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Ростовский Государственный Медицинский Университет
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therectumcangainanextracentimeterbeyondthatwhichcanbe laparoscopicallyachieved.Thatcentimetermaymeanthedifference betweenadouble-stapledorahand-sewncoloanalanastomosis.The editor’spreferenceistoperformtransanaltotalmesorectalexcision (TATME)inthesesituations.
Considerationofpreoperativesphincterfunctionandcontinenceis especiallyimportantwhencontemplatingaverylowanastomosis. Patientswithpoorbaselinecontinenceorseverelyimpairedmobilityare poorcandidatesforacoloanalanastomosisandshouldbeoffereda permanentcolostomy.Transientimpairmentduetoabulkytumororasa sideeffectofneoadjuvantradiationisnotasworrisomeifthepatienthad normalcontinencebeforediagnosisandnormalsphincters.Tumors invadingtheexternalsphincterorasignificantamountoflevatormuscle arebesttreatedbyabdominoperinealresection(APR).
PREOPERATIVEPLANNING
Beforesurgery,allpatientsshouldundergoappropriatestagingforrectal neoplasia.Tumordepth,nodalinvolvement,andthepresenceof metastaticdiseaseshouldbeassessed.Apathologicdiagnosisshouldbe establishedbytumorbiopsyandtheproximalcolonshouldbeclearedby fullcolonoscopywheneverpossible.Office-baseddigitalrectal examinationandrigidproctoscopyshouldbeperformedbytheoperating surgeontoevaluatetumorlocation,fixation,andsphincterfunction. Depthoftumorinvasionandnodalstatuscanbeassessedusing endorectalultrasound(EUS)and/ormagneticresonanceimaging(MRI). Thechoiceofexaminationshouldbebasedoninstitutionalexpertise. Early,mobiletumorsmaybebetterevaluatedbyEUS.Inmoreadvanced tumors,MRIprovidesgreaterdetailoncircumferentialmarginsand involvementofadjacentstructures.Forcancersofthedistalthirdofthe rectum,preoperativechemoradiotherapyisindicatedforT3andT4 tumorswiththreatenedcircumferentialmargins.Inaddition,verydistal tumorsforwhichAPRwouldotherwiseberequiredmaybetreatedwith neoadjuvantchemoradiationregardlessofstage,inanefforttodownsize thetumorandallowsphincterpreservation.MRIhasbecometheglobal preferredstandardstagingtool.PretreatmentMRIstagingisa requirementoftheCommissiononCancerNationalAccreditation Programforrectalcancer.
Metastaticevaluationincludescontrastedcomputedtomography(CT) ofthechest,abdomen,andpelvisandserumcarcinoembryonicantigen
(CEA)level.Althoughnotroutinelyindicated,18F-fluorodeoxyglucose positronemissiontomography/computedtomography(PET/CT)maybe usefulinthesettingofamarkedlyelevatedCEAwithoutobvious metastaticdiseaseonCT.ThefindingofstageIVdiseaseistypicallyan indicationforsystemicchemotherapybeforeconsiderationofsurgical treatmentoftheprimarytumor.Exceptionstothismaybebleedingfrom thetumor,andpotentiallyobstruction,althoughadivertingstomamay bemoreappropriatethanprimaryresection.Allpatientswithrectal cancershouldhaveallofthefindingsdiscussedinthemultidisciplinary rectalcancerteamconference.
Thepatient’soverallhealthandsuitabilityforsurgeryshouldbe assessedbyacarefulhistoryandphysicalexamination,routine laboratorywork,andadditionaltestingasindicatedforspecific comorbidities.Acarefulassessmentofbaselinecontinenceshouldbe established.Earlysymptomsofimpairedcontinenceincludingnighttime soilageorincontinencetoflatusorliquidstoolshouldbeelicitedand patientsshouldbecounseledthatthesesymptomswilllikelyworsenafter
acoloanalanastomosis.DocumentationofaWexner/ClevelandClinic IncontinenceScoreshouldbeperformed.Athoroughdiscussionofthe risks,benefits,andexpectedoutcomesofsphincter-preservingsurgery versusAPRshouldbeheldanddocumentedinthepatientchart.Patients shouldbeinformedoftheneedforatemporarydivertingileostomyas wellasthepossibilityofapermanentcolostomyshouldintraoperative findingsdifferfrompreoperativeimaging.Patientsshouldmeetwitha trainedenterostomaltherapistforcounselingandmarkingforleft-and right-sidedstomasitesbeforesurgicalpositioning.
Preoperativecomponentsofanestablishedenhancedrecoverypathway (ERP)shouldbeinitiatedintheclinicwithprovisionforpatient education,specificinstructionsonpreoperativefasting,andany preoperativeprescriptions.Preoperativebowelpreparationis controversial.Althoughdatademonstratethatbowelcleansingmaynot benecessaryinallcolonsurgery,bowelpreparationavoidsleavinga columnofstoolinthedivertedcolon.Inaddition,bowelcleansing providestheabilitytoperformintraoperativecolonoscopy.The combinationofmechanicalandantibioticbowelpreparationhasbeen showntosignificantlyreducetherateofsurgicalsiteinfectionandother complicationsaftercolorectalsurgery.Theauthorsandeditorsroutinely performpreoperativemechanicaloral,cathartic,andantibioticbowel preparationbeforeLAR.

SURGERY

EssentialequipmentforsuccessfullaparoscopicLARincludea5-or10­mm30-degreecameraforadequatevisualizationinthedeeppelvis, nontraumaticlaparoscopicbowelgraspers,laparoscopicscissorswith electrocauterycapability,avessel-sealingenergydeviceorendoscopic staplerforvesseltransection,andasuctionirrigator.Aself-retaining retractorsuchastheLoneStarretractorsystem(CooperSurgical,Inc., Trumbull,CT)andlightedHill-Fergusonanalretractorsfacilitate perinealdissection.
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ProphylaxisandPositioning
Inthepreoperativeholdingarea,patientsaregivenchemicalprophylaxis againstvenousthromboembolismintheformofsubcutaneousstandard orlow-molecular-weightheparin.Sequentialcompressiondevicesand antiembolicstockingsareappliedbeforetransfertotheoperatingtable. Intravenousantibioticswithappropriateanaerobicandaerobiccoverage aregivenwithin30minutesofskinincisionandredosedatappropriate intervalsthroughouttheoperation.
Theauthorspositionpatientsinmodifiedlithotomypositioninpadded stirrups,withbotharmstuckedatthesides.Careshouldbetakento ensurethatthelowerlegiswellprotectedtopreventinjurytothe peronealnerve.Anelectricoperatingtableislinedwitheitheragelpador beanbagtoreducetheriskofpressureinjuryandthepatientissecuredto theoperatingtabletoensurenomovementduringperiodsofextremetilt androtation.A“testrun”ofpositioninghelpsensurepatientpositionand preventintraoperativeinjuries.Forcoloanalaccess,itisessentialtoleave 3to4cmofthebuttockshangingofftheedgeofthetabletoallow adequateexposureforthetransanalportionoftheoperation.An orogastrictubeisplacedfortubegastricdecompression.Oncepositioned, acarefuldigitalexamination,proctoscopy,oranoscopymaybe performedtoconfirmthepreoperativeassessmentoftumormarginand ensurethatsphincterpreservationisfeasible.Rectalirrigationisthen performedwithdilutepovidone-iodinesolution.Skinpreparationofthe abdomen,perineum,andperianalregionisperformedperstandard protocol.AFoleycatheterisplacedafterpreparationtoensuretheentire fieldissterile.
OperativeSteps
vein(IMV)
PortPlacementandAbdominalExploration
Theabdomenisenteredusinganopentechniqueanda12-mmHasson portisplacedattheumbilicus.Twoadditional5-mmportsareplacedon therightsideoftheabdomenunderlaparoscopicguidance.Although portsaretypicallyplacedlateraltotherectussheath,inatallpatientwith anarrowpelvis,placingportsmoremediallymaybehelpfultoprevent coningoftheinstrumentsinthepelvis.Oneoftheportsmaybeplaced throughtheplannedileostomysite,butoftenthissiteisnotidealfora workingport.Athird5-mmportistypicallyrequiredforretraction.This maybeplacedintheleftlowerquadrant,suprapubicmidline,orupper abdominalmidline.Anuppermidlineporthasthebenefitofallowingthe cameraoperatortostandtotheleftoftheoperatingsurgeononthesame sideofthepatientandeasilyretracttherectumortransversecolonwith thelefthandwhilecontrollingthecamerawiththeright.Thispositionis especiallybeneficialwhenperformingasub-IMVmobilizationoftheleft colonandsplenicflexure.Theauthors’typicalportplacementand operatingroomsetupisshowninFigure15-2.
FIGURE15-2Portsetupforlaparoscopic
proctectomy.Supraumbilicalentrysite,withtworight­sided5-mmports.Theseportscanbemovedmore mediallytofacilitatereachdeepinthepelvisinalarge, ortallpatient.Theleftlowerquadrantsitemaybe usedastheextractionsite,oraPfannenstielincision maybecommonlyused.Thisportisgenerally extendedforplacementofa5-to12-mmportto facilitateintracorporealstapling.Thestomasite (circle)maybeusedforaportsite,ifappropriate.A well-placedrightlowerquadrantportisessentialfor dissection,andoperativedissectionshouldnotbe compromised.
Aninitialevaluationisperformedtodeterminethelaparoscopic feasibilityoftheoperationandtoevaluateformetastaticdisease.If significantadhesionsfrompriorsurgeryexist,thesurgeonmustdecideto attemptlaparoscopiclysisortoconverttoopensurgery.Theperitoneum isinspectedforsignsoftumorimplantationinallfourquadrants.The diaphragmisexaminedasisthecapsuleoftheliver,includingthe
inferioraspectsbyelevatingtheleftandrightlobes.Theovariesare inspectedbecausethereisa3–8%incidenceofovarianmetastasisin colorectalcancerpatients.Thepelvisisassessedtoevaluateforlateral extensionofthetumor,althoughthismaybedifficulttodetermineuntil thepelvicdissectionbegins.
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HighLigationoftheInferiorMesenteryArteryand InferiorMesenteryVein:Medial-to-LateralApproaches
ThepatientisplacedintheTrendelenburgposition,withtherightside downandthesmallbowelisreflectedoutofthepelvis.Occasionally, right-sidedadhesionspreventretractionofthececumandsmall intestines.Lysisoftheseadhesionshelpsprovideaclearwindowintothe pelvisandpreventsmallbowelmigrationintotheoperativefield.The sigmoidcolonisreflectedanteriorlyandtotheleftbytheassistantto placetherightsideofthemesorectumonstretch.Ifthesigmoidis adhesedtotheanteriorpelvis,itmaybenecessarytofreethese attachmentsaswelltoprovideadequatereductionofthesigmoidoutof thepelvis.Theperitoneumoverlyingtherightsideofthemesorectum distaltotheIMAisopenedoverthesacralpromontory.Thesuperior hemorrhoidalvesselsareelevatedintotheopenspaceexposingthe presacralvesselsandnerves(Fig.15-3).Branchesofthehypogastric nerveslyingbetweentheaortaandtheIMAarepreservedandswept caudallytowardtheaorta.Theleftureterisidentifiedinits retroperitonealpositionalongtheleftpelvicsidewallbeneaththevessels. Ifdifficultyisencounteredelevatingtheproximalrectumtoperformthis medial-to-lateraldissection,itmaybebeneficialtodividethelateralor anteriorattachmentstothesigmoidcolon.TheoriginoftheIMAistraced backtotheaorta,justcaudaltotheligamentofTreitz,andisisolated circumferentially,preservinglymphnodeswiththespecimen.TheIMAis transectedusingastapler,clips,oranenergydevice.Itisessentialthat theleftureterhasbeendefinitivelyidentifiedandpreservedbefore transectionofthevessel.
FIGURE15-3Dissectionoftheinferiormesenteric
artery(IMA).Atthelevelofthesacralpromontory,the IMAistentedanteriorlytowardtheabdominalwall, allowingfordissectionparallelanddeeptotheartery. NotetheIMAistransectedproximaltotheleftcolic artery.Nervefibersfromthesympatheticplexuslie belowtheartery,andaresweptdownandpreserved. Beforetransection,identificationoftheleftureteris vitaltoensureitisnotinadvertentlytransectedwith thevascularbundle.
Theleftcolonmesenteryisthenfurthermobilizedinamedial-to­lateralmanner,liftingthemesocolonoffoftheretroperitoneum.Thebare areaoftheleftcolonmesenteryisdividedcephaladfromtheIMAorigin alongtheanteriorsurfaceoftheaorta,medialtotheIMV,elevatingthe IMVandtheascendingleftcolicarteryintheprocess(Fig.15-4).High ligationoftheIMVisessentialforadequatelengthonthedescending colon.Thevesselshouldbeisolatedanddividedneartheinferiorborder ofthepancreaswhereitdivesposteriortoconvergewiththesplenicvein. Theleftcolicarterymaythenbedividedatthebifurcationoftheleftcolic andsuperiorhemorrhoidal,leavingtheIMAoriginandsuperior hemorrhoidalwiththespecimenandpreservinganybranchesfromthe leftcolicarterytothedescendingcolon.
FIGURE15-4Theassistantislocatedbetweenthe
patient’slegsorbelowthesurgeonontherightsideto enablehim/hertoworkwiththecamera.Themedial­to-lateraldissectionisfacilitatedbyreverse Trendelenburgwithleftsideelevated.Retractorsare placedunderthemesenterytokeeptensionontheline ofToldtandretroperitoneum.Openbowelgraspers elevatethemesenteryinanteriordirectionallowingfor awiderlineoftractionduringthedissection.The surgeoncanthendissectabovetheretroperitoneumto thelateralsidewall,superiorlytowardthesplenic flexureandinferiorlytowardtheiliacfossa.Caremust betakentoensurethattheureterandretroperitoneal structuresremainwiththeretroperitoneum,andthe planeofdissectiondoesnotveerunderthedistaledge ofthepancreas.
SplenicFlexureTakedownandLeftColonMobilization
Dissectionproceedsinamedial-to-lateraldirection,underthetransected IMAandIMV.Theretroperitoneumcanbemaintainedintactandswept caudally,preservingtheleftureter,gonadalvessels,andpsoasmuscle intact.Thisdissectioncontinuesfromthepelvicbriminferiorlytothe inferiorborderofthepancreassuperiorlyandlaterallytothewhitelineof Toldt.Aftermobilizingtheleftmesocolonoffoftheretroperitoneum,the colonisretractedmediallyandthelateralattachmentsaredividedalong thelengthofthedescendingcolon.Theplaneoftransectionshouldbe justmedialtothewhitelineofToldttoleavetheretroperitoneum
undisturbed.
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Withtheomentumreflectedcephalad,thepatientisplacedinaneutral orslightreverse-Trendelenburgpositionandthetransversecolonis retractedcaudad.Foraright-handedsurgeonthisstepiseasily accomplishedbytradingplaceswiththeassistantandliftingthe omentumwiththelefthandandworkingthroughtheuppermidlineport, whileusingmonopolarscissorsorenergywiththerighthandthroughthe rightupperport.Theassistantretractsthetransversecoloninferiorly throughtherightlowerport(Fig.15-5).Enteringthelessersac,the superioraspectofthetransversemesocolonisexposedandtheomentum isdissectedoffofthecolonaroundthesplenicflexureintheavascular plane.Thelessersaciseasiesttoentertowardthemidlineandis confirmedbyvisualizationoftheposteriorwallofthestomach.While approachingthespleen,careshouldbetakentoavoidtensionthatmay causecapsulartearingandbleeding.
FIGURE15-5Mobilizationofthesplenicflexure.
Anavascularplaneispresentbetweentheomentum andtheepiploicaeofthecolonandindicatedbysubtle changesintheadiposetissue.Entryisfacilitatedinthe midline,wheretheomentalplanesarefused.Proceed laterallytowardthesplenicflexure.
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