Advances In Surgery Channel

Case

Remember…

The patient was a 72-year-old female with high blood pressure, dyslipidemia and rheumatoid arthritis who was diagnosed with a well differentiated mriT1-N0  adenocarcinoma 7cm from the anal verge. Clinical staging by CT-Scan ruled out distant metastasis.  Local resection was performed through the TAMIS approach and the pathology analysis revealed an pT3 high grade mucinous adenocarcinoma with a lymphatic invasion, low grade budding, lateral free margins and a deep margin at 1.5mm.

The options presented were the following:

• Watch-and-wait approach
• Chemoradiotherapy and surveillance
• Chemoradiotherapy and radical surgery
• Radical surgery without neoadjuvant therapy

Treatment

Our final decision was taken in a multidisciplinary committee involving oncologists, radiologists, gastroenterologists and surgeons. The option selected was radical surgery with no neoadjuvant therapy (which was also the most voted option in our survey).

To continue, we will show the complete surgery, which was performed laparoscopically: a low anterior resection through the Cecil approach.

The patient was placed in the supine position with open legs. A total of 4 trocars were used. A 12mm trocar was placed in the umbilical position for a 30° scope, and three 5 mm trocars served as working channels on the right iliac fossa, and on each flank.

This video focuses on the transanal approach with some reference to the abdominal approach.

Once the transanal device was introduced, we were able to explore the rectum. You can see the perfectly closed scar of the resected tumor 6 weeks ago. Since the height of the scar was very low, we decided to perform the section of the rectum first, in order to have sufficient oncologic margin and to close the rectum safely.

A tattoo is marked circumferentially to guide the opening of the rectal wall  (first the mucosa and then the muscular layer).Step by step we opened all layers of the rectum to achieve a complete circumferential section.

In this case, as the patient was a woman, we took special care on the anterior side as we could injure the vagina. In a man we would have to avoid injuring the prostate at this level.

The hook is used to open the rectum and the pneumo helps to expose the avascular plane.  During this step the colon is clamped from the abdominal approach to prevent it from being filled with CO2.

Once the section of the rectum was performed, a purse-string was made to close the rectal lumen.  The pursestring should be closed tight to avoid pneumo leakage. Then we introduced a gauze to help with handling and continued with the dissection of mesorectum.

The plane must be followed from where it is identified to the point where the dissection must continue.  Mobilization must be circumferential, imagining a cylinder inside the pelvis curve. Avoid getting deep into one plane, as the rectum will retract and the quality of the dissection will be compromised.

In the posterior plane, the presacral fascia can be damaged and there may be bleeding from the presacral vessels. The bipolar is sometimes a useful tool to control the situation.

We continued with the lateral dissection, trying not to create any holes and stay always within the same plane circumferentially.

Finally we connected both approaches. Combined work from the transanal and transabdominal teams saves time and improves the dissection, helping to clarify some hard-to-reach planes. The dissection must be symmetrical. Gradually we see how the resection is completed by combining the work of two teams at a time, and is both safe and reliable.

Finally, we extracted the piece through the anus aided by the abdominal team, ensuring that the colon had no tension and was in the correct position to perform the anastomosis.

Coloanal manual side to end anastomosis was performed.  First of all, the long star was placed and we made four cardinal vicryl stitches in the distal rectum. Then the rectum was exteriorized and cut with an endoGIA. The colon was opened laterally so as to perform a side-to-end anastomosis. The previous sutures made were completed with four stitches in the proximal colon after opening the colonic wall. The anastomosis was completed with single vicryl stitches between the previous cardinal sutures. We can check that we have a correct colonic lumen during the procedure. We finally checked hemostasis and completed the surgery.

Outcome

The surgery took 100 minutes. The patient started oral intake 48 hours after the surgery and left hospital on the 5th postoperative day.

Pathological examination ruled out scar fibrosis and malignancy in the prior resection. The mesorectum was complete. Metastasis was observed in one of nine lymph nodes found.