When you have to chose who are the best patients to start performing the Cecil approach, everybody usually agrees in indicating the procedure for thin women with a middle rectal cancer. Nevertheless, older women have some specific characteristics that can make the procedure more difficult than expected, such as redundant colon, enterocele, lax tissues, etc.
We can see how the combined approach will help us to increase the traction countertraction to solve the problems caused by laxity. Thanks to TaTME we were able define the anterior plan, which we would probably miss and follow too anteriorly using a conventional laparoscopic approach.
After more than 200 cases, when people ask which kind of patient is the best to begin performing a trasanal total mesorrectal excision, we usually recommend a thin female with a middle rectal cancer. Thanks to their anatomical characteristics, women are the most appropriate patients as they have a wide pelvis, no prostate or seminal vesicles bordering on the anterior side, and provide the opportunity to mobilize the vagina for better definition of the surgical planes.
But is a female pelvis always easiest? There are some characteristics, especially in older women, that can make this procedure challenging in this group of patients. In this video, we will try to show which difficulties you could find in a female pelvis.
We present an 83-year-old woman with high blood pressure, dyslipidemia and Barrett’s esophagus. Due to rectal bleeding, the patient was diagnosed with rectal cancer 7 cm from the anal verge. Baseline staging revealed an mriT3N1 lesion plus resectable lung metastases by CT-Scan.
This older lady received chemoradiotherapy with moderate response to a mriT2N0. Finally a low anterior resection with TME transanally and transabdominally was performed (Cecil approach).
The patient was placed in a lithotomy position. Four trocars were used transabdominally, a 12 mm trocar was placed umbilically for the camera, and three 5 mm trocars were also placed, two in the right iliac fossa and one in the left hemiabdomen. A gel cap platform was used for the transanal approach.
A wide pelvis, typical of a female patient, is visualized. Then the mesosigmoid peritoneum is incised to define the correct posterior plane. The inferior mesenteric artery is individualized. A high ligation of the artery was accomplihed by using the Ligasure™ after placing some proximal clips. The epiploic adhesions and Toldt’s fascia , which adhere the descending colon to the lateral abdominal wall, are resected, as well as the possible adhesions to the spleen.
Simultaneously the transanal approach is performed. Firstly, after visualizing the rectal tumor, a pursestring suture is made with PDS or prolene to close the rectal lumen. After the rectum is closed a tattoo is made with the electrocautery. The down to up dissection is begun in a circumferential manner. We usually begin on the anterior side, where you can see some fibrosis secondary to the preoperative treatment.
We continue afterwards on the posterior side preserving the mesorectum. And on the lateral side connecting the anterior and posterior dissections. At the same time, the abdominal dissection is continued into the pelvic space to perform a total mesorrectal excision.
The left lateral side is also incised taking care not to damage the vessel and nerves. We continue our dissection through the presacral space preserving the mesorrectal fat.
We can now see a deep Douglas down in the pelvis so we continue our dissection on the left lateral side, keeping the anterior side closed until the connection with the transanal team is made.
This deep Douglas makes it difficult for us to maintain a correct traction countertraction so we require significant traction to proceed with the dissection and define the surgical plane. As you can see, the laxity of the tissues in older patients can complicate the procedure, making dissection more difficult. This patient has also a redundant sigmoid colon, which leads us to change the position of the instruments to maintain traction.
Patient characteristics such as tissue laxity and medical situations such as enterocele can pose a real problem when finding the rectovaginal space. Thanks to the help of neumorectum and the work of the transanal team, we can find the correct anterior plane to incise the peritoneum more easily: not too close to the rectum where we could damage it or too close to the uterus or vagina, where we could find a bleeding plane.
As you can see, the abdominal team is just increasing traction, pulling away the rectum from the vagina, in order to help the transanal team find the correct surgical plane.
Coming back to the transanal approach, we will now focus on the anterior side, where the abdominal team is having problems defining the plane due to the laxity of the patient’s tissues. Thanks to the traction performed by the abdominal team, we can visualize the light and the correct plane through the anus.
The rendezvous between both teams is achieved, thanks to the combined work. The correct plane is probably closer to the rectum than we had previously thought. Without the combined approach, we would probably have missed the anterior plane and done it too anteriorly. Once the correct plane is achieved, we can continue the abdominal dissection applying the right traction.
With these lax tissues, traction for both teams is essential to perform lateral dissection with no injuries. The abdominal team retract from the distal side of the rectum to increase posterior traction, in order to complete the dissection transanally. In this way, the transanal team can perfectly see the correct posterior plane to finish the rectal resection and the specimen is introduced in the abdominal cavity.
A prolene purse string on the distal rectum is made to perform the mechanical anastomosis. A silicon tube is connected to the spike of the stapler to exteriorize it through the anus more easily. The pelvis is now more narrow than we had thought at the beginning of the procedure, and the big uterus with an anterior myoma makes it even more difficult.
Transanally, a clinch is introduced through the anus under laparoscopic supervision to exteriorize the proximal colon and the spike of the stapler to finish the anastomosis. The correct proximal colon position is checked. The colorrectal anastomosis is checked for leakage or bleeding and solved as soon as possible.