en bloc' resection of the rectum and its enveloping mesentery to the level of the pelvic floor with a negative distal and radial resection margin, the total mesorectal excision (TME). This video illustrates a laparoscopic low anterior resection in a 62-year-old female patient with T3 N0 mid-rectal carcinoma approximately 8 to 9cm from the anal verge.

Classification

tips and tricks, contribution

Keywords

Low anterior resection, T3 N0 mid-rectal carcinoma, tips and tricks

Media type

Surgical video

Duration

07'34''

Publication

2010-04

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E-publication

WeBSurg.com, Apr 2010;10(04).
URL: http://www.websurg.com/doi-vd01en2941.htm

Low anterior resection in a patient with T3 N0 mid-rectal carcinoma: tips and tricks

1. Introduction 00'10''

This video illustrates low anterior resection in a 62-year-old female patient with T3 N0 mid-rectal carcinoma approximately 8 to 9cm from the anal verge.

2. Inferior mesenteric vein dissection 00'28''

The procedure commences by dissecting the inferior mesenteric vein below the pancreas using mainly diathermy scissors. It is not uncommon that duodenal adhesions require separation to clearly visualise the inferior mesenteric vein. We aim to stay above the left colic branch. The IMV is divided between two clips just below the pancreas and the peritoneum is lifted off the anterior surface of the pancreas.

3. Inferior mesenteric artery dissection 01'35''

The next part of the dissection involves dealing with the inferior mesenteric artery towards its origin. The patient is now in steep head down position and rotated to the right. The small bowel has been cleared from the pelvis. It is our practice to make an attempt to skeletonise the inferior mesenteric artery to ensure secure clipping. The peri-arterial adventitial tissue is dissected step by step. Staying close to the artery also ensures preservation of the hypogastric nerves. We place one clip towards the retaining part of the inferior mesenteric artery and after division with the Ligasure® device, the dissection is carried further laterally separating the mesocolon from Toldt’s fascia. The ureter and gonadal vessels are easily identifiable.

4. Medial dissection 04'24''

Medially, the peritoneal dissection is carried upwards just to the right of the inferior mesenteric vein, thereby lifting the whole mesocolic package. The rectal dissection is now carried on caudally in the mesorectal plane. The lateral attachments are divided next and carried upwards using a combination of diathermy scissors and Ligasure® dissection.

5. Splenic flexure mobilisation 05'50''

Omental attachments are divided and the lesser sac is entered as in open surgery and medial and lateral lines of dissection join posteriorly to complete the splenic flexure mobilisation.

6. Total mesorectal excision 06'45''

Because of the mid-rectal position of the cancer, a total mesorectal excision is being performed. The dissection continues from the posterior lateral aspect to the front and in this part of the video, the vaginal vault is being separated from the rectum. A T-retractor is being used to lift the uterus although the same can also be achieved with a suture either through broad ligaments or the uterine body. The pelvic floor can now be identified and rectovaginal separation continues.

7. Rectal transection 08'43''

The low rectal transection is carried out with the Endo-GIA linear stapler using two firings and the specimen is extracted through a suprapubic muscle-splitting incision using a wound protector. This was a constricting carcinoma, which had downsized with long course neoadjuvant chemo-radiotherapy.

8. Anastomosis 09'06''

The anastomosis is fashioned with the DST28 using standard technique and tested for air leak.

9. Defunctioning ileostomy 09'14''

This patient underwent a defunctioning loop ileostomy in the right iliac fossa. Because of the difficulty in identifying the afferent from efferent limb in laparoscopic surgery, we employ a technique of double-spout ileostomy, which is managed easily by the patients and liked by the stoma nurses.