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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_841_Библиотеки_им_академика_М_И_Перельмана.pdf
Pelvic Autonomic Nerve Preservation
. Fig. 50.13 Bipolar electrical stimulation slightly
above IAS level (blue arrow) at 8 o’clock lithotomy position for verification of extrinsic innervation (yellow arrows)
during TAMIS TME. Yellow star levator ani muscle ([9] Int
J. Colorectal Dis; Springer)
eral dissection, the procedure of neuromapping
is used for orientation and to monitor function
in the sense of repetitive stimulations. It is used
to more consciously preserve neuronal branches.
e nerve end segment to the internal anal
sphincter is also electrophysiologically identied
and preserved insofar as possible.
e “down-to-up” procedural concept of the
so-called TAMIS TME provides excellent access
to the extrinsic autonomic nerves responsible for
the maintenance of IAS function aer ultralow
anterior resection [9]. Intraoperative electrophysiological neuromapping objectied the specic
in situ neuroanatomical topography (
. Fig. 50.13
and additional Case Example 50.12).
e quality of intraoperative ner ve preservation
is checked aer the TME is completed. Its ability to
predict postoperative urogenital and neurogenic
anorectal dysfunctions means that the IONM
result constitutes a suitable surrogate parameter.
It allows well-founded, early and thereby more
promising, personalized, urologic, gynecologic,
and coloproctologic treatment.
393
50.5 Postoperative Aspects
e patient is informed about the surgeon’s assessment regarding nerve preservation and aspects
that must accordingly be taken into account in
the postoperative progression. In case of complete
pelvic autonomic nerve preservation, transurethral bladder catheter can be removed beginning
on the second postoperative day. Before removing
a suprapubic urinary catheter, the easily veriable
residual urine volume should be signicantly less
than 100ml.
Aer removing the transurethral bladder catheter, residual urine is sonographically determined,
no later than at the time of discharge. In the event
of abnormalities, patients are sent for a urologic
or urogynecologic consultation (7 Sect. 50.6).
A neurogenic bladder requires long- term catheterization. Nonetheless, severe bladder- emptying
disorders can improve.
In preoperatively sexually active men and
intraoperative suspicion of incomplete nerve
preservation, a specialized urologic consultation already takes place before discharge
(7 Sect. 50.6).
Before a protective stoma will be closed,
anorectal function should be assessed. In 1966
Friedrich Stelzner had already described internus
paralysis aer low anterior rectal resection:
A further indicator is shown when the
»
surgeon mobilizes the rectum stump up to
the pelvic wall in rectum resection near the
pelvic floor to obtain a better overview. When
healing is complete, such patients are able to
contract the sphincter upon command. But
if one now removes the finger after asking
the patient to loosen the sphincter again,
the examiner will observe that the anal canal
remains open. The request to actively tension
the sphincter again is promptly followed
by closure of the anal canal. This is internus
paralysis. [12]
Denervation of the internal anal sphincter
results in fecal incontinence. e IONM can
already predict this (7 Sect. 50.6).
50
394
W. Kneist
50.6 Case Examples
Case Example 50.1
50
A 51-year-old patient presented
with an adenocarcinoma at the 12
o’clock position in the lithotomy
position, extending from the linea
dentata into the anal canal. The
patient had had rectum resection
with simultaneous liver segment
resection one year previously as a
result of hepatically metastasizing
rectal cancer in the middle third
(ypT2, ypN0/18, ypM1[hepar], G2,
L0, V1, pR0). The anastomosis
appeared normal 6 cm from anal
verge (3 cm above the dentate line).
The patient urgently desired to
have the surgery performed while
maintaining his erectile function.
He consented to the already recommended abdominoperineal excision. He reported that he had
undergone sterilization years earlier
only when the detailed medical history was obtained.
After the diverting stoma was
closed, he had weaker, but nonetheless sufficient, erectile function
in the past half year (IIEF: 52 with
EF: 20). There were no problems
with micturetion (IPSS: 2; QoL: 1). A
new occurrence of fecal incontinence (II° according to Parks classification) had led to diagnostics and
current diagnosis. The specific
medical history was documented.
He was specifically informed
about the significantly higher risk of
loss of erectile function and occurrence of neurogenic bladder-emptying disorders. He desired an IONM
for intraoperative function control.
The possibility of postoperative
therapy in the interval of regenerating compromising nerves (reconvalescence) was addressed.
Intraoperative preparation conditions were difficult. The seminal
Case Example 50.2
One year after his protective stoma had been closed, a
72-year-old patient presented with status post open
TME as a result of rectal cancer of the central third and
adjuvant Chemoradiotherapy CRT with the symptom
complex of “anterior resection syndrome.”
Because of a severely impaired quality of life resulting from anal incontinence that could not be conservatively managed, the patient desired the creation of a
definitive stoma. Rectoscopically, the end-to-end anas-
vesicles were preserved. It was not
definitively possible to macroscopically identify the IHP. The IONM
repeatedly confirmed that the
innervation of the urinary bladder
remained intact. Following abdominoperineal excision (in the lithotomy position), the patient was
discharged without a bladder catheter because of spontaneous urination without residual urine (pT2,
pN0 (0/13), cM0, pR0, G2). According to the urologic recommendation, he initially took Cialis 20 mg
twice weekly for 6 weeks to prevent
spongy body fibrosis during the
reconvalescence interval. The
patient was preventively sent for a
specialized urologic consultation.
Three months postoperatively, the
patient stated good sexual function
while taking Viagra
(IIEF: 68 with EF: 27).
tomosis appeared normal 5 cm above anal verge. The
rectal digital examination showed severely impaired
squeezing (DRESS 1) and resting tone (DRESS 0)
(. Fig. 50.14).
The environmental diagnostics showed no signs of
relapse; therefore, the indication for a test simulation of
the sacral nerves was initially determined (. Fig. 50.15).
The postoperative test phase was successful, and a twochannel sacral nerve stimulation (SNS) system was then
implanted.
. Fig. 50.14 The anal canal remains open after a
rectal digital examination (resting tone: DRESS 0)
. Fig. 50.15 Performing SNS test stimulation as
an alternative to creating a stoma (successful)
Pelvic Autonomic Nerve Preservation
Case Example 50.3
395
50
In a low-lying rectal cancer 5–8 cm above anal verge,
4–7 o’clock in the lithotomy position, and status post
radiation resulting from prostate cancer
6 years previously, an open low anterior rectum resection was performed in a 69-year-old patient (Body
mass index (BMI), 29.1) with preoperatively unimpaired sphincter function (DRESS 3). The TME (MERCURY I°; pT2, pN0 (0/13), cM0, V0, L0, R0, G2) was
performed using monopolar diathermy, bipolar
scissors, and bipolar stoppage of bleeding.
Following dorsolateral preparation, the IONM confirmed intact innervation of the urinary bladder and the
internal anal sphincter on both sides. After completion
of the mesorectal dissection, the innervation of the urinary bladder was again confirmed. Innervation of the
sphincter muscle was no longer electrophysiologically
detectable.
There was no postoperative bladder-emptying disorder. Three months later, with a normal lateroterminal
anastomosis (3 cm above anal verge, immediately
above the linea dentata), impaired voluntary tone
(DRESS 1–2) and resting tone (DRESS 1), but a positive
Case Example 50.4
In a 65-year-old obese (173 cm, 105 kg, BMI: 35.1) and
multimorbid patient (status post stent implantation
because of coronary heart disease, insulin-requiring
diabetes mellitus, chronic obstructive pulmonary disease (COPD)), rectal cancer was diagnosed 10–13 cm
from and verge at the 2–4 o’clock in the lithotomy
position (cT2, cN−, cM0). There were no functional
urogenital or anorectal abnormalities. Open, low
anterior rectum resection was performed with a
lateroterminal descendorectostomy 5 cm above anal
verge (pT2, pN0 (0/14), cM0; G2; L1, Pn0, pR0;
MERCURY I°).
holding attempt, the protective stoma was moved
back. Eight weeks later, a colostoma was created
because of limp sphincter tone (DRESS 1/1), anal incontinence, and therapy-resistant perianal eczema and
proctitis (. Fig. 50.16).
. Fig. 50.16 Therapy-resistant perianal eczema
with anal incontinence after stoma closure
During dissection in the confined pelvic entry
level, the left hypogastric nerve was identified too late
because of a voluminous mesorectum and fat-coated
SHP and accidentally cut (. Figs. 50.17 and 50.18).
With stimulation of the nn. splanchnici pelvici, the
IONM still showed innervation of the urinary bladder
and m. sphincter ani internus even after complete
mesorectal dissection. Bladder function and anal continence were not impaired postoperatively. In terms of
genital function, impairments (IIEF 29/75 postoperatively; 69/75 preoperatively) were stated for erection
and ejaculation.
. Fig. 50.17 Hypogastric nerve accidentally cut
at the pelvic entry level and then resected to the
plexus hypogastricus
. Fig. 50.18 Detection of a normal nerve fascicle
(n. hypogastricus, clinical information; HE, 50× magnification, PD Dr. med. T. Hansen, Pathology Institute)
50
396
W. Kneist
Case Example 50.5
In a 50-year-old patient with stenosing, hepatically
metastasizing rectal cancer 10 cm above anal verge,
2–6 o’clock in the lithotomy position, an open low anterior rectum resection was initially performed.
The TME was unusually difficult because of
Bechterew’s disease, even with an extended median
laparotomy (. Fig. 50.19).
An injury to the presacral venous plexus at the S3
level was treated with a suture following compression
(1200 ml blood loss). In particular, the left-sided and
anterolateral preparation was complicated because of a
poorly visible site and peritumorally inflamed tissue
reactions. Because of the situation and for oncologic
reasons, the capsule of the left seminal vesicle was
included in the resection. The final IONM confirmed
only right-sided innervation of the urinary bladder and
the IAS.
An end-to-end descendorectostomy was
performed 5 cm above the anal verge, and a suprapubic urinary catheter was created (pT3, pN1b (2/36), cM1
(hepar), G2, minimal circumferential distance 0.6 cm;
MERCURY I°).
There was a postoperative need for long-term catheterization. Following left lateral liver dissection
because of a metastasis in segment III, the stoma was
closed back 4 months after the initial intervention. The
bladder-emptying disorder was transient and no longer present (IPSS: 2). Anorectal function was not
impaired (Wexner Score: 1). In regard to genital function, the patient stated impairments even with intermittent use of Viagra (IIEF 29/75; preoperative: 71/75).
Fifteen months after the initial intervention, segment I
was resected because of a newly diagnosed liver
metastasis.
. Fig. 50.19 Impaired positioning options with
spondylitis ankylosans – TME and nerve preservation
are complicated
Pelvic Autonomic Nerve Preservation
Case Example 50.6
397
50
In a 50-year-old obese patient (180 cm; 104 kg, BMI:
32.1) with circular stenosing rectal cancer with hepatic
and pulmonary metastases 4 cm above the anal verge,
low anterior rectal resection was initially performed
after an neoadjuvant chemoradiation therapy (nCRT).
The resection of a liver metastasis from segment VI
and radiofrequency ablation (RFA) of a central metastasis in segment VIII was simultaneously performed (ypT3,
ypN0 (0/15), pM1 (hepar), L0, V0, pCRM-negative, MERCURY I°; . Figs. 50.20 and 50.21). Continuity was realized with a coloanal stapler anastomosis. Left-sided
mesorectal dissection was unusually difficult because
of a narrow pelvis and voluminous mesorectum. The
final IONM confirmed only right-sided innervation of
the urinary bladder and the IAS.
. Fig. 50.20 TME (MERCURY I°), left lateral car-
bonization traces – due to possible thermal damage, also on the PHI, this must be discussed as a
cause of consecutive unilateral negative IONM and
postoperative genital functional impairments
The suprapubic urinary catheter was removed on
the seventh postoperative day. There were no urination problems in the long run (IPSS: 2). Three weeks
following the initial intervention, a right- and leftsided lower lobe metastasis was resected via minithoracotomies.
Eleven months after the initial intervention,
adjuvant chemotherapy was followed by closing the
protective transversostoma. Even in advance, the
patient took Viagra as recommended. Three months
after stoma closure, there were no signs of fecal
incontinence (Wexner Score 0, DRESS 3 for resting
and voluntary tone). Genital function was only moderately impaired with intermittent therapy with Viagra
(IIEF 49/75; preoperative: 62/75).
. Fig. 50.21 Parts of Denonvillier fascia, central
and symmetric on the specimen
398
W. Kneist
Case Example 50.7
50
Following a cutaneous nCRT in the case of low rectal
cancer 4–6 cm from the anal verge, 7–11 o’clock in the
lithotomy position, an open low anterior rectum
resection was performed in a 56-year-old patient. The
patient was small in stature (140 cm; 56 kg; BMI: 28.6)
and had a narrow pelvis (. Fig. 50.22).
Due to a relatively voluminous mesorectum and
the fact that the SHP was surrounded by retroperitoneal fatty tissues (. Fig. 50.23), it was unusually difficult to expose the hypogastric nerves.
Controlled nerve-oriented preparation in the
depths of the narrow pelvis was scarcely possible and
was made additionally difficult because of intention-
ally sharp preparation by a relatively bloody situs
(700 ml blood loss).
Following completion of the mesorectal dissection, it was possible to place the contour stapler
beneath the tumor (ypT3, ypN1b (2/24), cM0; L1; ypR0;
MERCURY I°). The lateroterminal anastomosis was
implemented with a circular stapler at the level of the
dentate line, about 3 cm above anal verge. The IONM
confirmed that the innervation of the urinary bladder
remained intact. It was no longer possible to make a
valid statement concerning the innervation of the IAS.
There were no postoperative problems urinating.
Voluntary tone was good prior to discharge (DRESS 3).
. Fig. 50.23 Increased retroperitoneal fatty
tissues with embedded autonomous nerves; relatively voluminous mesorectum
. Fig. 50.22 Boy-like pelvis; marked distance: 8.42 cm
Pelvic Autonomic Nerve Preservation
Case Example 50.8
Following multivisceral abdominoperineal rectum extirpation (wide excision anterolaterally with en bloc resection of the uterus and its adnexa and dorsal wall of the
vagina) in a 63-year-old female patient with locally
advanced rectal cancer 3.5 cm from anal verge (pT4,
pN2(5/14), cM1 (hepar, pulmo), G2), the lateral resection
margin was pathohistologically and immune histochemically examined after being marked with ink at the level of
the IHP. In representative steps, greater than 400 crosssections of nerve fascicles were identifiable in combination with 27 ganglia (max. 180 ganglia cells per ganglion)
(. Fig. 50.24).
Postoperatively, a neurogenic bladder developed,
requiring a catheter and therapy-resistant (cholinergics) secondary stress incontinence resulted due to
urethral closure insufficiency.
The patient was instructed in intermittent self-catheterization.
399
. Fig. 50.24 Ganglion from the plexus hypo-
gastricus inferior at the level of the cervix uteri
(Frankenhäuser ganglion), immune histochemistry
with S-100 (PD Dr. med. H. Radner, Pathology Institute)
50
Case Example 50.9
In mucinous rectal cancer 4–13 cm anocutaneously
(cT3, cN+, cM0), an nCRT was performed in a 73-yearold patient. The medical history showed a nephrectomy on the right side and a prostatectomy resulting
from a malignoma. Sphincter function, bladder function (IPSS 11), and genital function (IIEF 5/75) were
preoperatively impaired; imaging showed a suspected lymph node metastasis in the pelvic wall.
Abdominoperineal rectum excision and the excision of an easily palpable lymph node from the leftsided pelvic wall (lymph node metastasis) were
performed as well as a second lymph node from the
right-sided pelvic wall (mucin-containing lymph node
without vital tumor cells; . Fig. 50.25), (ypT3, ypN1a
(1/18), G3, M0, ypR0, MERCURY I°).
Before commencing the perineal section, the IONM
no longer detected innervation of the urinary bladder
and the IAS. A suprapubic urinary drain was created
and remained in long term.
. Fig. 50.25 Extramesorectal lymph node
metastasis on the left side
400
W. Kneist
Case Example 50.10
50
Following nCRT in rectal cancer 9–14 cm from the anus,
11–3 o’clock in the lithotomy position, laparoscopic low
anterior rectum resection was performed in a 74-yearold man (video at www.xxx.de). Intraoperatively, a most
likely postradiogenically related fibrotic adhesion of the
mesorectum with the pelvic wall was already seen
during dorsolateral preparation (. Fig. 50.26).
Directly at the height of the T-junction, separation
was carried out with the Ligasure directly at the IHP.
Dissection was simpler on the left side. The intermittently performed IONM confirmed that the innervation
. Fig. 50.26 Postinflammatory fibrotic adhesion
on the right lateral pelvic wall
of the urinary bladder and the IAS was preserved on
both sides (. Fig. 50.27). Continuity was restored by a
lateroterminal descendorectostomy 5 cm from the
anal verge (ypT2, ypN0 (0/13), M0; pR0, MERCURY I°).
Bladder function was postoperatively unimpaired. After the protective stoma was closed, there
were no changes in ano-neorectal function as compared with the preoperative findings. According to
the patient, his ability to have an erection and ejaculate was preserved.
. Fig. 50.27 Following stimulation of the pelvic
splanchnic nerves, audiovisual detection of positive IONM signals, that is, intact innervation of
the urinary bladder and m. sphincter ani internus
(yellow curve at tope: processed muscle signal
with amplitude elevation; lower yellow curve:
intravesical pressure elevation)
Pelvic Autonomic Nerve Preservation
Case Example 50.11
401
50
In a 70-year-old patient with palliative resection
resulting from cancer in the central third of the rectum
(pT3, pN2, pM1(hepar), L1, G3, R2), the right-sided
hypogastric nerve was resected because of a suspected tumor infiltration (. Fig. 50.28). The suspicion
was histologically confirmed (. Fig. 50.29). Numerous
nerve fascicles were found, and ganglia cells were only
. Fig. 50.28 Resected hypogastric nerve
(45.0 × 22.0 × 4.0 mm). A central, tumor-suspected
node (10 × 4 mm) was macroscopically detectable
(PD Dr. med. H. Radner, Pathology Institute.)
found in the distal dissection area. The proximal and
distal resection margins were free of the tumor. The
completely excised mesorectum showed perineural
cancer spread. According to the results of the IONM,
bladder innervation via the pelvic splanchnic nerves
remained bilaterally intact. There were no postoperative micturition problems.
. Fig. 50.29 Nerve fascicles, enlarged by cancer
complexes (HE; PD Dr. med. H. Radner, Pathology
Institute)
Case Example 50.12
In a 42-year-old male patient with
rectal cancer, 4.5 cm from anal
verge and 0.5 cm from the dentate
line involved the anterior quadrant
(. Fig. 50.30a). Staging results in a
cT3, cN,+cM0 situation. After neoadjuvant CRT restaging revealed
downsizing and downstaging
a
. Fig. 50.30 a Rectal cancer detect with endoscopy. b Proctoscopy: downsizing after neoadjuvant CRT
Fig. 50.30b). A nerve-sparing
(.
laparoscopic-assisted TAMIS TME
was performed. The IONM confirmed that the innervation of the
urinary bladder and the IAS
remained intact. The lateroterminal
coloanal anastomosis was hand
sewn at the level of the dentate
b
line, about 3.5 cm above anal verge
(ypT2, ypN0 (0/12), cM0, R0, pCRMnegative, MERCURY I°). There were
no micturition problems postoperatively. Erection and ejaculation was
not impaired, neither before nor
after stoma closure. After stoma closure no fecal incontinence occurred.
402
W. Kneist
. Table 50.3 Degree of intraoperative difficulties in terms of the identification and preservation of
autonomous nerves in patients with rectal cancer
50
Grade I: ideal
patient
Grade II: not entirely
ideal patient
Grade III: more
problematic
patient
Grade IV: very
problematic patient
Operation is technically simple,
each surgical method is
unproblematic
Moderate technical difficulties,
some surgical methods may be
more difficult than others
Difficult operation, some surgical
methods may be substantially more
difficult than others
Each surgical step is very difficult Emergency
50.7 Classification of Intraoperative
Difficulties
We classify intraoperative diculties in terms
of the identication and preservation of autonomous nerves in rectal cancer surgery, as shown in
. Table 50.3.
References
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excision: clinical topography and morphology of pelvic
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2. Junginger T, Kneist W, Herrmann M. Die nervenerhaltende
totale mesorektale Exzision bei Rektumkarzinom unter
besonderer Berücksichtigung der chirurgischen Anatomie. Deutsche Gesellschaft für Chirurgie. Düsseldorf,
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Surg. 2012;16:1218–24.
Female
cT1-2
Normal weight
No nCRT
No previous pelvic surgery
Male
Abdomino-perineal excision (CT1-2)
Local advanced tumor in the mid-rectal
third
Male + CT3 + anterior quadrant involvement
mrCRM-positive, nCRT
Previous pelvic surgery
Narrow male pelvis with voluminous
mesorectum
Bloody situs
Severe obesity
Supra-anal (type I) and juxta-anal (type II)
tumors
Indication for extralevator abdominoperineal
excision
Palliative surgery (consideration)
Adherence/infiltration of adjacent organs (cT4)
Recurrent rectal cancer
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of medical technology. Heidelberg: Springer; 2011,
p. 1043–57.
7. Kneist W, Kauff DW, Gockel I, Huppert S, Koch KP, Hoffmann KP, Lang H. TME with intraoperative assessment
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H. Topography of the extrinsic internal anal sphincter
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T. Chirurgische Anatomie und neurophysiologische
Parameter zur intraoperativen Identifikation und