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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_665_Библиотеки_им_академика_М_И_Перельмана.pdf
Figure 11-7
Chapter 11 • Laparoscopic Low Anterior Resection 185
Left ureter
Figure 11-8
mesenteric vein
mesenteric artery
Inferior mesenteric vein
Inferior vena cava
Inferior
Inferior
Ureter
Aorta
Mesentery
Ureter
Inferior
mesenteric artery
Figure 11-9
IMA
Aorta
Figure 11-10
186 Chapter 11 • Laparoscopic Low Anterior Resection
u
The IMV at the level of the ligament of Treitz has a branch approximately 3 cm caudad to
the IMV insertion into the splenic vein. The bifurcation should be included in the specimen
by transecting the IMV closer to the ligament of Treitz and the pancreas. The IMV is divided
under direct vision after opening the window between the pancreas, the IMV, and the branch
(Figure 11-11).
u
When the mesenteric vessels have been divided medially, a blunt dissection in the areolar
plane can be accomplished all the way out to the lateral aspect of the abdominal wall, dropping the vital structures in the retroperitoneum posteriorly (Figure 11-12). This dissection
frees the left colon and its mesentery from the retroperitoneum from the pelvic brim to the
splenic flexure. The lateral attachments are incised using the energy source from the pelvic
brim up to the splenic flexure (Figure 11-13).
First branch of IMV
IMV
Chapter 11 • Laparoscopic Low Anterior Resection 187
Figure 11-11
Figure 11-12
Figure 11-13
188 Chapter 11 • Laparoscopic Low Anterior Resection
u
The patient is positioned in steep reverse Trendelenburg and airplaned right. The splenic
flexure is released by dividing the lateral attachments of the mesentery of the left colon from
the tail of the pancreas, from the lateral side wall, and from the undersurface of the spleen
(Figure 11-14A and B). Electrocautery or other energy source is useful for this maneuver, and
combined traction toward the midline and anterior abdominal wall is essential to show the
attachments. Simple cross traction would not work (Figure 11-15).
u
The division of the suspensory attachments between the pancreas, spleen (Figure 11-16), and
omentum along the anterior mesenteric surface of the transverse colon finally releases the
left colon from the upper abdomen (Figure 11-17).
Transverse
colon
Sigmoid colon
A
Stomach
Pancreas
Spleen
Descending
colon
Spleen
Kidney
Inferior
mesenteric vein
B
Figure 11-14A-B
Chapter 11 • Laparoscopic Low Anterior Resection 189
Direction of traction
Figure 11-16
Figure 11-15
Lesser sac
Splenic flexure
Figure 11-17
190 Chapter 11 • Laparoscopic Low Anterior Resection
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The base of the splenic flexure mesentery is released from the lower edge of the tail of the
pancreas, and the lesser sac is opened all the way to the gastroduodenal artery causing the
transverse colon to fall toward the pelvis (Figure 11-18). This maneuver reveals the posterior
wall of the stomach, the stump of the IMV, and the pancreas after release of the splenic flexure
from the left upper quadrant.
u
The patient is placed in flat, steep Trendelenburg, and the sigmoid colon is lifted anteriorly
by placing a 5-mm grasper beneath the left and sigmoid colon and retracting this toward the
anterior abdominal wall. The operating surgeon, still standing on the patient’s right, incises
the areolar tissue plane posterior to the rectal mesentery and outside the mesenteric envelope
(Figure 11-19). The left pelvic side wall is easily seen at the level of the sacral promontory,
and the splanchnic pelvic nerve can be protected. Sharp dissection with electrocautery and
energy source is important at this level to keep the field clear of blood (Figure 11-20). The
right pelvic peritoneal surface is incised to the cul-de-sac to allow the rectum to be retracted
to the left.
Figure 11-18
Posterior wall
of stomach
Stump
of IMV
Pancreas
Mesorectum
Tumor-specific
bowel and
mesorectum
transection
mesorectal
excision
Chapter 11 • Laparoscopic Low Anterior Resection 191
Tumor
5-cm margin
Rectum
Total
Figure 11-19
Left pelvic
side wall
Rectal
mesentery
Areolar
tissue
Figure 11-20
Sacral promontory
192 Chapter 11 • Laparoscopic Low Anterior Resection
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The dissection is carried further into the pelvis, all the way down to the pelvic floor poste-
riorly to release the mesentery up and away from the sacral curve. The pelvic side wall on
the left is cleared, and the attachments are released with sharp and blunt dissection (Figure
11-21). The left pelvic peritoneal surface is incised all the way to the cul-de-sac.
u
The left and posterior dissection is completed, and the rectum is retracted to the patient’s
right. An incision is made anterior to the rectum in the peritoneal surface at the cul-de-sac
to expose the left anterolateral ligaments and the rectovaginal or rectoprostatic septum (Figure
11-22). The anterolateral ligaments are divided with the electrocautery hook at the side wall
of the pelvis (Figure 11-23).
u
The right side of the cul-de-sac incision is accomplished by changing the rectal retraction
toward the left side wall. The right anterolateral ligaments are easily stretched across the pelvis
(Figure 11-24) and divided from a posterior-to-anterior approach (Figure 11-25).
Chapter 11 • Laparoscopic Low Anterior Resection 193
Cul-de-sac
Rectum
Areolar tissue
Sacral promontory
Left ureter
Anterolateral
ligament
Rectum
Fallopian
tube
Figure 11-23
Right anterolateral
ligament
Rectum
Figure 11-21
Anterolateral
ligament
Figure 11-22
Bladder
Cul-de-sac
Figure 11-24
Right anterolateral
ligament
Rectum
Rectum
Right fallopian
tube
Figure 11-25
194 Chapter 11 • Laparoscopic Low Anterior Resection
u
The dissection in the rectovaginal or rectoprostatic septum is accomplished by retracting the
posterior aspect of the bladder anteriorly using the left port 5-mm grasper (Figure 11-26).
The rectum is pulled posteriorly and cephalad, and the cautery is used to extend the dissection in the areolar tissue plane behind the vagina or prostate all the way down to the level
of the anal canal (Figure 11-27). Care must be taken not to enter the vagina. The areolar
tissue plane should be easily followed with the flexible scope brought low into the pelvis.
The rectum can be transected with laparoscopic staplers or using regular transverse staplers
placed through an extraction incision or the hand access port above the pubis. We prefer to
use open stapling instruments. The rectum and sigmoid are pulled through the incision. The
transverse stapler is placed across the rectum at the level of distal dissection well below the
tumor to provide at least a 2-cm margin or as appropriate (Figure 11-28).
u
A colonic J pouch is constructed for improved fecal control if indicated. The distal left colon
is transected proximal to the sigmoid colon. The colon is folded up on itself, and a 7.5-cm
linear cutter stapler is passed through a purse-string placed at the apex of the “J” (Figure
11-29). The transverse staple line of the distal colon is approximated to the inlet of the J
pouch with interrupted 3-0 polyglactin 910 (Vicryl) sutures. The anvil of a 29-mm circular
stapler anvil and shaft is secured in the purse-string (Figure 11-30). All of this can be accom-
plished through the suprapubic hand port or extraction site.
u
The double-stapled anastomosis can be accomplished between the distal rectal stump and
the J pouch and guided through the extraction site or hand site (Figure 11-31). The anastomosis is checked by insufflating air through a rigid proctoscope with the proximal bowel
occluded with the pelvis filled with saline. Any leaks of air in the staple line can be repaired
with interrupted sutures.