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Surgical Technique andDicult Situations fromWerner Hohenberger
329
43
. Fig. 43.1 For mobilization of the splenic, the dissection
plane is running right along the bowel wall (---) to avoid
tension on the serosa of the spleen and eventually following bleeding. The lesser sac is opened, with the stomach
exposed (1)
. Fig. 43.2 The lesser sac is fully opened. Frequently, a
at groove right below the left pancreas is visible, indicating
the transection line of the anterior and afterward the posterior blade of the mesentery to be divided (---) (transition of
mesocolon to mesopancreas). Between these two blades,
3–4 small arteries originating vertically from the left branch
of the middle colic artery and running to the transverse
pancreatic artery inside the pancreas have to be divided.
Here are potentially regional lymph node metastases of a
transverse colon cancer
5 Further gain of length is achieved by dividing
the inferior mesenteric vein, again below the
pancreas. in sympathetic bers running
parallel vertically right to le to the aorta
must be watched and preserved, when dissecting this vein (. Fig.43.3).
5 is step is followed by the dissection and divi-
sion of the inferior mesenteric artery. Attention
has to be paid to the superior mesenteric plexus
(sometimes also called mesenteric plexus),
which extends like a tent from the aorta to the
proximal 1–2cm of the root of this artery
(. Fig.43.4).
. Fig. 43.3 Transection of the inferior mesenteric vein
(1, 4). Immediately next to it and lateral to the aorta, thin
sympathetic bers are running parallel (3), which have to
be preserved to avoid retrograde ejaculation, for example,
with males (2 = incision line)
. Fig. 43.4 The mesenteric plexus over the aorta includes
like a tent the root of the inferior mesenteric artery, too
(“adventitia”). These fibers are transected about 3cm
distally of the origin of the sup. mes. a. (2) with the vessel itself clearly exposed (1)
43.2.2 Anterior Rectal Resection
Now, the dissection in the small pelvis follows. An
anterior resection is eligible for cancer of the
upper rectal third, only and without obvious
lymph node metastases:
5 Alike with a low anterior resection, the meso-
rectum is exposed, rst, carefully watching the
hypogastric nerves on both sides. Frequently,
the Y-like splitting main cables form a thin
presacral network (. Fig.43.5).
5 For carcinomas of the upper third, a distal
margin of 5cm of the rectum in situ is sucient. erewith, the distal level of the rectal
transection lies closely below the seminal vesicles. is requires that even with an anterior
resection, the inferior hypogastric plexus at
330
W. Hohenberger
. Fig. 43.5 The mesorectum and the mesosigmoid as
well are fully dissected o the parietal plane. The gonadal
vessels (1) are crossing the iliac vessels. The sympathetic
bers are visible as thin white bers running parallel to the
inf. mes. a
. Fig. 43.7 View on the right anterolateral wall of the
small pelvis. The parietal plane over the right seminal vesicle
(2) is divided, and the Denonvilliers’ fascia (1) incidentally
incised, too
43
. Fig. 43.6 Exposure of the right lateral pelvic wall.
Sometimes, as in this demonstration, the “T junction” can be
dissected (1), which results from vessels crossing the dissection plane, thus creating an extension of the mesorectum
to the parietal plane. It contains the middle rectal artery or
sometimes small vessels. The transection has to follow the
dashed line (2). Putting a clamp just on the lateral pelvic
wall would increase the risk of damage to inferior hypogastric plexus just behind
the sidewall of the pelvis and the Denonvilliers’ fascia must be watched and preserved.
is fascia includes the parietal fascia, small
branches of the inferior hypogastric nerves
running to the seminal vesicles, and the base
of the bladder and muscle bers as well
. Figs.43.6 and 43.7).
(
5 When transecting the tube of the rectum, the
corresponding mesorectum must be divided
at the same level, to avoid coning. For restoring continuity, mainly with females, a handsewn anastomosis is usually performed. e
. Fig. 43.8 Fashioning of a descendorectostomy; the
sutures for the posterior half of the anastomosis are placed
already
posterior sutures are laid on a distance
(. Fig.43.8).
5 Next, interrupted sutures of the anterior part
of the anastomosis follow. If a stapler is
applied, the transection of the bowel is also
performed in an open manner, followed by a
hand sewn purse string suture.
43.2.3 Low Anterior Resection
Any tumor of the middle or lower rectal third
necessitates a low anterior resection, a procedure
which is well standardized, in the meanwhile.
Finally, it will result in an anastomosis within a
Surgical Technique andDicult Situations fromWerner Hohenberger
331
43
. Fig. 43.9 The twin coccygeorectal muscles are divided,
which is essential to get access to the intersphincteric space
(arrow). They are pretty pronounced in this patient
distance of no more than 2cm above the dentate
line. However, from technical and oncologic
aspects (no undierentiated carcinoma, at least
without neoadjuvant radiochemotherapy), a minimum of 0.5cm of a distal margin of clearance can
be accepted. Such a low resection demands always
an intersphincteric dissection down to the level of
the dentate line. In the vast majority of cases, this
can be achieved by an abdominal approach, exclusively.
> e exclusive abdominal approach for an
intersphincteric dissection necessitates the transection of the M. coccygeorectalis (Stelzner). is muscle is not known by most surgeons. It is a twin
muscle originating lateral to the os coccygis reaching
the rectal wall right below the mesorectal sac. ere
are individually enormous variations, including its
symmetry. It may present as a thin stringlike band
but also as a muscle up to 1 cm thick. e space
between the rectal wall (“internal sphincter”) and
the levator muscle (“external sphincter”) cannot be
reached without splitting this muscle (. Fig.43.9).
43.2.4 Abdominoperanal
Intersphincteric Rectal
Resection
With very obese males, for example, or if the
tumor is very close to the dentate line, it may be
uncertain, nally, whether an adequate distal margin of clearance can be achieved by an abdominal
approach only. Only then, a combined procedure
is needed. To make this clear and also because the
. Fig. 43.10 The peranal transection of the lowest rectal
wall right at the dentate line is completed. The retractor
shown facilitates the exposure of the low rectum and anal
canal as well
. Fig. 43.11 The anastomosis is performed
term “ intersphincteric” was stressed unreasonably
in recent years, the term “abdominoperanal” was
introduced by the author, several years ago,
already:
5 First, with a retractor placing the hooks into the
dentate line (
. Fig.43.10), the distal rectum is
exposed. e peranal intersphincteric starts
with the incision dorsally in a semicircular fashion through the rectal wall or even the dentate
line itself. e correct plane will be reached,
when the rectal wall retracts, abruptly. Anteriorly, over about one third of the circumference,
extensions of the external sphincter muscle are
crossing the intersphincteric space. erefore,
here sharp transection is needed (. Fig.43.10).
5 e anastomosis is fashioned by hand sewn
sutures including the dentate line and the
descending colon, which is brought outside
through the hole of the levator sling
(. Fig.43.11).
332
W. Hohenberger
5 A pouch reconstruction is desirable; however
it is not always realized, as a pouch may be too
bulky to pass the levator.
43.2.5 Low Anterior Resection
Syndrome
At least a quarter of all patients suer from symp-
toms of a low anterior resection syndrome. e
detailed obviously multifactorial etiology is not
yet clear. Preoperative irradiation and probably
preciseness of surgical dissection between the
lowest mesorectum and the shiny parietal plane
covering the levator muscle, too, have a signicant
impact on its severity.
e construction of a pouch may reduce
its symptoms (. Fig. 43.12). An end-to-side
. Fig. 43.12 A colonic pouch created with a 75mm stapler
and the anvil of a circular stapler already introduced
anastomosis and a transverse coloplasty are probably less eective; however, this is a matter
of ongoing trials.
43
333
Surgical Technique
and Difficult Situations
from Rolv-Ole Lindsetmo
(Laparoscopic)
KimErlendMortensen, StigNorderval, andRolv-OleLindsetmo
44.1 Contraindications to Laparoscopic Surgery – 334
44.2 The Surgery – 334
44.2.1 High Anterior Resection (HAR) – 334
44.2.2 Low Anterior Resection (LAR) – 336
44.2.3 Abdominoperineal Resection (APR) – 338
44
44.3 Locally Advanced Tumours – 338
44.4 When to Convert – 338
44.5 Tips – 339
44.5.1 Patient Positioning – 339
44.5.2 Port Placement – 339
44.5.3 Access in the Abdominal Cavity – 339
44.5.4 Technical Tips – 339
44.5.5 The Adipose Patient – 339
44.6 Quality Control – 340
44.7 Pitfalls – 340
44.7.1 Injury to the Inferior Epigastric Vessels – 340
44.7.2 Small Bowel Injury – 340
44.7.3 Injury to the Ureter – 340
44.7.4 Nerve Injury – 340
44.7.5 Colon/Rectum Injury – 341
44.7.6 Injury to the Vagina – 341
References – 341
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI 10.1007/978-3-662-49878-1_44
334
K.E. Mortensen et al.
44
44.1 Contraindications
to Laparoscopic Surgery
e obese patient oers a challenge in laparo-
scopic surgery in the pelvis, especially in men.
However, it is these patients which have the big-
gest potential benet from minimal invasive sur-
gery because they suer more oen from wound
infections and incision hernias aer open surgery.
It is therefore our opinion that obesity in itself
should not be a contraindication to laparoscopy.
In any case, most of the procedure may be done
laparoscopically before eventual conversion (like
taking down the splenic exure and mobilisation
of the descending colon). In fact, it is actually
oen easier to nd the right plane of dissection
under the mesocolon and behind the mesorectal
plane in obese patients due to less tenuous texture
of the tissues in the correct plane of dissection.
Previous abdominal surgery or radiation may
result in challenging adhesions. However, most
adhesions tend to be located in the midline and
may be taken down by placing trochars on either
side (outside the midclavicular line) advancing
towards the centre. A usually safe area to place the
rst trochar is under the le costal margin.
e need for extreme Trendelenburg position
creates increased intracranial pressure that must
5 mm
12 mm
. Fig. 44.1 Trocar placement
10 mm
5 mm
be recognised in patients with known intracerebral aneurysm or previous intracerebral bleeding/
stroke. Similarly, the increased cardiac aerload
will deteriorate a weakened cardiac muscle
because of ischemic cardiomyopathy or severe
aortic valve stenosis. Patients with group IV
chronic obstructive lung disease will also have
problems with ventilation of the CO2 gas used for
the needed pneumoperitoneum. An alternative
inert gas source might be used.
Locally advanced T4 tumours are in any way a
surgical challenge. e need for resection outside
the mesorectal fascia must be carefully evaluated
and the nal decision made individually to t the
patient’s need for an optimal oncological result.
e chosen operative technique should reect the
best treatment option available and not the preferences of the surgeon or lack of laparoscopic
experience.
44.2 The Surgery
44.2.1 High Anterior Resection (HAR)
For tumours located in the upper third of the rectum, a partial mesorectal excision will suce given
a minimum luminal distal margin of 2 cm [1].
Depending on the redundancy of the sigmoid
colon, the splenic exure may have to be taken
down, and this is usually the trickiest part of the
procedure and accordingly should be done initially when the surgeon is most attentive. Port
placement is illustrated in
. Fig. 44.1 or 10.29in
German version. With the patient tilted 30° to the
right and in the anti-Trendelenburg position, the
omentum majus and small bowel is lied over the
stomach and liver (in that order) until the transverse colon is clearly visible. Sometimes the transverse and the descending colon are fused together
on the medial aspect of the splenic exure in
which case oen necessitates division when taking
down the splenic exure. Once the medial aspect
of the colon is clear, the jejunum at the ligament of
Treitz is exposed, together with the upper part of
the inferior mesenteric vein (IMV) just before it
disappears under the pancreas. Exposing this area
is sometimes dicult if the small bowel is not
placed over the transverse colon as much as possible. An additional retractor placed from a port
placed in the suprapubic area is sometimes useful
to hold the small bowel over to the right at this
Surgical Technique and Difficult Situations from Rolv-Ole Lindsetmo (Laparoscopic)
Traktion
Traktion
Traktion
335
Traktion
Traktion
44
Kolon
M. suspensorius
duodeni
. Fig. 44.2 Triangulation-traction of transverse and
descending colon for identification of the inferior mesenteric vein
Pankreas
V. mesenterica inferior
Traktion
point. Sometimes, adhesions between the proximal small bowel and the medial aspect of the
descending colon’s mesentery may have to be
taken down with scissors without diathermia.
Traction with triangulation of the tissues away
from the point of dissection is vital (
. Fig. 44.2 or
10.30 in German version). When the IMV is
exposed, go under it. Do not divide it immediately
because it is oen useful to use it as an anchor to
li up the mesocolon when taking down the
splenic exure with the medial approach. At this
point you should begin seeing the anterior aspect
of Toldt’s fascia. Go straight laterally and cranially
but be careful here not to go too deep, as it is easy
to go under the pancreas here. Once the lateral
abdominal wall is reached, come back and divide
the IMV with vascular clips or LigaSure (never use
Ultrasonic for this). e next step will be to enter
the omental bursa by going cranial over the pancreas through the transverse mesocolon. Be careful not to damage the vascular arcades of the
transverse colon as your anastomosis depends on
the arcade from the middle colic artery
(Drummond’s arcade) going down to the descending colon. Once in the bursa, proceed lateral. Here
there usually is a tenuous adhesion between the
lower border of the pancreas and the colonic mesentery which must be divided with LigaSure or
UltraCision but be careful not to pull too hard
ventrally as you might triangulate the anterior surface of the pancreas and damage the capsule eventually leading to pancreatitis or leakage of
pancreatic uid. Once everything is released from
the medial aspect, go caudally, following the avas-
SA
LCA
IMA
Aorta
. Fig. 44.3 Traction of mesosigmoid for identification
of the inferior mesenteric artery LCA – left colic artery;
SA – sigmoid artery; SRA – rectal superior artery
SRA
Kolon
cular plane over Toldt’s fascia until you arrive at
the inferior mesenteric artery (IMA) trunk. Again,
upward traction of the mesocolon is vital to separate the tissue in the right plane. Be careful not to
go too deep (dorsally) when dissecting laterally
and caudally in which case you may end up underneath the ureter or testicular/ovarian vein (especially when using a 30° camera). If you decide to
do a D3 resection (high tie), the IMA should be
isolated 1cm from the aorta. In this area, the inferior hypogastric plexus lies directly on the IMA
and aorta and must be spared as much as possible
. Fig. 44.3 or 10.31 in German version). Try to
(
avoid using monopolar diathermia here. If you
nd locating the IMA trunk dicult, go further
down along the medial aspect of the sigmoid. Have
the assistant li the distal mesosigmoid ventrally
to create traction on the superior rectal artery, creating the mesenteric groove, and incise the peritoneum directly underneath the superior rectal
artery. Follow the vascular trunk all the way down
past the promontory until you nd the beginning
of the avascular plane behind the mesorectum (the
“holy” TME plane). Now, you will see that the
IMA trunk will be easier to identify when coming
back. Before dividing the IMA, the retroperitoneum with all the nerves, ureter and testicular/
ovarian vein must be pushed downwards dorsally.
Finally, the IMA and the le colic artery (LCA) are
secured with vascular clips and divided. e rest of
the peritoneal fold lateral to the descending colon
and sigmoid are divided until the TME plane in
the pelvis is reached. Now the dissection proceeds
down in the TME plane until you have reached a
44
K.E. Mortensen et al.
336
a
b
Ischemia
. Fig. 44.4 a correct stapler line b bad transection with
Z shaped stapler line (increased risk of ischemia)
margin of 4–5cm distal to the tumour. Be aware
that the nerve trunks of the inferior hypogastric
plexus can be damaged if the plane of dissection is
not kept close to the mesorectal fascia. At the same
time, it is important, for oncological reasons, not
to breach the mesorectal fascia. Transecting the
bowel can be done either before or aer dividing
the mesorectum. In adipose patients, it is oen
easier dividing the bowel rst. At this level (i.e.
high anterior resection) there is usually no problem dividing the bowel with one 60mm Endo GIA
magazine. Start by carefully incising the peritoneum just under the bowel wall and advance
slowly under the serosa along the fascia transversalis by using a long-armed forceps spreading the
fatty tissue to both sides, meticulously taking care
of any possible bleeders with a bipolar, LigaSure or
UltraCision. What is most important here (as
always) is to maintain a bloodless operation eld
so you can see what you are doing. Once under to
the other side of the mesentery, place the Endo
GIA perpendicular to the bowel wall, close, inspect
on both sides and re slowly aer allowing 20 s for
tissue moulding. Fire slowly. If a second magazine
is required, be sure that the staple line crosses on
the distal side (
. Fig. 44.4 or 10. 32in German ver-
sion). Now divide the mesorectum. When dividing the mesorectum before the bowel, make sure
not to spiral downwards around the bowel wall. A
good locking forceps (e.g. Endo Babcock) is placed
on the distal end of the bowel to be externalised
through a wound protector. We prefer making this
incision at the 5mm trochar on the le hypogastrium. e proximal level of resection should be at
least 10cm proximal to the tumour, but in any case
a spurting arterial bleeding from the mesocolic
arcades should be veried. Once the colon is transacted at least 10cm proximal to the tumour and an
anvil is secured with a purse string, the bowel is
replaced in the abdomen, the fascia closed and
pneumoperitoneum re- established. Do not
remove too much fatty tissue around the anvil as
this may compromise the vascular supply to your
anastomosis. Before making the anastomosis,
make sure that the bowel is not rotated by visualising a tenia all the way from the le exure down to
the anvil. e circular stapler is introduced into a
well-cleaned rectum and the anastomosis completed. Do not push too hard on the stapler in the
rectum, as this may damage the rectal stump.
Check both rings and test for an air leak. If you see
bubbles in the irrigation water in the pelvis,
remove the water by suction, have the assistant
inject more air and slowly pour water over the
anastomosis to nd the exact spot of leakage. en
place one or more cross sutures over the anastomosis line until the leak is stopped. Unless the eld
is very bloody, we do not routinely place a drain.
Make sure the small bowel is not herniated underneath the descending colon’s mesentery. Reposition
the omentum and small bowel, deate and remove
trochars. Depending on the size and type of trochars (cutting), we close the fascial openings aer
12mm trochars with a suture.
44.2.2 Low Anterior Resection (LAR)
Before a LAR, the patient receives bowel prep
because he or she will have a diverting loop
ileostomi. The initial steps for a LAR are the
same as for a HAR.The splenic flexure is always
taken down to attain a tension-free anastomosis. For a LAR, it is absolutely essential that the
small bowel is out of the pelvis. It is sometimes
necessary to incise the peritoneum of the lower
border of the ileal mesentery due to adhesions
on the promontory. Start the TME excision by
following the avascular plane in front of the
promontory and straight downwards as far as
you can go. Then develop this plane out laterally to both sides. The key to success in lateral
pelvis dissection is traction and countertraction. Be careful not to damage the sympathetic
nerve bundles ofthe inferior hypogastric plexus
and the parasympathetic nerves from S3 and S4
as they are easily drawn inwards sticking to the
Surgical Technique and Difficult Situations from Rolv-Ole Lindsetmo (Laparoscopic)
337
44
mesorectal fascia. At the same time, it is important not to breach the mesorectal fascia. When
pushing/pulling the mesorectum to the side, it
is sometimes beneficial to use a 10 × 10 cm
dressing (introduced through a 10 or 12 mm
trochar) between the forceps and the mesorectum. This dressing may also be of use in the
pelvis when using suction because placing the
tip of the suction instrument into the dressing
prevents fatty tissue blocking the tube. At
approximately 2 and 10 o’clock, the TME plane
becomes somewhat obscure around the socalled side ligaments. Stop here and go ventrally
to incise the peritoneum at 12 o’clock and work
your way outwards to both sides (. Fig. 44.5 or
10.33in German version). In women the uterus
usually needs to be hoisted up with a suture and
in men the bladder and vesiculae seminalis and
prostate can be lifted up with an angulated
retractor introduced via the suprapubic port. In
men, if the tumour is located ventrally, the
Denonvillier’s fascia in men should be dissected
off the prostate to attain a proper oncological
margin (the trade-off being probable impotence). Be careful not to go straight into the
vesiculae initially, as this will mess things up
due to bleeding. As this is an avascular plane,
bloodless dissection can be accomplished if dissection is aided by traction and countertraction.
Any use of monopolar or bipolar diathermia or
12
10 2
Rektum
Mesorektum
6
. Fig. 44.5 Dissection plane in paraproctium surface to
avoid nerve damage
UltraCision with heat dissipation in this area
will damage bres of the hypogastric nerve
plexus and the nervi erigentes but is oen dicult to avoid. Follow this plane as far as you can
past the tumour. Have a second assistant indicate the lower border with a rigid rectoscope, or
palpate by digital rectal examination yourself.
For low anterior resections, we routinely go all
the way past the mesorectum at the level where
the puborectal muscle becomes visible. To transect the bowel on the pelvic floor, a 45 mm
Endo GIA is needed and often more than one
firing. Make sure to fire as perpendicular to the
bowel as possible, introducing the stapler
through the 12mm port in the right iliac fossa
or through the suprapubic fossa (now changed
from a 5 to a 12mm port). Angulate the head as
much as possible. Pass the branches over and
under the bowel wall carefully with your right
hand, at the same time pulling the rectum into
the stapler with your left. Close, wait 20 s and
fire slowly. If placing a second magazine, make
sure to make a straight line and not a Z-line
. Fig. 44.4 or 10.32in German version). The
(
limited space in a male pelvis can make this
step of the operation technically challenging.
A third assistant might push the perineum
upwards giving an extra 1–2cm closer view. If a
fatty mesorectum and a narrow pelvis make the
placement of the stapler under vision control
impossible, then transect the rectal wall anterior to posterior. Still, it is mandatory to have a
90° angle of the transection. The rectum and
colon with the tumour is externalised and transected in the same manner as when performing
a HAR.When advancing the EEA stapler head
into the rectal stump, do it gently so as not to
stretch the top of the rectal stump because this
will result in a smaller diameter of the distal
ring. Make sure that no epiploica from the
colon becomes interposed between the colon
and the rectum when closing the stapler (to
make the anastomosis). Make sure the proximal
bowel is not rotated. Again, as after a HAR, do
a leak test with air insufflation. Place a drain for
1 day if the field is bloody. Make sure no small
bowel is herniated underneath the descending
colon. Reposition the omentum and small
bowel. We routinely perform a diverting loop
ileostomi if the patient received preoperative
radiochemotherapy or if the anastomosis is
below 7cm from the anal verge.
338
K.E. Mortensen et al.
44.2.3 Abdominoperineal
Resection (APR)
Laparoscopic APR is identical to LAR in that the
dissection is performed all the way to the pelvic
oor. Be sure to scrutinise the preoperative MRI
closely if the tumour is locally advanced (i.e.
aecting the levator ani or puborectal bundle)
because this will determine how far down the pelvic dissection should go. If the tumour lies dorsally, one should stop in a safe distance to the
tumour and excise the whole area with the coccyx
once the patient is turned around in the jackknife
position. We routinely divide the sigmoid so that
all lymph nodes around the IMA and sigmoid
arteries are removed en bloc. A 10 × 10cm dressing is placed in the midline behind the rectum on
the pelvic oor and then an 18 French drain in the
pelvis. e proximal descending colon is pulled
out to make a permanent stoma. e patient is
turned around on his/her stomach to complete
the amputation. e anus is closed with a purse
ring suture aer meticulous cleaning of the skin.
e incision line is drawn with a waterproof pencil. e upper border of the incision is the os
coccyx. Depending on the extent of the cancer,
the levator or extralevator plane is dissected by
monopolar diathermy. Enter the abdominal cavity beneath the os coccygus or under the distal
sacrum if the coccygus is de-articulated and
removed with the specimen. Identify the dressing
and remove it. If needed to ensure safe resection
margins, the pelvic oor muscles are resected
with or without the posterior part of the prostate
or posterior vaginal wall. Be aware of the risk for
urethral dissection injury in men during the dissection because the traction of the specimen will
li up the so tissue inferior to the genitourinary
membrane.
whether laparoscopy is an acceptable approach. If
deciding upon laparoscopic resection, it is advisable (as with open surgery) to place ureter stents
preoperatively to identify the ureter ostia. e transection of the bladder wall should be done with at
least 1cm margin to the tumour involvement. An
UltraCision scissors is useful. Closure of the wall is
done in two layers with running or interrupted
sutures. Always do a patency test by lling the bladder with methylene blue via a Foley catheter. e
patient should keep this catheter (opened) in place
for 3 weeks.
Small Bowel When encountering a small bowel
segment or mesentery with suspected local
ingrowth from a colonic or rectal tumour, just do
the same as when performing the operation open,
that is, a wide en bloc resection of the bowel and its
mesentery. If the mesentery dissection is deemed
risky due to impending damage to the superior
mesenteric artery, make a low midline incision,
resect the small bowel, anastomose and proceed
laparoscopically. e same incision can be used
later to extract the rectal tumour.
Pelvic Lymph Nodes Sometimes, pathological
lymph nodes will be found outside the mesorectal
fascia. ese should be removed, irrespective of
whether they respond to neoadjuvant chemotherapy or not. It is feasible to do a laparoscopic lymph
node dissection by following the bifurcation of the
iliac artery and vein down to the pelvic oor. is
will invariably result in ipsilateral nerve damage.
Synchronous Liver Metastasis e management of
synchronous liver metastasis must follow national
guidelines. However, supercial metastasis, if easily
accessible, can easily be removed with free margins
during the primary laparoscopic rectal cancer
operation. LigaSure or UltraCision can be used for
the liver resection.
44
44.3 Locally Advanced Tumours
Locally advanced tumours are not in themselves a
contraindication to laparoscopic oncological surgery as long as a radical margin is attained.
Urinary Badder Some high rectal tumours do
seem to grow into the dorsal bladder wall but with
close scrutiny of the preoperative MRI, and possibly a preoperative cystoscopy will aid in deciding
44.4 When to Convert
Previous trials have shown a larger incidence of
complications in patients where the surgeon converts to open surgery (cost, classic, colour).
However, it is not the actual conversion in itself
but the delay in conversion which results in complications. In other words, convert early when it
becomes evident that complications may occur or