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FIGURE13-3A.Isolationoftheinferior
mesentericvein(IMV).B.HighligationoftheIMVatthe levelofthepancreas,lateraltotheligamentofTreitz. C.Lowanteriorresectionforamid-rectalcancerwith highligationoftheinferiormesentericarteryandIMV anddivisionoftheleftcolicartery.
LeftColonandSplenicFlexureMobilization
Medial-to-lateraldissectionproceedsaftertheIMA/IMVhavebeen ligated.Althoughthelateral-to-medialapproachmayseemtobeless difficultinopensurgery,foroncologicpurposesthisauthorutilizesa medialapproachfirstforallcases.Theretroperitonealstructures, includingtheureter,gonadalvessels,andthepsoasmusclesareswept posteriorlyanddissectioniscarriedlaterallytotheabdominalwall,over Gerota’sfascia/perinephricfatandtowardthespleen.Next,lateral dissectionbeginsattheiliacfossaandcontinuessuperiorlytowardthe splenicflexure.Thedissectioniscarried1mmmedialtothewhitelineof Toldt(becausethewhitelineshouldstaywiththepatient)untilthe
spleenisreached.Thesplenicflexureiscarefullymobilizedtotrynotto causeeitherspleniccapsulartearorcolonicwalldamage.Gentlemedial tractiononthecolonwillallowforthesplenocolicandretroperitoneal attachmentstobesafelyandsharplydissectedfree(Fig.13-4).Ifthis approachbecomestoodifficult,weoftenwillenterthelessersacwhere theomentumattachestothetransversecolonandmobilizetowardthe spleentomeetupwiththepreviousdissectionplane.Routineseparation intheavascularplanebetweenthetransversemesocolonandthegreater omentumiscompulsoryforproperreachintothepelvis.
FIGURE13-4Mobilizationofthesplenicflexure.
Gentlemedialtractionisplacedonthecolonandthe peritonealattachmentsaredivided.
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TotalMesorectalExcision
Adoptedasthestandardapproachtorectalcancersurgery,TMEisthe sharpdissectionintheavascularplanethatliesbetweenthefascia propriaoftherectumandthepresacralfascia.Thefasciapropriaofthe rectumcontainsthemesorectumanditsassociatedlymphnodesand bloodvessels,whereasthepresacralfasciacoverstheanteriorsacral surfaceandthehypogastricnerves(Fig.13-5).AstandardTMEshouldbe performed5cmdistaltothemostinferioraspectofthetumor.Incasesof verylowrectaltumors,acoloanalanastomosismaybeused:adistal marginof1–2cmisconsideredadequate.
FIGURE13-5Fasciaplanesofthepelvis.
Thedescendingcolon/sigmoidcolonjunctionisoccludedbetweenan atraumaticbowelclampandacrushingbowelclampandissharplycut beforetheTMEisundertaken.Thesigmoidcoloncanbeusedasahandle tohelpfacilitatetherectaldissectionofthecase.Themesorectalplaneis enteredbyelevatingtherectosigmoidcolonsuperiorlyandanteriorlyand followingtheposterioraspectofthesuperiorrectalarteryuntilashiny, filmymembraneisencounteredatthepelvicbrim.Thesympathetic nervesareonceagainidentifiedastheybilaterallycourseoverthesacral promontory(Fig.13-6).Posteriordissectioniscarriedoutthroughthis filmymembraneasfarascansafelybeachievedwithgoodvisualization. Atalltimes,thisposteriordissectionshouldbeundertakeninasharp mannerwithoutbluntmaneuversandtheutilizationoflighted,deep pelvicretractorsisessentialinthisportionoftheoperation(Fig.13-7). Avoidanceofdissectingintothepresacralspaceiscompulsory,because thelargeanddifficult-to-controlpresacralveinsofthevalve-less presacralplexusarelocatedinthislocation.Properdissectioninthe posteriorplaneisespeciallyimportantwhentheconcavityofthesacrum
beginstostraightenoutasoneapproachestheanorectaljunction,where thesurgeonmustanteriorlyadjusttheangleofdissection.Oncethe posteriordissectionreachestheproperdistallevel(dependingon locationofthetumor),lateraldissectionisundertaken.Lateraldissection involvesstayingjustlateraltothefasciapropriawithoutenteringthe pelvicsidewallwithitsassociatedneurovascularstructures.Themiddle rectalvesselsarebilaterallydividedinthelateralstalksofthemidrectum (usuallywithsutureoroccasionallywithonlydiathermy).Theanterior dissectionshouldbereservedforthelastportionoftheTME,becauseitis themostdifficult.Theanteriordissectionisdonejustposteriorto Denonvilliers’(retroprostatic)fasciainmostcases,unlessthetumoris anteriorlylocated,inwhichthesurgeonmustdecidewhetherthe dissectionmustincludeDenonvilliers’fascia(Fig.13-8).Thisdecisionis animportantone,becausetheparasympatheticnervesthatsupplythe penilecorporaandcontrolerectilefunctioninmalesliejustanteriorto Denonvilliers’fasciaandhencewillundoubtedlybeinjuredifthisfacial planeisviolated.Theanteriordissectionextendsbeyondtheinferioredge oftheprostateinmenandbetweenthevaginaandtherectuminfemales untiltheproperdistalmarginisobtained.
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FIGURE13-6Enteringintothemesorectalplane.
Notethesympatheticnervescoursingoverthesacrum andtheuretercrossingtheiliacvessels.
FIGURE13-7Totalmesorectalexcision:posterior
dissection.
FIGURE13-8Totalmesorectalexcision:anterior
dissection.
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RectalTransectionandPreparationoftheProximal Colon
Oncethedesireddistaltransectionsiteontherectumhasbeen establishedonthebasisofthemarginstatus,theuseofa30-mmlinear staplingdeviceismostoftenemployedwhenperformingadouble-stapled anastomosis(Fig.13-9).ThePI-30(Medtronic,Minneapolis,MN)isthe staplerofchoicebecauseofitsnarrowdesignforreachingdownverylow inthenarrowconfinesofthepelvis.Theentirecircumferenceofthe transectionsiteshouldbeclearedofanymesorectum,lateral attachments,andanteriorstructures(especiallythevagina).Iftoomuch
materialisplacedinthestapler,itwillnotproperlyfire.Onlyonestaple loadshouldbeneeded,ifproperdissectionhasbeenperformedinthis criticalportionoftheoperation.
FIGURE13-9Distaltransectionoftherectumwith
30-mmlinearstapler.
Itshouldbenotedthatatthebeginningofthecase,rectalirrigation withsalineandbetadinesolutionisusedtomechanicallyclearanyfecal debrisintherectum.Manyofthesurgicalstaffatourinstitution, includingthisauthor,use40%ethylalcohol(Turnbullsolution)fortheir rectalcancercases.Afterthe30-mmlinearstaplerisclosed,theTurnbull solution(oralternativecytotoxicagent)isinstilledintotherectumto potentiallykillanycancercellsinthelumen,toperhapsdecreasesuture lineorlocalrecurrence,althoughthishasnotbeenprovedinanylarge studies.
Beforemakingacolorectalorcoloanalanastomosis,thedistalcolonic conduitmusthaveadequateperfusion.Asmentionedpreviously,because theIMAhasbeendividedinahigh-ligationmanner,thedescending colonbloodsupplyisbasedonthemarginalarteryviathemiddlecolic artery.Itisroutinetosharplytransectthemarginalarterynearthesiteof thefuturepursestringsuturetocheckforgoodvascularperfusion. Pulsatilebleedingfromthemarginalarteryisbest,butagood,steady flowisadequate.Essentially,ifonehastoclampandligatethemarginal artery,itwillprovideadequateperfusionfortheanastomosis.After assuringawell-perfusedconduit,ahand-sewnpursestringsutureof0­polypropylenemonofilamentisplacedwithcarefulattentiontoinclude theseromuscularlayerofthebowelwallwithshallowmucosalbitesin
ordernottooverwhelmthecircularstapler.Theappropriatesizeanvilfor thedouble-stapledanastomosisisthenplacedinthelumenandtied snuglyintoplace.
ColorectalorColoanalAnastomosis
Incaseswhereacolorectalanastomosisisperformed,atraditionalend­to-enddouble-stapledcircularanastomosisispreferred.Thisdefault anastomosisiseasilyconstructedwiththeuseofcircularstaplers.In caseswhereanultra-LARisperformedwithacoloanalanastomosis,the surgeonmaychoosefromseveralvariationsinanastomosisconstruction. Briefly,acolonic-Jpouch,transversecoloplasty,oraside-to-end(Baker) anastomosismaybeconstructedtotryandalleviatesymptomsofLAR syndrome(urgency,clusteringofevacuations,andincontinence).These anastomotictechniquesaredescribedingreatdetailinotherchapters.
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Regardlessofthestapledanastomotictechnique,thefundamentalsof stapleruseholdtrueforallreconstructiontechniques.Upongently placingthestaplerperanus,itiscarefullyadvancedpastthesphincter mechanismtotherectalstapleline.Thetrocarisadvancedatorjust posteriortothestaplelinetoensurethatanyanteriorstructures, especiallythevagina,arecarefullyexcludedfromtheanastomosis(Fig.
13-10).Aftercareismaintainedtoensurethecolonicconduitisnot
twistedandthereisthereisnounduetension,andtheanvilandthe staplerisfired.Theanastomoticringsareexaminedforcompletenessand anairleaktestisperformedwithflexiblesigmoidoscopy.Theauthor preferstouseflexibleendoscopytoclearlyviewtheanastomosis intraluminally,toensurehemostasis,integrity,andperfusionofthe bowelbothproximalanddistaltothestapleline.Positiveairleaktests arecontrolledonacase-by-casebasis.Smallleaksaregenerallysimply oversewn;largedefectsareeitherprimarilyrepairedortheanastomosis maybecompletelyredone.Surgicaldrainsareusedonacase-by-case basis,butmostpatientsinwhomalowcolorectalorcoloanal anastomosishasbeenconstructedwillreceiveaclosedsuctionor irrigation/sumpdrainforthefirst24–48hours.
FIGURE13-10Properstaplerinsertionandspike
advancement.Notehowthespikecomesoutposterior totherectalstaplelineawayfromanyanterior structures.
AdjunctManeuversforDifficultiesinReach
Properreachofthecolonintothepelvismaybedifficultincertaincases, duetovariationsinanatomy,vascularsupply,andbodyhabitus.If,after highligationofthevessels,completeandfullmobilizationoftheleft colon,andsplenicflexureandremovaloftheomentumfromthe transversecolon,well-vascularizedcolondoesnotreach,several maneuversmaybeemployedtohaveatension-freeanastomosis.Because theIMAandIMVhavebeenligatedattheirorigin,bloodsupplyisbased offthemiddlecolicvessels.Ifreachisinadequate,aseriesoftechniques canbeemployed.Thefirstmaneuverinvolvescreatingaretroileal, transmesentericwindowthroughanavascularplanetotherightofthe superiormesentericpedicleneartheterminalileum(Fig.13-11).The coloncanbeplacedthroughthiswindowandintothepelvis.Ifthis maneuverdoesnotwork,thesurgeonmustmakethedecisiontotransect therootoftheentiretransversecolon,withhighligationinthemiddle colicvessels.Mobilizationtothehepaticflexureandremovaloftheentire omentumoffthecolonmustbeperformed.
FIGURE13-11Retroilealwindow.Awindowis
createdtotherightofthesuperiormesentericartery (SMA)neartheterminalileum.Thecoloncanbe deliveredtotheanastomosiswiththerectum/anus. Middlecolicvesselsmayneedtobeligated.
Ifthistechniquedoesnotsufficientlyprovidetheneededlength,a complete180-degreecounterclockwiserotationoftherightcolonbased offtheileocolicpediclecanbeperformed.Thehepaticflexureandright colonmustbecompletelymobilizedandallattachmentsreleased.The rightcolicvesselsandmesenteryoftherightcolonareligatedandthe colonisrotatedsoastohavetheanteriorwallofthececum/rightcolon againsttheretroperitoneum;andifthececumisintherightiliacfossa withtheappendixpointingtowardthehepaticflexure,itisnotnecessary toperformanappendectomy(Fig.13-12).
p.98
p.99
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