46.7.6 Loop Ileostomy

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360

A. Parvaiz and M. Odermatt

. Fig. 46.25 The spike of the stapling device perforates where the two staple lines meet

once again checked. e stapler is closed and red aer a short time of compression. e integrity of the two doughnuts is checked. We always perform a exible sigmoidoscopy to assess the anastomosis

and the viability of the bowel mucosa from the endoluminal side. At the same time, the water test to exclude air leaks is done. A 20 French non-suction tube drain is placed into the pelvis.

Surgical Technique and Diﬃcult Situations from Amjad Parvaiz (Laparoscopic)

361

46.7.6 Loop Ileostomy

Aer a total mesorectal excision with primary anastomosis, we always perform a loop ileostomy. An ileal loop next to the caecum is brought to the abdominal wall. e fascia of the umbilical midline incision and the 12mm port site as well as the skin is closed. An ileostomy is performed in usual fashion.

46.8 Postoperative Care

Patients are managed according to the principles of enhance recovery as described by Kehlet [14]. Oral intake in the form of liquid diet is started in the evening of surgery followed by normal solid diet the next day. Epidural analgesia is le in place for 48h aer surgery. Before removal of the epidural catheter, oral analgesics like paracetamol and non-steroidal anti-inammatory agents are started. Urinary catheter and pelvic drain are also removed at day 2 following surgery. Once the patient is considered to be stoma competent by the stoma nurse and meets all other criteria for discharge, they are discharged home. Our median length of hospital stay for patients undergoing laparoscopic TME surgery is 5 days.

46.9 Conclusion

Laparoscopic rectal resection with TME is safe and confers all the benets of laparoscopic colonic surgery. With improvement in techniques, better instrumentation and increasing experience, the quality of TME and the oncological results will continue to improve. However, it is a challenging procedure to learn, requiring a stringent training programme as with the introduction of open TME.We believe that by standardising the technique of laparoscopic TME surgery, consistent results can be achieved which are at par if not better when compared to open surgery. With appropriate training, laparoscopic TME is likely to become the new gold standard for rectal cancer resection.

References

1. Jacobs M, Verdeja JC, Goldstein HS. Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc. 1991;1:144–50.

2. Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet. 2005;365:1718–26.

3. Jayne DG, Guillou PJ, Thorpe H, et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol. 2007;25:3061–8.

4. Abraham NS, Young JM, Solomon MJ. Meta-analysis of short-term outcomes after laparoscopic resection for colorectal cancer. Br J Surg. 2004;91:1111–24.

5. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopy- assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet. 2002;359:2224–9.

6. Anderson C, Uman G, Pigazzi A. Oncologic outcomes of laparoscopic surgery for rectal cancer: a systematic review and meta-analysis of the literature. Eur J Surg Oncol. 2008;34:1135–42.

7. Lujan J, Valero G, Hernandez Q, Sanchez A, Frutos MD, Parrilla P. Randomized clinical trial comparing laparoscopic and open surgery in patients with rectal cancer. Br J Surg. 2009;96:982–9.

8. Laurent C, Leblanc F, Wutrich P, Scheﬄer M, Rullier E. Laparoscopic versus open surgery for rectal cancer: long-term oncologic results. Ann Surg. 2009;250: 54–61.

9. Braga M, Frasson M, Vignali A, Zuliani W, Capretti G, Di Carlo V. Laparoscopic resection in rectal cancer patients: outcome and cost-beneﬁt analysis. Dis Colon Rectum. 2007;50:464–71.

10. Zhou ZG, Hu M, Li Y, et al. Laparoscopic versus open total mesorectal excision with anal sphincter preservation for low rectal cancer. Surg Endosc. 2004;18: 1211–5.

11. Bretagnol F, Lelong B, Laurent C, et al. The oncological safety of laparoscopic total mesorectal excision with sphincter preservation for rectal carcinoma. Surg Endosc. 2005;19:892–6.

12. Law WL, Lee YM, Choi HK, Seto CL, Ho JW. Laparoscopic and open anterior resection for upper and mid rectal cancer: an evaluation of outcomes. Dis Colon Rectum. 2006;49:1108–15.

13. Morino M, Allaix ME, Giraudo G, Corno F, Garrone C. Laparoscopic versus open surgery for extraperitoneal rectal cancer: a prospective comparative study. Surg Endosc. 2005;19:1460–7.

14. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606–17.

363

Surgical Technique andDicult Situations fromPeter M. Sagar (Conventional, AbdominoSacral Resection)

PeterM.Sagar

47.1 Introduction – 364

47.2 Composite Abdomino-Sacral Resection – 364

47.2.1 Preoperative Evaluation – 364

47.2.2 Preoperative Radiotherapy – 364

47.2.3 Preparation – 364

47.2.4 Theatre Set-Up forFirst Stage – 364

47.2.5 Surgical Procedure – 364

47.3 Surgical Approach If Urinary Structures Are Also Involved – 367

47.3.1 Reconstructive Options toClose thePerineal Defect – 368

47.4 Dealing withUnexpected/Dicult Situations – 369

47.4.1 Bleeding – 369

47.4.2 The Correct Level ofSacral Division – 369

47.1 Introduction

e incidence of rectal cancer remains high – there are 13,000 new cases each year in the United Kingdom (population 60 million). A small proportion of these cases will present with direct posterior invasion of the tumour with involvement of the sacrum. Moreover, 5–15 % of patients who undergo resection with intent to cure will develop local recurrence of their tumour. Such recurrences may involve the neorectum ± the adjacent genitourinary organs, the pelvic sidewall, the sacrum or a combination of these three sites. ere is, therefore, a small but denite cohort of patients with either primary or recurrent rectal cancer with sacral involvement. ose suitable for resection need careful preoperative assessment and a well thought-out and executed surgical strategy.

47.2 Composite Abdomino-Sacral

Resection

47.2.1 Preoperative Evaluation

5 Complete history and examination (with digi-

tal rectal examination as appropriate)

5 Assessment of performance status of the

patient

5 Examination under anaesthesia with cystos-

copy and urogynaecological examination if indicated

5 Colonoscopy to assess (neo)rectal lesion and

exclude synchronous colorectal pathology

5 MR imaging with fat suppression and gado-

linium enhancement

5 oraco-abdominal CT imaging with PET if

available to identify FDG uptake of the primary/recurrence and metastases

5 Biopsy of suspicious lesions

47.2.2 Preoperative Radiotherapy

5 All patients who are radiotherapy naïve

should receive long-course chemoradiotherapy (5-week course) followed by a 6–8-week delay before resection with restaging at this time.

5 Patients who have previously had either long-

or short-course radiotherapy may be considered for a boost.

47.2.3 Preparation

5 Stoma site marking by colorectal nurse spe-

cialists.

5 Epidural and general anaesthesia. e anaes-

thetist is aware that the second stage will be in prone jackknife position.

5 Central venous and arterial lines. 5 Placement of bilateral ureteric stents.

47.2.4 Theatre Set-Up forFirst Stage

5 Modied Lloyd-Davies position 5 Electronic table with scope for steep reverse

Trendelenburg

5 Lower limbs in Allen stirrups with padding at

pressure points

5 Arms wrapped in padding and positioned at

the sides

5 Urinary catheter, nasogastric tube 5 Passage of ureteric stents

47.2.5 Surgical Procedure

First Stage: Abdominal Phase

5 e abdomen is entered though a midline

laparotomy with complete adhesiolysis.

5 orough laparotomy to exclude occult peri-

toneal metastases.

5 e site of the pelvic mass is identied and

the mass assessed. e main concern at this stage is the involvement of adjacent organs. As well as the suspected and presumed sacral involvement, it is important to ensure that the preoperative staging has not underestimated the anterior and lateral extent of the tumour. In order to achieve tumour-free resection margins (R0 resection), involved organs should be resected en bloc with the primary mass.

5 Both ureters are identied. It is usually easier

to nd them in the sigmoid fossa rather than lower down on the pelvic sidewall especially in redo/irradiated cases. Once found, they can be isolated on vasiloops.

5 e iliac vessels are similarly isolated

(. Fig.47.1). Decisions about which of the iliac vessels need to be ligated can be le for later in the operation. When ligating, doubly ligate the internal iliac artery before the vein. Try to preserve the rst branch of the vessel

Surgical Technique andDicult Situations fromPeter M. Sagar

. Fig. 47.1 Left iliac internal artery and vein have been

looped. In dicult situation are the vessels easy to access

365

paced just above the tumour pressed against the sacrum at the proposed level of division.

5 It can be dicult to be certain as to the precise

level of sacral division and the surgeon needs to think ahead so that he is condent that what is perceived to be the level of division when viewed from the anterior (abdominal) aspect remains the same once the sacral stage is underway. With higher levels of sacrectomy, it is helpful to place a sterilised thumbtack into the presacral fascia. is will permit identication at uoroscopy should the need arise.

5 Stomas are constructed and the abdomen is

closed.

in order to promote skin and muscle ap healing.

5 Once the ureters and iliac vessels have been

identied and control is obtained, an initial dissection of the tumour can begin. It is oen helpful to start relatively proximal as this tends to be a more friendly eld and allows entry into the correct planes of zygosis. Early division of the colon at a site deemed likely to be appropriate for later construction of the colostomy allows the posterior plane to be entered. is tends to be a safer plane and allows the lateral plane to be developed under direct vision. Care should be taken when approaching the pelvic sidewall veins. While arterial control may have been gained by earlier exposure of the iliac vessels, the veins are part of an extensive collateral circulation. ey tear easily, and, once damaged, a small hole in a vein can quickly extend with brisk loss of blood. Prompt judicious action is called for but blind aggressive clamping oen worsens the situation.

5 Identication of the S1 and S2 nerve roots at

this stage with vasiloops helps to prevent later inadvertent damage.

5 As dissection proceeds caudally, resist the

temptation to dissect too close to the superior extent of the tumour. is may happen in an attempt to make the level of division of the sacrum as low as possible. Breeching the tumour mass with escape of tumour will compromise the oncological clearance.

5 Dissect towards the sacrum resecting the

Waldeyer’s fascia.

5 e tumour is mobilised anteriorly and laterally.

is leaves the tumour mass only attached posteriorly. It is helpful to leave a small gauze swab

Second Stage

Sacrectomy Phase

5 e patient is carefully placed into the prone

jackknife position. It is important that the surgeon supervises this phase not only to ensure safe transfer from Lloyd-Davies to the prone jackknife position but also to ensure correct support and exion of the pelvis to help minimise blood loss in the next phase of the operation. e buttocks are taped to aid exposure. e sacroiliac joints are palpated and marked with an ink marker pen (. Fig.47.2).

5 A dorsal longitudinal incision over the sacrum

is made extending from L5 to the perineal scar/anus. e gluteal muscles are reected laterally (. Fig.47.3). e sacrotuberous and sacrospinous ligaments are divided to allow entry into the pelvic cavity by breaking through the endopelvic fascia (note: division of the sacrospinous and sacrotuberous ligaments BEFORE division of the sacrum helps to minimise blood loss). A nger is placed

. Fig. 47.2 Patient is in prone position. Lumbosacral

joint and os coccyx have been marked

366

P. M . S a g a r

. Fig. 47.3 Vertical incision along of os sacrum and

lateral mobilisation of gluteal muscles

into the presacral space to verify the level of sacral division.

5 Laminectomy: An osteotome is used to incise

the cortex and develop a plane between the sacral vertebrae. Bone nibblers are used to divide the lateral pedicles. Once the distal sacrum has been dislocated, the presacral fascia can be visualised. is is a tough structure but yields to cutting cautery on a high setting (

. Fig.47.4).

5 e dural sac may extend distally as far as S4

and should be ligated with a non-absorbable suture.

5 e cephalad, lateral and caudal planes of dis-

section are joined, and any residual anterior areas of attachment (usually to the prostate or vagina) are divided to permit removal of the specimen via the sacral/perineal wound (. Fig.47.5).

5 Omentum, absorbable mesh or pedicled aps

may be used to reconstruct the wound and limit the descent of small bowel into the pelvis (. Figs.47.6 and 47.7).

. Fig. 47.4 Os sacrum has been transected and it distal

part has been removed in order to provide a pelvic approach above of tumour location

Extension of Tumour Above the S2/S3

Junction

5 Technically very challenging with high mor-

bidity.

5 Cases may have invasion of the presacral fas-

cia without involvement of the bony cortex and may be suitable for en bloc resection of the fascia alone.

5 Anterior approach:

5 Ligate internal iliac arteries and veins. 5 Ligate the branches of the internal

iliac artery along both sides of the sacrum.

5 Beware of the low division of the aorta and

especially the inferior vena cava (note: right common iliac runs almost straight down to the groin and is easily damaged in this situation).

5 Anterior osteotomy (unicortical) and

marked with a tack or screw.

5 Vertical osteotomy through the ileum. 5 Place a silastic mesh in front of the

sacrum.

Surgical Technique andDicult Situations fromPeter M. Sagar

367

. Fig. 47.5 Preparation of neorectum from sacral space

5 Posterior approach:

5 Vertical incision over the sacrum with

reection of the gluteal muscles and division of the sacrotuberous and sacrospinous ligaments.

5 Division of the piriformis with preserva-

tion of the sciatic nerve if possible.

5 Laminectomy, ligation of the dural sac and

nal osteotomy.

5 High division, above S1, will require some

form of stabilisation with free bular gras and titanium rods.

47.3 Surgical Approach If Urinary

Structures Are Also Involved

e operation of total pelvic exenteration with sacrectomy adds an extra dimension to the above operation and, inevitably, is associated with increased morbidity. e additional steps relate to the abdominal phase of the procedure.

5 Early ligation of the internal iliac arteries and

then the veins reduces loss of blood.

. Fig. 47.6 A neorectum and distal colon are dissected

completely

. Fig. 47.7 A specimen with distal sacrum (transection

by S3/4) and neorectum

5 Conventionally, the inferior vesical vessels are

ligated and divided under direct vision. Advent of energy sources such as the harmonic scalpel or Ligasure device permits mobilisation of the bladder with sealing of the vessels without the need to dissect out each vessel.

5 Anterior mobilisation of the bladder can be

more dicult than expected as a result of damage from radiotherapy. Care must be

368

P. M . S a g a r

. Fig. 47.8 Transpelvine myocutaneous ap of rectal abdominal muscle with inferior epigastric vessels has been

used for reconstruction of perineal defect as well as for reconstruction of vagina

taken in this situation not to tear into the bladder or to traumatise the veins that run in this plane. Again, the use of the newer energy sources is advantageous.

5 Division of the dorsal veins of the penis leads to

a brisk bleed. e bladder and prostate need to be retracted posteriorly to allow good exposure. e veins need to be suture ligated. Ination of a 30ml balloon on a wide-bore catheter that is then connected to a urinary bag lled with a litre of saline to provide pressure helps reduce the risk of reactionary bleeding from these veins. e weight-providing traction can be released on the rst post-operative day.

5 Gracilis aps provide less tissue for cover-

age and may be associated with an increased failure rate.

5 A rectus abdominis ap based on the inferior

epigastric vessels provides a substantial myocutaneous ap that adequately lls the gap le aer sacrectomy. Care should be taken to ensure correct orientation especially as the ap is passed down into the pelvis (remember the orientation may alter aer placement of the ap in the pelvis on transfer of patient between the two phases of the operation).

5 Superior and inferior gluteal perforator aps.

Reconstruction of the perineal and posterior vaginal wall defects with myocutaneous aps based on the course of the superior and

47.3.1 Reconstructive Options

toClose thePerineal Defect

inferior gluteal perforators allows replacement of the lost volume of tissue between the perineum and sacrum and allows restoration

5 e most common aps used include the

transpelvic rectus abdominis myocutaneous ap, gracilis myocutaneous ap and gluteal myocutaneous rotational or advancement aps.

of a functional vagina. Such aps avoid the sacrice of functional muscle, do not interfere with formation of a colostomy and avoid the use of irradiated tissue (

. Fig.47.8).

Surgical Technique andDicult Situations fromPeter M. Sagar

369

5 In situations where pedicled aps are not an

option, free aps may be used.

5 Overall, closing the defect with aps appears to

decrease the rate of perineal wound complications, notably dehiscence. In a study from the Mayo Clinic, myocutaneous ap repair was compared with both primary closure and primary closure with pedicled omentoplasty. Flap repair was found to be superior to the alternatives and led to reduced wound complications and length of hospital stay.

47.4 Dealing withUnexpected/

Dicult Situations

47.4.1 Bleeding

5 Venous pressure is low– digital pressure

allows time for thought.

5 Inform the anaesthetist. 5 Good exposure, lighting and assistance are

crucial.

5 Application of point pressure with, say, a pled-

get above and below the tear may allow accurate placement of a suture.

5 A wider tear in a non-compliant vessel

(because of previous surgery/radiotherapy) may necessitate suturing with a patch.

5 Application of thrombogenic agents such as

FloSeal or SurgiFlo.

5 Pack and apply pressure for 15 mins and then

review.

5 Remove packs aer rst dampening the packs

with sterile saline. Gradually peel the packs back with two suckers on stand-by.

5 If bleeding has ceased, make a judgement

about the wisdom of completing the dissection based on the patient’s condition and extent of resection still to be completed. is is the best opportunity to achieve a successful oncological resection, but this has to be judged against the risk to the patient.

5 If bleeding continues despite the above mea-

sures, repeated as necessary, then the pelvis should be packed and the abdomen closed. Plan to remove the packs at second-look laparotomy ideally within 48h. Only very rarely does the bleeding continue at this stage (note: a pelvis is easier to pack eectively once the rectum/neorectum has been removed.)

47.4.2 The Correct Level ofSacral

Division

is can be dicult. While low pelvic recurrences that involve the coccyx/lower sacrum alone should not present too much diculty especially in patients where intestinal continuity and an anal orice have been preserved, recurrences at higher levels aer APER can be a problem.

5 Check the preoperative imaging both before

the operation and again before the sacrectomy phase of the operation.

5 During the abdominal phase, count down the

sacral vertebrae from the lumbosacral junction. Match this (which can mislead) with the preoperative images.

5 If in doubt, and particularly with the higher

tumours, insert a metallic pin into the presacral fascia immediately above the tumour.

5 Be aware of how the position of the tumour

changes with respect to the operative eld as the patient is moved from modied LloydDavies to prone jackknife. e tumour always seems further away from the perineum!

5 Use uoroscopy to check where the pin was

placed and use this marker as the point of reference for sacral division.

5 Avoid inadvertent entry through the sacrum

and into the posterior aspect of the tumour mass. Check and recheck the level before breaking though the presacral fascia and into the pelvic cavity.

46.7.6 Loop Ileostomy

46.8 Postoperative Care

46.9 Conclusion

References

47.1 Introduction

47.2.1 Preoperative Evaluation

47.2.2 Preoperative Radiotherapy

47.2.3 Preparation

47.2.5 Surgical Procedure

First Stage: Abdominal Phase

Second Stage

47.4.1 Bleeding

Further Reading