This video is focused in the main steps for combined transanal and transabdominal approach for rectal cancer, highlighting the most frequent mistakes and how to prevent them.
Following the oncological principles, the first maneuver is the division of the inferior mesenteric vessels followed by the sigmoid mobilization. The dissection of the mesosigmoid begins after accommodation of the small bowel and performing traction of the IMV.
The hook is used to open the peritoneum and the pneumo helps to expose the avascular plane. Ligation of the IMV is accomplished with a 5 mm LigaSure™. Colonic dissection is made from medial to lateral and finished by taking down the Told´s Fascia.
Splenic flexure mobilization is performed in selected cases in order to achieve a tension free anastomosis.
Simultaneously, the transanal team starts dissecting from Down to Up. A dilator is placed to facilitate the setting of the trans anal platform. A special insufflator is used, it evacuates the smoke and maintains the pressure of the pneumorectum at the same time.
A purse-string is made to close the rectal lumen, it will be the distal margin depending on the height of the tumor, it is important to be symmetrical and tight. A tattoo is marked circumferential to the knot to guide the opening of the rectal wall, (first the mucosa and then the muscular layer) it is important to respect the rectal stump and avoid cutting the purse string.
Go deep in order to reach the posterior plane, remembering the curve of the pelvis and respecting the presacral fascia.
Lateral dissection is more difficult from below than from above, a trick is to follow the avascular plane from a zone where it is well dissected. In difficult cases, the bipolar can be used for dissection and hemostasis.
For anterior dissection, structures like the vagina, seminal vesicles and the prostate must been taken in conscience. Digital examination of the vagina is used to avoid unexpected lesions. The mesorectal fat is thinner, pushing with the hook can clarify the correct plain.
In the big screen you can see a correct dissection of the posterior plane. In the smaller screen you can see bleeding due to an injury of the presacral vessel. The correct plain is higher; improvement of tension can help for visualization.
Combined work from the transanal and transabdominal teams saves time and improves the dissection, helping to clarify some difficult to reach planes. The dissection must be symmetrical, like a cylinder.
The specimen is extracted through the anus and colotomy is performed to place the anvil shaft above the level of the IMV. It is re-introduced into the pelvis and the rectal stump is closed.
As a last step, an end-to-side mechanical anastomosis is performed under direct laparoscopic vision.