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378
12.3 Laparoscopic Second Stage Hartmann Procedure
Fig. 12.3.7 Second stage Hartmann operation.
After the blind end of the rectal pouch has been identified and freed, the
cartridge of the circular stapler is advanced into the rectal pouch. After
proper postioning, the trocar is advanced fully, exiting the midportion of
the staple line. The hollow central rod follows and should fully clear the
end of the pouch. The trocar is then removed using a grasper (This can be
facilitated by tying a heavy suture to the tip prior to the transanal insertion).
2
1
6
3
4
5
Fig. 12.3.8 Second stage Hartmann operation.
The anvil and descending colon are then retrieved from the left gutter.
(The heavy suture tied to the anvil sometimes aids in locating it). Using
Babcock clamps the anvil rod is brought into the pelvis taking care not to
twist the bowel. It is connected to the hollow central rod of the cartridge.
The stapler is carefully closed as care is taken not to incorporate any additional tissue into the anastomosis. The stapler is then fired and removed
through the anus, after separating anvil from cartridge by turning the
knob three times counterclockwise (Figs. 12.4.12 and 12.4.13).
The integrity of the anastomosis can be confirmed by the retrieval of two
intact doughnuts from the stapler. Additionally irrigation can be placed
into the pelvis to submerge the anastomosis. Air can carefully be introduced transanally across the anastomosis. Lack of bubbles confirms an
airtight seal.
Note: This operation can also be performed without a pneumoperitoneum, utilizing a retractor which can be inserted through the old
colostomy site. Using this configuration the laparoscope is placed
through an umbilical port. The lateral “working” port can be omitted and
the operation performed solely through the old colostomy site.
Fig. 12.3.9 Step-by-step procedure:
1 Dissect the colostomy from the surrounding abdominal wall.
2 Place annular staple anvil with “leash” into colon lumen.
3 Close the bowel with linear stapler and excise fibrous ostomy scar, leaving
“leash” intact in center of staple line.
4 Pull “leash” and attached anvil trocar through center of linear staple line.
5 Dissect adhesions off the anterior parietal peritoneum.
6 “Park” descending colon and “leashed” anvil in left lateral gutter.
Indications
11
379
13
12
Fig. 12.3.10 Step-by-step procedure:
7 Liberate Hartmann’s rectal pouch by lysis of pelvic adhesions.
8 Incise white line of Toldt and liberate splenic colon flexure.
9 Advance descending colon with anvil into pelvis.
10 Introduce cartridge of annular stapler through anus, and place it against
blind end of rectum.
Bibliography
Gorey TF, O’Connell PR et al. Laparoscopically assisted reversal of Hart-
mann’s procedure. Br. J. Surg. 1993; 80:109.
Rosenbaum J, Thabit M, Feinberg M. A Simplified method of laparoscopic-as-
sisted reversal of Hartmann’s procedure. Surg. Rounds 1995; 18(1):17−20.
Sosa JL, Sleeman D et al. Laparoscopically assisted colostomy closure after
Hartmann’s procedure. Dis. Colon Rectum 1994; 37:149−152.
Verna AM, Liebscher G, Kongo WE. Laparoscopic Restoration of intestinal
continuity after Hartmann’s procedure. Surg. Laparosc. Endosc. 1995;
5(2):129−131.
10
8
9
7
Fig. 12.3.11 Step-by-step procedure:
11 Advance trocar of cartridge shaft through the midportion of the rectal
stump closure. Remove trocar after hollow cartridge shaft has cleared the
blind end closure.
12 Mate anvil rod and cartridge shaft.
13 Activate circular stapling instrument to accomplish end-to-end-colo-rec-
tal anastomosis.
12.4 Laparoscopically Assisted Anterior Resection and Recto-Sigmoidostomy
S. D. Potter , C. A. Schneider , M. Rangraj, R. Welter
Objectives and Methods
Anterior resections of recto-sigmoid lesions, especially of mid-
rectal cancers, have been greatly facilitated by the development
of stapling devices. Laparoscopic methods combined with established stapling techniques provide many advantages over
traditional open procedures. Patients experience less pain and
therefore are more compliant with postoperative instructions.
Additionally, return of bowel function is quicker, hospital stay
shorter, and return to daily activities is accelerated.
Indications
− Benign neoplastic lesions of the distal sigmoid colon, upper
and mid-rectum.
− Uncomplicated diverticular disease localized to the rectosigmoid colon.
− Palliation for bleeding or obstructing malignant lesions with
known distant metastasis.
− Locally contained malignant lesions.
380
12.4 Laparoscopically Assisted Anterior Resection and Recto-Sigmoidostomy
Contraindications
Resection of bulky malignant disease.
Instrumentation
− General Purpose Laparoscopic Set
− Laparoscopic Babcock Clamps
− 1 10/11-mm port
− 2 12-mm ports
− 1 5-mm port (Optional)
− Circular Stapler
− Circular Stapler Sizers
− Linear Stapler
− Laparoscopic Endo GIA-60 (United States Surgical Corporation) with multiple refill cartridges
Additional Instrumentation for Laparoscopically Assisted Anterior Resection (Perineal Approach)
− Open Colon Resection Set.
Risks and Information to the Patient
Informed consent should be obtained as with any surgical procedure. Additionally, the added risks of laparoscopic surgery
should be discussed. These include the hemodynamic effects of
a pneumoperitoneum and possible trocar injuries such as
bleeding and puncture injuries. Risks pertaining to this particular procedure should also be discussed and include anastomotic
leakage, possible ureteral or bladder injuries and the risk of
possible sexual dysfunction.
Operative Positioning
Port Placement
Ports are placed as shown in Fig. 12.4.2. The laparoscope is in-
serted through the 10 mm periumbilical site. Retraction is provided through the 12-mm port in the right lower quadrant and
the 12-mm left lower quadrant port is the operative port. The
patient is placed in the Trendelenburg position and rotated to
the right. The recto-sigmoid lesion should be identified and the
point of proximal transection determined. Intraluminal colonic
lesions can either be identified by one of three ways: Laparoscopic instruments can be used to palpate the lesion, the lesion
can be identified preoperatively via sigmoidoscopy and marked
with transmural dye, or a combined laparoscopic and intraluminal endoscopic approach may be used.
Anesthesia
General endotracheal anesthesia.
Complications
Intra- and postoperative anastomotic leak. If noticed intraoperatively and the leak is small a corrective suture may be
enough. If the leak is substantial the anastomosis should be redone by open technique.
Trocar injuries to bowel and vessels. If they are substantial they
should be repaired by open procedure.
There have been instances of port site recurrences occurring
with Dukes B lesions. At this time participation in a suitable
prospective randomized study and use of all precautions (specimen bag, avoidance of trocar dislocations, etc.) have resulted in
the practical elimination of this worrisome complication.
Lithotomy position with operative preparation of the abdomen
and perineum (Fig. 12.4.1).
Fig. 12.4.1 Laparoscopically assisted anterior resection and recto-sigmoidostomy.
Patient position.
Fig. 12.4.2 Laparoscopically assisted anterior resection and recto-sigmoidostomy.
Trocar placement.
Step-by-step Procedure
381
Step-by-Step Procedure
(Figs. 12.4.14 to 12.4.16)
Laparoscopically Assisted Anterior Resection and RectoSigmoidostomy
1. A chemical and mechanical bowel preparation is performed
the day before surgery.
2. The patient is placed on the operating room table in the
lithotomy position with operative preparation of the abdomen and perineum (Fig. 12.4.1).
3. A pneumoperitoneum is established and ports are inserted. A
10-mm port is placed in the infraumbilical position for the laparoscope. Two additional 12-mm ports are placed in the left
and right lower quadrants just lateral to the rectus abdominus
muscles (Fig. 12.4.2).
4. The patient is placed in the Trendelenburg position and rotated to the right.
5. The rectosigmoid lesion is identified and a level of proximal
transection determined.
6. A laparoscopic Babcock clamp retracts the sigmoid colon to
the right which is then sharply mobilized along the white line
of Toldt (Fig. 12.4.3).
7. If necessary, the descending colon and possibly the splenic
flexure should be mobilized to facilitate a tension free anasto-
mosis.
8. The sigmoid colon is elevated to the anterior abdominal wall,
fanning out the sigmoid mesentery. (An additional 5-mm su-
prapubic port may aid in this maneuver (See Fig. 12.4.2).
9. A window is created through an avascular portion of the
mesentery. Serial applications of the Endo-GIA stapler are
then employed to divide the mesentery into the pelvis to a
level below the peritoneal reflection (Fig. 12.4.3).
10. The peritoneum overlying the rectum is then sharply divided
circumferentially, mobilizing the superior rectum.
Laparoscopically Assisted Anterior Resection (Perineal Approach)
1. The pneumoperitoneum is released.
2. A transverse incision is made through the intergenital fold approximately 2 cm in front of the anus (Fig. 12.4.4).
3. The anobulbar or anovulvar raphe is identified and divided,
exposing the anterior aspect of the rectum just above the external sphincter.
4. Dissection around the circumference of the rectum and
toward the abdominal cavity will join the perineal dissection
with the intraabdominal dissection. This will fully free the
bowel which can then be pulled through the perineal wound
to the planned level of proximal transection (Fig. 12.4.5).
5. The bowel is divided proximally between the pursestring in-
strument and a noncrushing clamp (Fig. 12.4.5).
6. A linear stapler is used for the distal division creating a short
anal stump (Fig. 12.4.5).
7. The proximal bowel is sized and the proper circular stapler
selected.
8. The anvil is advanced, central rod first, into the open, purse-
stringed proximal sigmoid colon (Fig. 12.4.6).
9. The central rod is brought out through the antimesenteric
wall of the bowel approximately 10 to 15 centimeters proxi-
mal to the pursestringed end. The pursestring is then closed
temporarily (Fig. 12.4.6).
10. The cartridge of the circular stapler is placed transanally and
advanced into the anal pouch (Fig. 12.4.7).
11. The trocar of the hollow central rod is advanced fully through
the midportion of the pouch’s staple line. The hollow central
rod should fully clear the linear stapler closure of the pouch
(Fig. 12.4.7).
13. The trocar is then removed using a grasper.
14. The anvil rod is connected to the hollow central rod of the cartridge (Fig. 12.4.7).
15. The stapler is closed as care is taken not to incorporate any
additional tissue into the anastomosis. The stapler is then
fired and removed (Fig. 12.4.8).
16. The excess sigmoid colon lateral to the side-to-end anasto-
mosis is excised distal to a linear stapler closure (Fig. 12.4.8).
17. The integrity of the anastomosis is confirmed by the retrieval
of two intact tissue rings from the stapler cartridge. Additionally the bowel can be distended using a dilute iodine preparation injected transanally and checked for leakage under direct
vision.
18. An occlusion pack is placed and the pneumoperitoneum is reestablished.
19. The abdomen is inspected as is the perineal operative site. If
all is well the pack is removed and the various incisions are
closed.
Laparoscopically Assisted Recto-Sigmoid Resection (Abdominal Approach)
1. In the pelvis, the rectum is divided with the Endo-GIA stapler
creating a rectal pouch (This may require multiple stapler fir-
ings) (Fig. 12.4.9a).
2. The entire sigmoid colon is then pulled out through a small
(approximately 4 cm) incision in the left lower quadrant
(Fig. 12.4.9b).
3. The bowel is next divided between noncrushing clamps at the
planned level of proximal transection (Fig. 12.4.9b).
4. Circular stapler sizers are used to select the proper size sta-
pler.
5. The anvil is placed in the proximal colon with a heavy gauge
suture “leash” tied to its spike (Fig. 12.4.10 a).
6. A linear stapler is placed around the bowel just proximal to
the open end and fired with the “leash” suture in tail to exit
through the mid staple line (Fig. 12.4.10 b).
7. The suture is pulled bringing the spike of the anvil out
through the middle of the staple line (Fig. 12.4.11).
8. The colon with the anvil are returned to the abdominal cavity
and stored in the lateral gutter. The incision is closed and the
pneumoperitoneum is reestablished (Fig. 12.4.11).
9. The cartridge of the stapler is then advanced transanally into
the rectal pouch (Fig. 12.4.12).
10. After proper positioning the trocar is advanced fully through
the midportion of the staple line. The hollow central rod fol-
lows and should fully clear the end of the pouch (Fig. 12.4.12).
11. The trocar is then removed using a grasper. (This can be facilitated by tying a heavy suture to the trocar prior to the transanal insertion).
12. The anvil and descending colon are then retrieved from the
left gutter. (The heavy suture tied to the anvil sometimes aids
in locating it).
13. Using Babcock clamps the anvil rod is brought into the pelvis
taking care not to twist the bowel. It is connected to the hol-
low central rod of the cartridge (Fig. 12.4.12).
14. The stapler is closed as care is taken not to incorporate any
additional tissue into the anastomosis. The staple is then fired
and removed (Fig. 12.4.13).
15. The integrity of the anastomosis can be confirmed by the retrieval of two intact doughnuts from the stapler. Additionally
irrigation can be placed into the pelvis to submerging the
anastomosis. Air can carefully be introduced transanally
across the anastomosis. Lack of bubbles confirms an airtight
seal.
382
12.4 Laparoscopically Assisted Anterior Resection and Recto-Sigmoidostomy
Operative Techniques
Fig. 12.4.3 Laparoscopically assisted anterior resection and recto-sigmoidostomy.
A laparoscopic Babcock clamp is used to retract the sigmoid colon toward
the right exposing the white line of Toldt which is taken down sharply mo-
bilizing the sigmoid colon. Proximal sigmoid lesions and short or short-
ened sigmoid colons (diverticular disease) may require mobilization of the
entire descending colon and possibly splenic flexure in order to facilitate a
tension free anastomosis.
The sigmoid colon is then elevated to the anterior abdominal wall fanning
out the sigmoid mesentery. A grasper, inserted through an additional 5mm port (see Fig. 12.4.2), can greatly help with this exposure. A window
is created through an avascular portion of the mesentery. Serial applica-
tions of the Endo-GIA stapler are then employed to divide the mesentery
down into the pelvis to a level below the peritoneal reflection. The peri-
toneum overlying the anterior aspect of the rectum is then sharply
divided circumferentially mobilizing the superior rectum.
Laparoscopically Assisted Anterior Resection
(Perineal Approach)
Fig. 12.4.4 Laparoscopically assisted anterior resection and recto-sigmoidostomy.
The pneumoperitoneum is released. A transverse perineal incision is
made through the intergenital-anal-fold approximately 2 cm in front of
the anus. The anobulbar or anovulvar raphe is identified and divided. This
will expose the anterior aspect of the rectum just above the external
sphincter. Dissection around the circumference of the rectum first and
then toward the abdominal cavity will join the perineal dissection with the
intra-abdominal dissection freeing the bowel, which then can be pulled
through the perineal wound to the planned level of proximal transection.
1
2
Fig. 12.4.5 Laparoscopically assisted anterior resection and recto-sigmoidostomy.
The bowel is divided proximally between the pursestring instrument and a
noncrushing clamp. A linear stapler is used for the distal division creating
a short anal stump. The specimen is removed.
1 Proximal transection site
2 Distal transection site.
Operative Techniques
1
383
Fig. 12.4.6 Laparoscopically assisted anterior resection and recto-sigmoidostomy.
The proper stapler size is selected with the aid of the circular stapler sizers. The anvil is advanced into the open, pursestringed proximal sigmoid
colon with the pointed central rod entering first. The central rod is
brought out through the antimesenteric wall of the bowel approximately
10 to 15 centimeters proximal to the pursestringed end. The pursestring
is then closed temporarily.
1 Site of exit for central rod
Fig. 12.4.7 Laparoscopically assisted anterior resection and recto-sigmoidostomy.
The cartridge of the circular stapler is then placed transanally and ad-
vanced into the anal pouch. After proper postioning, the trocar of the hollow central rod is advanced fully through the midportion of the pouch’s
staple line. The hollow central rod follows and should fully clear the linear
stapler closure of the pouch. The trocar is then removed using a grasper.
Fig. 12.4.8 Laparoscopically assisted anterior resection and recto-sigmoidostomy.
The anvil rod is connected to the hollow central rod of the cartridge. The
stapler is closed as care is taken not to incorporate any additional tissue
into the anastomosis. The stapler is then fired and removed. The excess
sigmoid colon lateral to the side to end anastomosis is excised distal to a
linear stapler closure.
The integrity of the anastomosis can be confirmed by the retrieval of two
intact doughnuts from the stapler cartridge. Additionally the bowel can
be distended using a dilute iodine preparation injected transanally and
checked for leakage under direct vision.
Prior to closure of the perineal wound, an occlusion pack is placed and the
pneumoperitoneum is reestablished. The abdomen is inspected as is the
perineal operative site. If all is well the pack is removed and the various incisions are closed.
384
12.4 Laparoscopically Assisted Anterior Resection and Recto-Sigmoidostomy
Laparoscopically Assisted Recto-Sigmoid Resection (Abdominal Approach)
Fig. 12.4.9a, b Laparoscopically assisted anterior resection and recto-
sigmoidostomy.
a After the rectum has been mobilized circumferentially it is divided
with the Endo-GIA stapler creating a rectal pouch (This may require
multiple stapler firings). The entire sigmoid colon is then pulled out
through a small (approximately 4 cm) incision in the left lower quad-
rant.
b The bowel is divided next between noncrushing clamps at the planned
level of proximal transection.
Fig. 12.4.10 a, b Laparoscopically assisted anterior resection and recto-
sigmoidostomy.
a Circular stapler sizers are used to select the proper size stapler. The
anvil is placed in the proximal colon with a heavy gauge suture “leash”
tied to its spike.
b A linear stapler is placed around the bowel just proximal to the open
end and fired with the “leash” suture kept intact to exit through the
mid staple line.
The suture is pulled bringing the spike of the anvil out through the
middle of the staple line.
Operating Techniques
385
Fig. 12.4.11 Laparoscopically assisted anterior resection and recto-sigmoidostomy.
The colon with the anvil are returned to the abdominal cavity and stored
in the lateral gutter. The incision is closed and the pneumoperitoneum is
reestablished.
The cartridge of the stapler is then advanced transanally into the rectal
pouch. After proper positioning the trocar is advanced fully through the
midportion of the staple line. The hollow central rod follows and should
fully clear the end of the pouch. The trocar is then removed using a
grasper (This can be facilitated by tying a heavy suture to the top of the
trocar prior to the transanal insertion).
Fig. 12.4.12 Laparoscopically assisted anterior resection and recto-sigmoidostomy.
The anvil and descending colon are then retrieved from the left gutter
(The heavy suture tied to the anvil sometimes aids in locating it). Using
Babcock clamps the anvil rod is brought into the pelvis taking care not to
twist the bowel. It is connected to the hollow central rod of the cartridge.
The stapler is closed as care is taken not to incorporate any additional
tissue into the anastomosis. The stapler is then fired and removed.
Fig. 12.4.13 Laparoscopically assisted anterior resection and recto-sigmoidostomy.
The integrity of the anastomosis can be confirmed by the retrieval of two
intact tissue rings from the stapler. Additionally irrigation fluid can be
placed into the pelvis to submerge the anastomosis. Air can then be care-
fully introduced transanally across the anastomosis. Lack of bubbles con-
firms an airtight seal.
Fig. 12.4.14 Laparoscopically assisted anterior resection and recto-sigmoidostomy. Step-by-step procedure.
1 Retract the sigmoid colon towards the midline.
2 Incise white line of Toldt and elevate sigmoid colon and mesocolon.
3 Divide the mesocolon at the level of the planned proximal bowel transec-
tion. Branches of the inferior mesenteric vessels and/or their trunks are
divided between clips.
4 Incise the pararectal peritoneal attachments down to the caudal level of
planned resection.
386
12.4 Laparoscopically Assisted Anterior Resection and Recto-Sigmoidostomy
3
Fig. 12.4.15 Laparoscopically assisted anterior resection and recto-sigmoidostomy.
Step-by-step-procedure.
Abdominal approach:
1, 2 Liberate and mobilize the segments of
7
4
5
6
10
11
9
rectum and colon and corresponding
mesenteries satisfactorily to assure
complete control of the lesion at hand.
3 Transect the future specimen caudally be-
tween linear staple lines and/or clamps.
4 Transect the specimen cranially between
linear staple lines and non crushing
clamp.
5 Place annular anvil with “leash” into proxi-
mal colon.
6 Close proximal colon with linear stapler
leaving “leash” intact in its center (7).
8 Place proximal colon end with anvil into
pelvis.
9 Advance circular cartridge into rectum
against blind rectal end and pierce linear
rectal closure with cartridge trocar.
10 Remove cartridge trocar after hollow
shaft has cleared linear staple line.
11 Mate anvil trocar and cartridge shaft,
close circular stapler, activate and accomplish circular anastomosis. Remove instrument.
8
2
1
Fig. 12.4.16 Laparoscopically assisted anterior resection and recto-sigmoidostomy.
4
Step-by-step-procedure.
Perineal Approach:
1 Transverse perineal incision in intergenital
fold, anterior to the anus, down to rectum.
2 Dissect rectum circumferentially and pull the
2
5
9
7
1
8
4
previously liberated specimen (Fig. 12.4.14)
into incision. Transect bowel proximally between pursestring instrument and clamp.
3 Transect rectum caudally between linear sta-
pler (rectum) and clamp (specimen).
4 Place circular anvil, central rod first, into pro-
ximal bowel lumen and pierce antimesosigmoid wall with pointed rod some 10−15 cm
proximal to pursestring.
5 Close pursestring of proximal sigmoid tem-
porarily.
6 Introduce cartridge of circular stapler into
rectum against linear closure and advance its
trocar through the center of the staple line.
7 Remove the cartridge trocar after the hollow
rod has cleared the linear staple line.
8 Mate anvil trocar and cartridge shaft, close
instrument, activate and accomplish circular
anastomosis. Remove instrument.
9 Close the excess of sigmoid colon to the left
of the recto-sigmoidostomy and excise it, in-
cluding the temporary pursestring, periph-
eral to the linear stapler used as a guide for
excision.
63
Indications
12.5 Abdominoperineal Excision or Amputation of the Rectum (with High Ligation of the Inferior Mesenteric Artery)
F. Köckerling, I. Gastinger
387
Goals and Methods
The surgical treatment of rectal cancer is governed by the extent
of the primary tumor, its histological specifications, and lymphatic invasion. In contrast to other gastrointestinal tumors,
radical excision/resection is possible in a high percentage of the
various rectal tumors. The incidence of rectal cancers cured by
resection or excision is currently about 80%. In 15% of patients
only a palliative operation is possible, and in only 5% of patients
is the tumor unresectable.
The procedures available for surgical treatment of rectal cancer
are named according to the nomenclature of the International
Documentation System (IDS). This system divides tumor resec-
tions into three groups:
1. Local therapy includes endoluminal, endoscopic poly-
pectomy and localized surgical excision (mucosal to submucosal excision or excision of the entire wall thickness). These
operations are often referred to as rectum-preserving therapeutic procedures.
2. Limited resection refers to removal of the tumor with or
without limited regional lymphadenectomy and includes
procedures such as segmental resection or sleeve resection.
3. Radical resection or excision refers to removal of the tumor
with systematic regional lymphadenectomy along the superior rectal artery and the inferior mesenteric artery.
The definition of radical resection or excision includes abdo-
minoperineal excision or amputation of the rectum with
complete removal of the anal canal and creation of a permanent
colic stoma, or sphincter-preserving procedures, i. e., high anterior resection (anastomosis superior to the peritoneal fold) and
low anterior resection (anastomosis inferior to the peritoneal
fold); and abdominal anterior perineal resection with anastomosis between the colon and anus.
In the curative treatment of rectal cancer, the proportion of
sphincter-saving procedures (high and low anterior rectal resection and abdomino-anterior perineal rectal resection with
anastomosis between the colon and anus) and rectum-preserving procedures (endoscopic polypectomy, transanal mucosal to
submucosal excision, and transanal excision of the entire wall
thickness) is increasing with appropriate indications based on
tumor type, extent, and staging. The same criteria have led to a
relative retreat of abdominoperineal excision and permanent
colostomy. When sphincter-preserving and rectum-preserving
procedures are used along these strict guidelines, abdominoperineal rectum excision or amputation is indicated in the
curative treatment of rectal cancer in only about 10−20% of all
cases.
The use of laparoscopic techniques in high and low anterior, and
abdominoperineal rectum resection with anastomosis between
the colon and distal rectum or anus is still in an uncertain, con-
ditional stage of development. Due to the infiltrative nature of
rectal cancer, longitudinal and lateral margins of healthy tissue
must be excised during the abdominal and pelvic dissection.
These tissue margins are excised not only around the rectal
wall, but also with the mesorectum; the level of tissue margins
depends on the stage of the neoplasm. Determining these mar-
gins in situ without direct palpation remains difficult. For this
reason, the use of laparoscopic rectal resection procedures is not
currently recommended for treatment of rectal cancer confined to
the mucosa and inner mucosal wall of the rectum.
With the possible exception of abdominoperineal resection
with sphincter preservation and abdominoperineal excision or
amputation with permanent colostomy, the laparoscopic stage
of the operation consists of a visually enhanced abdominal and
upper pelvic dissection, and the perineal part of a traditional,
open operation: an ideal union of the two components of a laparoscopically assisted rather than guided procedure. The open,
perineal stage of this procedure permits direct palpation high
into the pelvis and affords the potential for locally corrective
measures as directed by the palpation. The oncologic requirements for a radical procedure are more easily fulfilled with this
approach than in rectum resection, with high or low anastomosis, entirely laparoscopically guided. High ligation of the inferior
mesenteric artery to permit extended lymph node dissection
can be accomplished by laparoscopy. Laparoscopy may also be
used for upper and mid-pelvic dissection in the anterior and
posterior fascial planes including removal of the perirectal fat
and nodes along the lateral pelvic walls. The mid-rectal artery
can be transected on both sides imme diately lateral to the pelvic musculature. The visual magnification permits recognition
and preservation of the nerves controlling erection if this step is
desirable and oncologically reasonable. This ensures adequate
mobilization of the rectum including the entire surrounding
layer of connective, fatty, and lymph tissue down to the floor of
the pelvis. In view of the strict indications for abdominoperineal
excision or amputation of the rectum, this procedure is suitable
only in the treatment of rectal cancers in the immediate vicinity
of the anal sphincter. Therefore, the actual removal of the tumor
is essentially performed as in a conventional abdominoperineal
approach, during the perineal part of the operation. It also allows a last minute judgement as to the lower margins of the
tumor (more than four centimeters from the sphincters) and
the potential for a safe colo-anal anastomosis under direct vision, if the perineal portion of the operation was limited in its
first step to a cautious, exploratory, anterior perineotomy. Additional factors that favor the use of laparoscopy in abdominoperineal excision or amputation of the rectum are the fact that removal of the resected tissue is done through the open perineum. Creating a terminal colostomy of the descending colon if
indicated is not a problem in laparoscopic surgery.
Indications
The surgeon must review the disorder critically before deciding
that abdominoperineal excision or amputation of the rectum is
indicated. If a sphincter-preserving or rectum-preserving procedure offers comparably favorable results, then such a procedure should be preferred. Indications for laparoscopically assisted abdominoperineal excision or amputation of the rectum
potentially include the following situations:
− The maximum distance between the inferior margin of the