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lymphadenopathy.Theresultsofthesepreoperativeevaluations,in conjunctionwiththosefollowingtheneoadjuvanttherapy,shouldbe usedtodeterminethedistalmarginofresectionandpotentialfor resectionwithmaintenanceofintestinalcontinuity/sphincter preservation.
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Bodyhabitusalsoplaysasignificantroleinoperativedecisionmaking. Ideally,thepatientshouldnotbeobese(BMI<30–32kg/m2).Patients
whoare:male,haveanarrowpelvis,oralonganalcanalmayalsomakeit moredifficulttoperformanideal,oncologicresection.Indeed,anIRPis morelikelytobeperformedinpatientswhoaremale,havedistaltumors, orincreasedBMIduetodifficultyintroducingstaplingdevices(forLAR).
Itisalsoimportanttodeterminethepatient’spreoperativecontinence. Thisassessmentcanbemadeviahistory,digitalrectalexamination, manometry,oracombinationofthesemethods.Inpatientswithgood sphincterfunctionondigitalrectalexaminationbutrecentdevelopment ofclinicalincontinence,thedysfunctionmaybeattributabletothe neoplasticprocess,anditisreasonabletoexpectthattheymaybenefit fromanIRP.Otherpatientswithpreoperativeincontinencemaybe betterservedwithapermanentstoma.Whenpossible,thesepatientsmay benefitfromanintersphinctericnon-restorativeproctocolectomydueto itshealingbenefitsoverAPR,especiallyafterundergoingneoadjuvant chemoradiationtherapy.Althoughageperseisnotanexclusioncriteria, generallyolderpatientshavedecreasedsphinctertoneandalsoless physiologicalreserveoftheirremainingmusculatureafterundergoing radiationtherapyandinternalsphincterresection.Apreoperative evaluationwithawoundcareandostomynurseforstomacareteaching andstomamarkingispivotalinthesepatientsandforlong-termsuccess ofthesepatients.
CONTRAINDICATIONSTO INTERSPHINCTERICRESECTION
Therearecertainexclusioncriteriathataregenerallyacceptedwhen evaluatingidealcandidatesforIRP:pretreatmentinvolvementofthe externalsphincterbytumor;inadequatedistalmargin(<1–2cm);poor preoperative(oranticipatedpostoperative)sphincterfunction;patient preference;oraninitial,pre-neoadjuvantuT3lesionwithanexternal sphinctercomplexinvolvement.Whenlookingatanationwidedatabase, factorsthatwerenotedtobeindependentpredictorsofsphincter preservationincludedyoungage,proximallesions,non-fixedlesions,and institution.Althoughnotspecificallyaddressed,individualtraining, technique,andoutcomesarelikelytobeattributabletothesuccessofan IRP.Onecannotstressenoughtheimportance,aswithanyprocedure,of specialtytrainingandexperiencemandatoryforselectingandthen completingtheseprocedures.Thereisahighlearningcurve,particularly whenapproachedlaparoscopically.Furthermore,amulti-or interdisciplinaryapproachtoevaluationandselectionofthesepatients mayhelpinthepostoperativeperiod.
SURGICALANATOMYAND CONSIDERATIONS
AutonomicNervesinRectalDissection
Duringanyoperationforrectaldisease,whetherbenignormalignant,the surgeonshouldbeacutelyawareoftheinnervationsanddistributionof theautonomicnervesandtheirrelationtothetargetresectionspecimen. Traumatotheautonomicnervesmayoccuratseveralpoints.Duringhigh ligationoftheinferiormesentericartery(IMA),closetotheaorta,the sympatheticpreaorticnervesmaybeinjured.Divisionofbothsuperior hypogastricplexus(SHP)andhypogastricnervesmayalsooccurduring dissectionatthelevelofthesacralpromontoryorinthepresacralspace. Insuchcircumstances,sympatheticdenervationwithintactnervi erigentesresultsinretrogradeejaculationandbladderdysfunction.The nervierigentesarelocatedintheposterolateralaspectofthepelvis,and atthepointoffusionwiththesympatheticnervesarecloselyrelatedto themiddlehemorrhoidalartery.Injurytothesenervescompletely abolisherectilefunction.Thepelvicplexusmaybedamagedeitherby excessivetractionontherectum,particularlylaterally,orduringdivision ofthelateralstalkswhenthisisperformedclosetothelateralpelvicwall. Finally,dissectionneartheseminalvesiclesandprostatemaydamagethe periprostaticplexus,leadingtoamixedparasympatheticandsympathetic injuries.Thiscanresultinerectileimpotenceaswellasaflaccid, neurogenicbladder.Sexualcomplicationsafterrectalsurgeryarereadily evidentinmen,butareprobablyunderdiagnosedinwomen.
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SurgicalTechnique
Variousdescriptionsofintersphinctericrestorativeproctectomyhave beenpresentedintheliteratureoverthepast40years.Thisextended resectionforrectalmalignanciesispredicatedontheknowledgethat rectaltumorinfiltrationisinitiallylimitedbyanembryonicplane betweenthevisceralstructuresandthesurroundingsomaticskeletal musclesofthepelvicfloor(Fig.20-1).IRPattemptstoridthepatientof thediseasewhilethetumorisstillconfinedtothisenvelop.Throughout thedissection,particularattentionispaidtominimizedamagetothe sympatheticandparasympatheticfibersthatareinvolvedinbladder
functionandsexualpotency.Whereasdamagetothesympatheticfibers aloneleadstoadecreasedabilitytoattainorgasm,parasympatheticor combineddamageresultsinimpotenceinmenandvaginaldrynessin women,manifestingasdyspareunia.
FIGURE20-1Schematicrepresentationofthe
distalanorectalcanal.Themesorectumnarrowsandis completelyterminatedatthepointofmeetingthe puborectalismusclesandthelevatorplate.Thisthen proceedscircumferentiallyinacaudadfashionasthe externalsphinctermuscle,asomaticmusclealongthe analcanal.Medially,theinternalsphinctermuscle,a visceralsmoothmuscle,isobservedasacontinuation andinappositiontotherectalwall,andisseparated bytheintersphinctericplaneorspacefromthe externalsphinctermuscleintheembryonicplanebya glisteningwhiteperitonealreflection.
FecalDiversion
Theauthor’sandeditors’preferenceisforfecaldiversionofallpatients thatundergoIRP.Thereremainssomecontroversyabouttheroleof diversioninrectalsurgeryduetothemorbidityassociatedwithastoma aswellasasecondsurgerytoreverseit.However,wefeelthat,the increasedsalvagerate,decreasedrateofreoperation,anddecreased clinicalsignificanceofanastomoticfailuresinpatientswithdiverted stomasmakesthedivertingprocedurejustifiable.
Althoughthereisonerandomizedprospectivetrialthatshows decreasedmorbidityintermsofpostoperativeileusandsmallbowel
obstructionswithadivertingtransverseloopcolostomy,ourpreferenceis toutilizeadivertingloopileostomy.Asthesplenicflexureisoften mobilizedtoprovideadequatelengthforacoloanalanastomosisduring anIRP,maturingatransverseloopcolostomybecomessignificantlymore difficultthanadivertingloopileostomy.Theoperationtoreversealoop ileostomyisalsomucheasierwithdecreasedpostoperativemorbidityin termsofwoundinfectionandabdominalwallherniaformation.
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Theanastomosisisstudied6weekslaterandiftheresultsare satisfactory,thediversionisreversed.
TotalMesorectalExcision
Theabdominalphaseofthedissectionhasbeendescribedvia laparotomy,laparoscopy,andnowrobotics.Itisbroadlyacceptedthat theapproachtocancersoftherectumshouldincludesharpTME.Others haveadvocatedthattumors,particularlythoseintheupperpartofthe rectum,mayberesectedifadequatemarginscanbeachieved— particularlyatleast5cmofmesorectumdistaltoandproximalfromthe rectaltumor.Ifthesemesorectalmarginscannotbeattained,then completeTMEisadvocated.Generally,anLARwithastapled anastomosiscanbeperformedifsufficientdistalmarginsareachieved andastaplerisabletobeintroducedatorabovethelevelofthelevator plate.Inthesettingofmoredistaltumorsrequiringintersphincteric restorativeproctectomy,ourpreferenceistoperformacomplete laparoscopicTME.Basedonnumeroustrials,andalsosummarizedby positionstatementsfromtheAmericanSocietyofColon&Rectal SurgeonsandtheSocietyofAmericanGastrointestinalandEndoscopic Surgeons,laparoscopictechniquesforcurablecolonandrectalcancer havebeendeemedtobeasafealternativewhencorrectoncological techniquesarefollowed.However,itiscriticallyimportanttoemphasize thatalaparoscopicapproachisnotasimpleprocedure,andthatit requirespropertrainingandexperienceinadvancedminimallyinvasive surgery.Mostofthedatapresentedarebasedonnationaldataevaluating laparoscopiccolonandrectalsurgeryandextrapolatedbasedon multicenterexperiencewithlaparoscopicrectalcancersurgery.Recently, twoWesternrandomizedmulticenteredtrialshavecompleted investigatingtheuseofthelaparoscopic(andinsomecases,robotic) techniqueforrectalcancerTME.Forthesetrials,theAmericanCollegeof SurgeonsOncologyGroupZ6051andtheAustralasianLaparoscopic CanceroftheRectumTrial(ALaCaRT)usedasurrogatepathological
metrictoevaluateappropriatesurgicalresectionandattemptedtouse thiscompositeindexasanoncologicalmarkerforappropriatenessof resection.ThissurrogatewasasummationofcompletenessoftheTME, negativecircumferentialmargin,andnegativedistalmargin.Although therewerenodifferencesbetweentheopenandlaparoscopicapproaches intheseindividualoutcomes,thecompositeindexunfortunatelydidnot meetthenon-inferioritybenchmarkcriteria,andcautionwasadvised whenrecommendingorperformingrectalcanceroperationsusingthe minimallyinvasivelaparoscopicapproach.Therehavebeennumerous editorialreviewsandcommentaryinsocietiesontheoutcomesofthese trialsandcurrently,intheUnitedStates,centerscontinuetoproceed withminimallyinvasive,andinparticular,roboticdissectionsforrectal cancer.Long-termoncologicaloutcomesfromtheabovetrialsarestill pending.
PREOPERATIVEPLANNING
Aswithalloperationsforrectaladenocarcinomas,patientsshouldbe appropriatelyandthoroughlyevaluated.Acompleteandfullcolonoscopy shouldbeperformedanddocumentedtoexcludeanyothersynchronous lesions.Flexiblesigmoidoscopyafterneoadjuvantchemoradiation therapymaybeutilizedtoassessclinicalresponse.Preoperativeimaging withcomputedtomographyofthechest,abdomen,andpelvisshouldbe performedtoexcludemetastaticdiseaseand/orprogressionduring chemoradiationtherapy.DedicatedMRIwithrectalcancerprotocols (withorwithoutendorectalcoilorendoluminalgel)shouldbeperformed todocumentlocalstaging,andinparticular,assessclosenessofthe circumferentialanddistaltumorextent.Theselatterfeaturesmayaffect theextentofoperationperformed.Acarcinomembryonicantigenlevel shouldbedrawnpreoperativelyasabaseline.Baselineassessmentof sphinctertoneshouldbeperformedpriortotheoperationtoassure appropriaterestingandsqueezetone.Absentordiminishedtoneisa contraindicationtoISR.Finally,documentationofamultidisciplinary tumorboardreviewofthepatientandtheirdiseaseandsubsequentplan ishighlysuggested.
Preoperatively,allpatientsareplacedonanenhancedrecovery protocol.Itisthesurgeon’spreferencetohavepatientscompletea completeoralantibioticandmechanicalbowelprepthedaypriortothe operation.Inaddition,allpatientsreceiveintravenousparenteral prophylacticantibioticsaccordingtoJointCommissionSurgicalCare ImprovementProjectguidelines.Patientsalsoreceivepreoperativeoral acetaminophen,celexocib,andgabapentinintheholdingareaaspartof theenhancedrecoveryprotocol.
SURGERY/DESCRIPTIONOFTECHNIQUE
Theproceduremaybebrokendownconvenientlyintosevendistinct steps:(1)medial-to-lateralmobilizationandhighintracorporealvascular divisionoftheIMAandvein;(2)mobilizationofthesigmoidcolonand leftcolon;(3)splenicflexuremobilizationandinferiormesentericvein transection;(4)sharpTMEwithenbloclymphadenectomy;(5) intersphinctericdistaldissectionviaabdominalapproach(anddouble­stapledanastomosisifpossible)orviatransperineal transection/intrasphinctericdissection;(6)extracorporealtransperineal creationandanastomosisofareservoir;and(7)temporarydiversion. Followingisdescribedthelaparoscopicandrobotictechniquesforan IRP.
IntraoperativePreparationandPositioning
Thepatientisplacedinamodifiedlithotomypositionandbothlegsare securedinAllenstirrups.Intraoperativeevaluationoftherectaltumoris performedviadigitalrectalexaminationandrigidproctosigmoidoscopy todetermineresectabilityandthesiteofthedistalresection.Therectum isthenirrigatedwithacytocidalsolutionofdilutedBetadine.Boththe abdomenandtheperineumarepreppedanddrapedinasterilemanner. Infemales,thevaginaisalsosterilelyprepped.Cystoscopyandbilateral ureteralcatheterplacementmaybehelpfulinthesettingofanirradiated pelvistohelpvisualizetheuretersduringdissection.
LaparoscopicPortPlacement
PeritonealaccessisobtainedutilizingtheopenHassontechniqueviaa1 cmsupraumbilicalincision.Onobtainingpneumoperitoneum,a10mm 30-degreescopeisutilizedtoperformadiagnosticlaparoscopy. Particularattentionispaidtotheliversurfaceaswellasthesurfaceofthe peritoneumtoevaluateformetastaticdisease.A10–12mmisplacedin therightlowerquadrantabout2cmmedialand2cmcephaladfromthe anteriorsuperioriliacspine.Anadditional5mmportisplacedinthe rightupperquadrantabout8cmcephaladfromthepreviousrightlower quadrantport.Afinal5mmportmaybeplacedintheleftlowerquadrant ifneededforlateruse.Thisportcanhelpwithretractionoftherectum outofthepelvis,definingtheanteriordissectionplane,andin mobilizationofthesplenicflexure.
RoboticPortPlacement
Currently,theauthorprefersperformingmostofthedistalrectal dissectionswiththeaideoftherobot.Theonlyrobotscurrentlyonthe marketaretheIntuitivedaVinciSiandXiplatforms(IntuitiveSurgical, Inc.,Sunnyvale,CA).Theroboticsystemallowsforenhanced visualizationduetothe3Dstereoscopicviewandenhanceddistal articulationanddissectionduetothewristedinstrumentation.In addition,inthesecomplexcases,surgeonergonomicsareimprovedover laparoscopyandcertainlymoresooverconventionalopenabdominal approaches.
PortplacementforbothSiandXiplatformsisgenerallysimilar. AdvantagesoftheXiplatformincludesmallerports,a levitating/articulatingboom/armpositioningsystem,andalsoport­hoppingthatallowsforthetransferofthecameratovariousports, enablingfullmobilizationofthesplenicflexureandalsotherectumwith singledocking.UsingtheXisystem,asupraumbilical8-mmcameraport isplacedabout15cmcephaladtothepubis.Thisisperformedusingan optiviewtechnique.Pneumoperitoneumisattainedandsimilarto conventionalopenandlaparoscopicapproaches,diagnosticevaluationto excludeperitonealorhepaticmetastaticdiseaseisperformed.When local,non-metastaticdiseaseisconfirmed,astaplingportisplacedinthe rightlowerquadrantapproximately3cmmedialandsuperiortothe anteriorsuperioriliacspine,andthenthreeadditional8-mmportsare placedasfollows:rightupperquadrantparalleltotheRLQport;leftmid­abdominalportapproximately2–3cmcephaladtotheumbilicalportand alongthemid-clavicularline;andleftlateralportparalleltothe umbilicusalongtheanterioraxillaryline(Fig.20-2).Withthisport placement,single-dockingfeasibletomobilizethecolonfromthemid­transversecolondistallytoandthroughtheintersphinctericplane aroundtheanorectalcanal.TheadditionofTableMotionsoftwarewith theTrumpfMedicalTruSystem7,000surgicalbed(both,Trumpf MedizinSystemeGmbH,Saalfeld,Germany),allowsforrepositioningof thepatientswhiletherobotic(Xi)systemisdocked,enablingsplenic flexuremobilizationandsingledocking.
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FIGURE20-2Roboticlowanteriorand
intersphinctericportplacementusingtheIntuitive daVinciXiplatform.Withthissetup,thepatientbedis initiallypositionedin20degreesTrendelenburgand10 degreesrightinclinationforthetotalmesorectal excisionportionoftheoperation.Therobotisdocked perpendicularlyfromthepatient’sleftside. Instrumentationisasfollows:1—bipolarfenestrated grasperforstaticretractionofthedistalsigmoidand anteriorretractionofthevaginaorprostatic structures;2—Cadieregrasperfordynamicgrasping andmanipulation;3—0degree8mmroboticcamera; and4—monopolarscissors,bipolarvesselsealer,and 45mmendostapler.Whenport-hoppingforsplenic flexuremobilization,thebedisrepositionedinto reverseTrendelenburgpositionandtheCadiere graspermovedtotheassistantportandmonopolar scissorstoport2.
Step1:Medial-to-LateralMobilizationandHigh
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