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J.B. Tuynman and N.J. Mortensen
45
dissection plane in total mesorectal excision. Dis
Colon Rectum. 2005;48:37–42.
11. de Campos-Lobato LF, etal. Prone or lithotomy positioning during an abdominoperineal resection for rectal cancer results in comparable oncologic outcomes.
Dis Colon Rectum. 2011;54:939–46. doi:10.1097/
DCR.0b013e318221eb64.
12. Nilsson PJ.Omentoplasty in abdominoperineal resection: a review of the literature using a systematic
approach. Dis Colon Rectum. 2006;49:1354–61. doi:10.
1007/s10350-006-0643-x.
13. de Bruin AF, Gosselink MP, van der Harst E, Rutten
HJ.Local application of gentamicin collagen implants
in the prophylaxis of surgical site infections following
gastrointestinal surgery: a review of clinical experience. Tech Coloproctol. 2010;14:301–10. doi:10.1007/
s10151- 010-0593-0.
14. Holm T, Ljung A, Haggmark T, Jurell G, Lagergren
J.Extended abdominoperineal resection with gluteus
maximus ap reconstruction of the pelvic oor for rectal cancer. Br J Surg. 2007;94:232–8. doi:10.1002/
bjs.5489.
Surgical Technique
and Difficult Situations
from Amjad Parvaiz
(Laparoscopic)
AmjadParvaiz andManfredOdermatt
46.1 Introduction – 352
46.2 Laparoscopic TME Offers Better Short-Term
Outcomes Without Oncological Compromise
When Compared to Open TME – 352
351
46
46.3 Initial Workup – 352
46.4 Patient Preparation – 352
46.5 Patient Positioning – 352
46.6 Equipment – 353
46.7 Operative Technique – 353
46.7.1 Port Placement – 353
46.7.2 Colonic Mobilisation – 353
46.7.3 Laparoscopic Total Mesorectal Excision (TME) – 356
46.7.4 Extraction of Specimen – 359
46.7.5 Anastomosis – 359
46.7.6 Loop Ileostomy – 361
46.8 Postoperative Care – 361
46.9 Conclusion – 361
References – 361
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI 10.1007/978-3-662-49878-1_46
352
A. Parvaiz and M. Odermatt
46
46.1 Introduction
Since the rst laparoscopic colonic resection
undertaken by Jacob [1] in 1991, laparoscopy has
now become a gold standard for colorectal cancer
surgery. Early doubts over oncological safety have
been quashed in numerous randomised controlled trials which have shown that laparoscopic
resection is associated with better short-term outcome and without oncological compromise [2–5].
However, many who might accept that laparoscopic resection may be appropriate and optimal
for colonic carcinoma still have reservations
regarding its use for rectal cancer and question
whether an oncologically sound total mesorectal
excision (TME) is feasible laparoscopically.
46.2 Laparoscopic TME Offers
Better Short-Term Outcomes
Without Oncological
Compromise When Compared
to Open TME
Advances in instrumentation and imaging technology coupled with increased surgical skill,
training and experience have led to several reports
of successful laparoscopic resection for rectal cancer with TME, and there is increasing evidence
that this is safe and appropriate [6–13].
As regards short-term benets of the laparoscopic approach, operative blood loss, duration of
ileus and length of hospital stay were signicantly
reduced in most studies. Operating times are signicantly longer. Complication rates are not
increased. Long-term data suggest that there is no
compromise on oncological outcome when laparoscopy is compared to open technique.
46.3 Initial Workup
Once the diagnosis of rectal carcinoma has been
conrmed by biopsy, a systemic staging is performed with a CT scan of the abdomen, pelvis
and chest. Routinely, an MRI scan of the pelvis is
performed for loco-regional staging.
In cases of low rectal carcinoma, we oen
employ endo-anal ultrasound to better visualise
the exact tumour location and in particular its
relationship to the sphincter complex. Once
the staging is complete, each individual case is
discussed in the multidisciplinary tumour board
meeting. Preoperative chemo-radiotherapy is
given to patients with T3b and T4 rectal cancer
with either threatened or involved circumferential resection margins.
46.4 Patient Preparation
5 Preoperative assessment of operability takes
place in the anaesthetic clinics
5 For mechanical bowel preparation, the patient
has to take two sachets of Picolax
picosulfate) the day before surgery.
5 Modied enhanced recovery programme as
popularised by Henrik Kehlet [14] is applied
in all patients, however, with exception of a
more selective use of an epidural catheter for
postoperative pain control.
5 Patient is marked preoperatively for loop ile-
ostomy by the stoma nurse.
5 Informed consent is signed by the patient.
46.5 Patient Positioning
5 Patient is placed in a modied Lloyd-Davies
position on an operating table that allows
maximal head down and side tilting during
surgery.
5 To avoid the patient to slip during the head-
down position, a vacuum bean bag is used.
5 We avoid any additional supporting devices.
Shoulder supports can result in brachial plexus
injury particularly in patients with high BMI.
5 Sequential compression devices are placed on
the lower extremities.
5 Prophylactic single-shot antibiotic is adminis-
tered before the start of the operation.
5 Digital rectal examination in the relaxed
patient is essential to assess tumour height in
relation to the sphincter.
5 e operating surgeon and the assistant
holding the camera stand to the right of the
patient. A further assistant is required to
stand on the le side of the patient in order
to provide traction and counter-traction during the operation.
5 Monitors are placed on both sides and on the
lower le side of the patient so that all surgeons have appropriate view during the dierent steps of the operation (. Fig. 46.1).
®
(sodium
Surgical Technique and Difficult Situations from Amjad Parvaiz (Laparoscopic)
. Fig. 46.1 Setting of surgeon (S), first assistant (A1),
second assistant (A2) and scrub nurse (SN) in the theatre. For
splenic flexure mobilisation from above (division of
gastrocolic ligament, transverse mesentery and splenic
attachments), the surgeon and first assistant change places
46.6 Equipment
. Fig. 46.2 Port placement: The camera port is inserted
at the umbilicus. Two 5 mm ports are placed at the level of
the umbilicus and lateral to the rectus muscle. A 12 mm
port is inserted 20 mm above the right anterior superior
iliac spine. An additional 5 mm port is placed subcostal
and in the mid-clavicular line
353
46
5 High-denition camera and monitor system
with two screens are preferred.
5 30° 10mm laparoscope.
5 Atraumatic bowel graspers.
5 Monopolar hook electrocautery and addition-
ally a harmonic scalpel (Harmonic®).
5 Alexis® wound protector.
5 Articulating endoscopic linear stapler for divi-
sion of the rectum.
46.7 Operative Technique
46.7.1 Port Placement
Pneumoperitoneum is set by using a modied
Hasson technique at the umbilicus. e umbilical
port is a 10mm trocar and used for the 10mm 30°
camera. e following ports are placed under
vision aer subperitoneal injection of a local
anaesthetic. A 5mm port is inserted on the le
side at the level of the umbilicus and at the outer
border of the rectus muscle. A second 5mm port
is placed on the right side at just above the level of
the umbilicus and at the lateral border of the rectus muscle. A third 5mm port is placed in the
mid-clavicular line below the costal margin. is
port is helpful to elevate the rectum out of the pelvis during the total mesorectal excision. e
patient is then brought in head-down position to
allow the small bowel to leave the pelvis by gravity. is leads to a safe placement of a 12mm port
2.5cm medial to the right anterior superior iliac
spine. All ports are inserted perpendicularly to
the skin which allows for less fatigue during a
lengthy operation (
46.7.2 Colonic Mobilisation
. Fig. 46.2).
Exposure
Optimal exposure at any stage of the procedure is
essential for accurate and safe laparoscopic surgery. For the mobilisation of the le colon, good
exposure is achieved by having the patient in
steep head-down and right tilt position. is will
place the small bowel away from the pelvis and to
the right side. en the greater omentum with the
attached transverse colon is placed under the le
lobe of liver (. Fig. 46.3). If the stomach is
distended, a nasogastric tube has to be inserted.
e tube is removed at the end of the operation.
46
354
A. Parvaiz and M. Odermatt
. Fig. 46.3 The greater omentum with the attached
transverse colon is placed under the left liver lobe
In case of a short mesentery of the small bowel or
in patients with higher BMI, we routinely place a
small swab at the edge of the small bowel package
in order to prevent bowel loops from gliding into
the operating eld. To expose the course of the
inferior mesenteric artery, the mesentery of the
sigmoid colon at the level of the pelvic brim is
now lied by the assistant standing on the le side
of the patient. Sustained traction is applied. e
operating surgeon should have a clear view of
themedial aspect of the sigmoid mesentery and
the inferior mesenteric artery.
Isolation and Ligation of the Vascular Pedicle
e dissection is started by using a monopolar
cautery hook inserted through the 12mm port.
With an additional grasper for counter-traction,
the mesentery is brought under tension. e
power setting of the electrocautery is on 25W
each, for coagulation and cutting. No spray function is used at any time. In our experience, this
setting allows for minimal charring of the tissues
leading to precise dissection of the embryologic
planes. First, the peritoneum is scored at the
level of the sacral promontory in a caudo-cranial
fashion (parallel and below to the IMA) in the
direction of the duodeno-jejunal junction
(
. Fig. 46.4). When opening the peritoneum
with the cautery hook, gas enters the retroperitoneal space (. Fig. 46.5). is air is like a roadmap for further dissection. If there is no air
spread, the entry point is either too low or too
high. e dissection has to stay at the upper border of the air close to the dorsal side of the IMA,
keeping a safe distance from both the le ureter
and the gonadal vessels. Once the peritoneum is
incised alongside and below the IMA, the vessel
is supported by a grasper from below. e fatty
. Fig. 46.4 The operation is started with scoring of the
peritoneum below the inferior mesenteric artery which is
brought under tension by lifting up the sigmoid
mesentery at the level of the pelvic brim
. Fig. 46.5 Fatty tissues dorsal to the inferior
mesenteric artery is dissected until a shiny and smooth
plane is identified
tissue of the mesentery is divided until a shiny
surface appears which indicates that the right
embryologic plane for further dissection has
been found. Dissection continues bluntly from
medial to lateral. As long as the IMA has not
been divided yet, the dissection stays below and
close to the IMA until its origin at the aorta. By
using gentle traction and counter-traction and
by teasing o the adjacent fatty tissue of the vessel, the clean surface of the IMA can be exposed
for subsequent ligation and division. Further
dissection of the initially identied correct
planes from medial to lateral is achieved by using
blunt dissection staying on top of Gerota’s fascia
keeping this thin layer of fascia intact overlying
both the le ureter and gonadal vessels. is dissection leads to a better access to the root of the
inferior mesenteric artery. Once the le ureter
has been safely identied and put out of harm,
the IMA is ligated and divided at its origin. is
is done by creating a window around the IMA
proximal to the ascending le colic artery. We
®
divide the IMA between Hem-o-Lock
clips
Surgical Technique and Difficult Situations from Amjad Parvaiz (Laparoscopic)
. Fig. 46.6 Division of the inferior mesenteric artery
close to its origin using clips
(. Fig. 46.6). It is important at this stage not to
carry out prolonged thermal dissection at the
root of the IMA as this may result into injury to
the main trunk of the hypogastric nerve which
runs at this level near to the origin of the vessel.
. Fig. 46.7 Medial to lateral mobilisation after division
of the inferior mesenteric artery
Medial to Lateral Mobilisation and Ligation and Division of the Inferior Mesenteric Vein
Once the inferior mesenteric artery has been
divided, the focus turns to the inferior mesenteric
vein. However, we attempt to delay the division of
the vein as long as possible during the medial to
lateral mobilisation. e free mesentery border
containing the inferior mesenteric vein can be
supported by a grasper in the le hand of the
operating surgeon. is creates a curtain preventing the small bowel to glide into the operating
eld. Furthermore, the vein is an important reference point for the retroperitoneal plane which
begins just below the vein and continues from
medial to lateral aspect over the fascia of Toldt
(
. Figs. 46.7 and 46.8). Oen, there are small and
easily bleeding vessels between the two layers of
fascia which should be pre-empted and sealed
using harmonic scalpel as they result in staining
of the retroperitoneal plane in case of bleeding.
Once the dissection has been completed at the
duodeno-jejunal level, the superior border of the
pancreas is identied, and the lesser sac is entered
from below by scoring the outer layer of the transverse mesentery (
tates later the splenic exure mobilisation which
in most cases is necessary in total mesorectal excision. If total splenic exure mobilisation is necessary, we place a swab on top of the pancreas,
which serves as a reference point and protection
of the pancreas when completing the dissection
coming from the lesser sac at a later stage of the
. Fig. 46.9a, b). is step facili-
. Fig. 46.8 The avascular embryologic plane is
dissected from medial to lateral
operation. When the dissection from medial to
lateral is completed, the inferior mesenteric vein
is clipped and divided just below the lower border
of the pancreas and next to the duodeno-jejunal
junction (. Fig. 46.10).
Lateral Mobilisation
e lateral le colonic mobilisation is carried out
by monopolar hook cautery joining a plane which
has already been created from the medial aspect.
e lateral peritoneal top layer is divided by
holding the colon towards the right side. Care
must be taken to always stay close to the colon as
it is very easy to get behind the le kidney. Lateral
dissection begins from the pelvic brim and continues up to the spleen (
ments to the spleen have to be divided at the turn
of the splenic exure. Care must be taken to avoid
any traction on these attachments as this may
result into traction injury to the splenic capsule
resulting into bleeding.
355
. Fig. 46.11). e attach-
46
356
A. Parvaiz and M. Odermatt
46
a
. Fig. 46.9 a Blunt dissection continues until the pan-
creas can be identified (arrow). b Scoring of the transverse
mesentery at the top border of the pancreas (blue line). After
. Fig. 46.10 Division of the inferior mesenteric vein at
the lower border of the pancreas
b
that, a swap is placed on top of the pancreas, and the transection of the left-sided transverse mesentery is completed
from the lesser sac
. Fig. 46.12 Detachment of the omentum from the
transverse colon in order to enter the lesser sac
. Fig. 46.11 Lateral mobilisation of the colon
Mobilisation of the Left-Sided Transverse Colon
To completely free the splenic exure, the le- sided
mesentery of the transverse colon has to be divided
immediately above the pancre as. is can be achieved
from below or from the lesser sac. We oen choose
the second option. To enter the lesser sac, either the
gastrocolic ligament has to be divided, or the omentum has to be detached from the transverse colon
(. Fig. 46.12). Aer one of these steps, the lesser sac
is entered and the mesentery of the transverse colon
divided over the swab (. Fig. 46.13) which has been
. Fig. 46.13 Division of the transverse colon over the
swab (arrow) which has been placed on top of the pancreas
in a previous step. This avoids injury to the pancreas
placed on top of the pancreas in a previous step of the
operation from below. e splenic exure and the le
colon should now be completely mobilised allowing
a tension-free anastomosis.
46.7.3 Laparoscopic Total
Mesorectal Excision (TME)
Step 1: Posterior Dissection
First, the correct plane of further dissection has to
be identied; in fact, the correct plane is a continuation of the plane previously identied during the
Surgical Technique and Difficult Situations from Amjad Parvaiz (Laparoscopic)
357
46
. Fig. 46.14 Dissection following the angulation of the
superior haemorrhoidal artery leads to the correct
posterior TME plane
colonic medial to lateral mobilisation. e inferior
mesenteric artery is continued to be mobilised
towards the pelvis staying very close to its dorsal
surface. Following the angle of the superior haemorrhoidal artery will automatically lead into the
pelvis and guide to the correct embryologic plane
at the top of the TME plane, allowing preservation
of the nerves. e posterior dissection further
down is then performed by separating the cobweb
plane staying close to the mesorectal package and
using monopolar hook diathermy (. Fig. 46.14).
e dissection always stays in front of both hypogastric nerves. e monopolar hook dissection is
carried out in very small and short contacts so that
no charring is produced and clear vision of the
planes is maintained. Traction on the specimen is
provided by a swab hold in the surgeon’s le hand
grasper in order to minimise trauma to the specimen itself. e posterior dissection is continued all
the way down to the beginning of Waldeyer’s fascia.
Step 2: Right Lateral Dissection
Aer having completed the posterior dissection as
described above, the right lateral mobilisation of
the specimen is performed by separating the rightsided pelvic attachments (. Fig. 46.15). e rectum is retracted out of the pelvis, and to the le,
traction and counter-traction is performed with
two additional graspers at the site of hook dissection. As the plane at the lateral attachments is more
dicult to identify, care must be taken not to enter
the mesorectal package or to go too wide at the
posterolateral side in order to avoid injury to
thevery close hypogastric nerve bres at this level.
e right hypogastric nerve can be visualised
completely during this step. Once the attachments
have been divided and the nerve bres preserved,
we complete the division of the peritoneal reection on the right side and anteriorly (. Fig. 46.16).
. Fig. 46.15 Dissection of the right lateral peritoneum
and attachments
. Fig. 46.16 Division of the peritoneal reflection
. Fig. 46.17 Transabdominal hitch of the anterior peri-
toneal fold at the base of the bladder in a male to expose
the anterior pelvis
Step 3: Anterior Dissection (Exposure)
Anterior dissection is facilitated by proper exposure of the deep pelvis. is is achieved by suturing the fundus of the uterus in female patients or
the peritoneal fold at the base of the bladder in
male patients (. Fig. 46.17) to the abdominal
front wall. For this, we use a 2-0 Prolene transabdominal suture on a straight needle. To dissect the
anterior aspect, the divided peritoneal reection
adjacent to the specimen is held by a grasper in
the le hand of the operating surgeon, while the
le-sided assistant applies counter-traction onto
the anterior pelvic wall with a pledget (a small
compress).
46
358
A. Parvaiz and M. Odermatt
. Fig. 46.18 Division of the left lateral peritoneum and
attachments
. Fig. 46.19 Anterior dissection between Denonvilliers’
fascia and seminal vesicles in a male
Step 4: Left Lateral Dissection
After division of the anterior peritoneal
reflection and some hook dissection further
down, the specimen is held in place by a thin
layer of the peritoneum on the left side. This
peritoneal layer is scored and the lateral
attachments beneath are divided by the hook
cautery (. Fig. 46.18). Care must be taken not
to go too wide on the left side while coming
down into the pelvis as this may result into
injury to important structures like the left ureter or left hypogastric nerve. Counter- traction
is again provided by the assistant to facilitate
this step.
Step 5a: Anterior Dissection in Male
e plane between the Denonvilliers’ fascia and
the seminal vesicles is entered anteriorly by
applying dorsal traction on the specimen and
counter- traction on the seminal vesicles
. Fig. 46.19). is dissection has to be very pre-
(
cisely in order not to risk bleeding which would
stain the cobweb plane and make the dissection a
lot more dicult. As usual, this step is performed
by monopolar hook diathermy under avoidance
of any charring.
. Fig. 46.20 Anterior dissection of the vaginal back wall
in a female
. Fig. 46.21 Nerve fibres at 4 and 8 o’clock position have
to be preserved
Step 5b: Anterior Dissection in Female
e hitched uterus helps to visualise the posterior
wall of the vagina (. Fig. 46.20) from where the
mesorectal fascia has to be dissected. Care has to
be taken not to perforate the vagina. In case of difculty to delineate the vagina, a sponge stick is
inserted into the vagina.
Step 6: Right and Left Posterolateral Dissection, Exposure of Erigent Pillars
Before addressing the deeper lateral dissection, the
anterior and posterior dissection has to be performed as far down as possible. Especially the established posterior plane serves as a reference point
whenever the dissection plane becomes unclear.
Both the anterior and posterior planes should be
used as a constant reference for division of the lateral attachments of the specimen. Care must be
taken at the four and eight o’clock position of the
specimen, as the nerve bres have to be teased o
the specimen in order to avoid injury (
. Fig. 46.21).
Step 7: Completion of Dissection
Arrived on the pelvic oor, dissection is carried
out using the harmonic device as traction and
counter-traction may be dicult to achieve. e
Surgical Technique and Difficult Situations from Amjad Parvaiz (Laparoscopic)
359
46
. Fig. 46.22 The stapling device is inserted from lateral
and rotated in a vertical position
. Fig. 46.23 Vertical position of the stapling device
rectal tube is dissected circumferentially in order
to be able to place a stapling device. e tumour
height and clearance are assessed by digital rectal
examination. In case of upper rectal cancer, intraoperative exible endoscopy may help to delineate the lower border of the tumour.
Step 8: Rectal Washout
Although there is sparse evidence, we perform arectal washout with a cytotoxic solution (Betadine®).
Step 9: Stapler Division
A linear Endo GIA stapler (Covidien USA) is
inserted through the 12mm port. Depending on
the thickness of the bowel wall, we choose a purple or a green cartridge. We prefer a cartridge
length of 45mm as it allows easier manipulation
in the narrow pelvis. Normally two rings are
necessary. e rectum is retracted out of the pelvis and dorsally. en the stapler is maximally
angulated and rotated in a vertical position
. Fig. 46.22). is allows an anterior-posterior
(
staple line straight at the level of the pelvic oor
(. Fig. 46.23). is step can be further facilitated
by pushing on the perineum from below. Both
staple lines should meet exactly and not cross
. Fig. 46.24 Anteroposterior staple lines straight on the
pelvic floor without overlap
each other (. Fig. 46.24). A tensionless anastomosis is crucial. A grasper is placed at the end of
the dissected rectum to facilitate extraction.
46.7.4 Extraction of Specimen
To extract the specimen, the umbilical port site is
extended to about 4–5cm in the midline. We use
an Alexis® wound retractor to protect the wound.
e exteriorised descending and sigmoid colon
and the rectum are laid out anatomically. e site
of transection is marked and the mesentery
divided accordingly. Before dividing the marginal
artery at the level of the transection site, its pulsatile ow is assessed.
46.7.5 Anastomosis
We perform an end-to-end colorectal stapler anastomosis using a CDH 29 mm device (Ethicon
Endo-Surgery). e stapler anvil is inserted into
the proximal bowel end and secured with a pursestring suture. en, the exteriorised bowel is put
back into the abdominal cavity. To seal the extraction site, we pull a glove over the Alexis® retractor
and use one of the glove ngers to insert the
10mm camera port. Pneumoperitoneum is established. e descending colon is aligned anatomically to exclude any torsion of the mesentery.
eproximal end with the anvil is brought into the
pelvis to make sure that a tensionless anastomosis
is possible. e spike of the stapler should perforate where the two staple lines meet (
. Fig. 46.25).
e anvil of the proximal bowel end is connected
with the stapler gun. Before closing the stapler, the
aligning and the rotation of the le-sided colon are