Stepwise approach for intersphincteric dissection in colo-anal anastomosis

The surgical technique of intersphincteric resection (ISR) with colo-anal anastomosis has been proposed to offer sphincter preservation and to avoid permanent colostomy in patients with very low rectal carcinoma. Several studies have reported that functional results and local recurrence rates after ISR are satisfactory. The goal of intersphincteric resection is to perform a dissection between the internal sphincter and the external sphincter by beginning the dissection either at the pectinate line or underneath the pectinate line to obtain adequate distal margins as in this case. The trans-anal approach appears to be the optimal way because the dissection is more anatomic and visual and permits a more accurate evaluation of the lower edge of the tumor. In addition, this enables to obtain optimal distal and lateral margins respecting oncological principles and restore bowel continuity in a difficult narrow pelvis and in obese patients. The objective of this video is to show the correct intersphincteric dissection technique used to perform colo-anal anastomosis after complete total mesorectal excision.

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Stepwise approach for intersphincteric dissection in colo-anal anastomosis

Authors

J Leroy, J Marescaux

Abstract

The surgical technique of intersphincteric resection (ISR) with colo-anal anastomosis has been proposed to offer sphincter preservation and to avoid permanent colostomy in patients with very low rectal carcinoma. Several studies have reported that functional results and local recurrence rates after ISR are satisfactory.
The goal of intersphincteric resection is to perform a dissection between the internal sphincter and the external sphincter by beginning the dissection either at the pectinate line or underneath the pectinate line to obtain adequate distal margins as in this case.
The trans-anal approach appears to be the optimal way because the dissection is more anatomic and visual and permits a more accurate evaluation of the lower edge of the tumor. In addition, this enables to obtain optimal distal and lateral margins respecting oncological principles and restore bowel continuity in a difficult narrow pelvis and in obese patients.
The objective of this video is to show the correct intersphincteric dissection technique used to perform colo-anal anastomosis after complete total mesorectal excision.

Classification

tips and tricks

Keywords

Stepwise approach, intersphincteric dissection, colo-anal anastomosis

Media type

Surgical video

Duration

03'30''

Publication

2009-02

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E-publication

WeBSurg.com, Feb 2009;9(02).
URL: http://www.websurg.com/doi-vd01en2465.htm

Stepwise approach for intersphincteric dissection in colo-anal anastomosis

1. Schematic 00'17''

The objective is to perform a dissection between the internal sphincter and the external sphincter by beginning the dissection either at the pectinate line or underneath the pectinate line as in this case.

2. Anal canal exposure 00'27''

After exposing the anal canal with a Lonestar® retractor, we first infiltrate the submucosal tissues using a xylocaine with 1% adrenaline solution.

3. Mucosal incision 00'41''

Then the mucosa is incised approximately 1cm underneath the pectinate line or even less if possible.

4. Intersphincteric dissection 01'10''

Using electrocautery progressively, dissection is continued until we reach in contact with the longitudinal muscular fibres of the internal sphincter. These fibres are maintained in contact with the mucosa; then dissection is continued in a semi-circular fashion on the posterior portion of the sphincter in order to avoid any massive bleeding originating from the superior portion. Dissection is pursued until we reach the superior border of the external sphincter and the abdominal dissection area is reached under laparoscopic control. Dissection is extended anteriorly and laterally, always using electrocautery or Metzenbaum scissors, continuing the dissection between the transverse fibres of the external sphincter and longitudinal fibres of the internal sphincter. This maneuver is facilitated by traction on the rectal stump with the aid of a Babcock forceps. Continuous aspiration is oftentimes very useful to maintain the operative field as clean as possible and to correctly identify the anatomical structures. Once the circular dissection is complete, digital control of the entire dissection may be carried out.

5. Rectum extraction 03'14''

The use of a finger may also facilitate the extraction of the rectum that had been previously dissected laparoscopically. Here we can see that the mesorectum has been perfectly dissected and the propria fascia is intact.