Книга_861_Библиотеки_им_академика_М_И_Перельмана

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LigationofInferiorMesentericArtery

WiththepatientinslightTrendelenburgpositionandairplanedtothe right,themedial-to-lateralmobilizationisinitiated.Althoughsomehave usedenergizedshears/electrocauterydevices,theauthorcontendsthat anultrasonicdissectororbipolarvesselsealermaysubsequentlyhavea roleinlaterportionsofthecaseforIMAtransectionandmaintenanceof hemostasis.Themesenteryoftherectosigmoidistentedanteriorly directlyoverlyingthesacralpromontory,justtotheleftoftheright commoniliacartery.Withagentleapplicationofcoagulationcurrent electrocauteryinthisarea,theretroperitonealpresacralspacebeginsto billowascarbondioxideentersthisplaneanddiffusesandexpandsthe alveolartissue.Then,dissectionofthemesocolonoftherectosigmoid withtheIMAisproceededinthespacebetweenthemesenteryandthe autonomicnervesoverlyingtheaorta.Careistakentoidentifytheleft ureterandtopreserveitsposterolateralposition(Fig.20-3).Oncethese vitalstructuresareidentified,combinationsofmedial-to-lateraland lateral-to-medialarecontinuedcephaladtoidentifytheIMAandits originattheaorta.

FIGURE20-3Duringmedial-to-lateral

mobilization,themesenteryoftherectosigmoidis tentedanteriorlyoverlyingtheaortaandautonomic nerveswithvisualizationoftheretroperitoneal structure.Theappropriateplaneisidentifiedwitha positiveobservationoftheretroperitonealreflection line,theureterandtheleftexternaliliacartery.Priorto

thispoint,duringdissection,careshouldbetakennot todisrupttheautonomicnervesoverlyingtheaorta.

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AhighligationoftheIMAisperformed.Therelativeanatomyofthe sympatheticnervesinthisregionshouldbekeptinmindwhile performingthissegmentofthedissection.TheSHPandtheoriginofthe hypogastricnervesoverlietheaorta,andthesacrumneedtobevisualized andpreserved.TheyliebehindtheIMAasittravelstowardtherectum. ThesesympatheticfiberscansometimesbeincorporatedintheIMA pedicleifligationoftheIMAisperformedtooclosetoitsoriginfromthe aorta.Injurytothesestructuresmayresultinretrogradeejaculationor vaginaldryness.

Withthesigmoidcolononstretchandthepatientairplanedtothe right,mesentericdissectioniscontinuedproximallyuntilthevascular pediclecontainingtheIMAisidentified.Awindowiscreatedaroundthe IMA.HighligationoftheIMAisthenperformedjustdistaltoitstakeoff fromtheaorta.Theauthorpreferstoutilizeanenergydevice(robotic bipolarvesselsealerorlaparoscopicadvancedenergyultrasonic dissector)forthisligation(Fig.20-4).Alternativesincludeamechanical endostapleroftheappropriatestapleheight.

FIGURE20-4Highligationoftheinferior

mesentericartery(IMA).Notetheureterandpelvic sidewallstructuresontheleftclearlyidentifiedand preservedoutofharm’sway.ThetakeoffoftheIMAoff theaortaisseenwithhighligationandtransection (leavinga1-cmstump)withtheroboticvesselsealer.

Step2:LeftColonMobilization

JustproximaltothisIMAtransectionandligation,themesocolonisthen dividedinaperpendicularfashiontothelevelofthedescending-sigmoid colonjunction.Priortotransectionofthecolonandsubsequent anastomosis,thecolonproximaltothemesocolicdivisionisevaluatedfor appropriatevascularity.Thisiscurrentlyperformedusinganintravenous injectionof4mlofindocynaninegreenandendoscopicfluorescence imaging(NovadaqSystems,Ontario,Canada).Continuedproximal dissectionofthedescendingcolonmesenteryfromtheretroperitoneal structuresisperformedandfacilitatedbydownwarddissectionofthe whiteretroperitonealreflectionline.Thisdissectioniscontinued proximallytillabovetheupperpoleofthekidney.Insomecases,this mobilizationcanbecontinuedandthewrongplaneenteredbydissected inferior/posteriortothepancreas.Ifthishappens,theappropriateplane shouldbereenteredseparatingthetransversemesocolonandpancreas keepingthesestructuresseparateanteriorlyandposteriorly,respectively. Theinferiormesentericveinisalsothendissectedfreeanddividedusing anotherfiringofthevascularstaplerorultrasonicdissectororbipolar vesselsealer.Thesemaneuversallowenoughproximalcolonlengthto performreconstructionwithatension-freeanastomosis.

Step3:SplenicFlexureMobilizationandInferior MesentericVeinDivision

Thedescendingcolonismobilizedbyfreeingitsremaininglateral abdominalwallattachmentsalongthelineofToldt.Theseareallthatwill beleftafterpreviouscephaladmedial-to-lateralmobilizationofthe mesenteryfromtheretroperitoneum.Thisdissectioniscarriedout proximallytothesplenicflexure.Thepatientisthenplacedinslight reverseTrendelenburgpositionandstartingapproximatelyhalfway betweenthehepaticflexureandthefalciformligament,thegastrocolic omentumanditsattachmentstothetransversecolonaredivided. Dissectioniscarriedoutdistallytowardthepreviousdissectionplane. Thesplenicflexureisthuscompletelyandfullymobilized.Careshouldbe takentopreservethemiddlecolicarteryandvein.Theinferior mesentericveinshouldbedividedatthispointifnototherwisedone. Thisshouldbedoneinahighfashionimmediatelycaudadtothe pancreas.Thisallowsforappropriatetension-freelengthforthe descendingcolontoreachtheanus.Themesentericdissectionmay proceedproximallytotheleveloftheligamentofTreitz.Incertaincases, withchallengingsplenicflexures,itmaybeeasiesttoenterintothelesser sacbyopeninguptherelativelyloosealveolarspaceimmediately

superiortotheligamentofTreitzwithinthetransversecolonmesentery. Dissectioncanthenproceedanterogradealongthedistaltransversecolon anddistallytomobilizethesplenicflexureuntilthepriortransectionis metfrombelow.

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Step4:SharpTMEwithEnBlocLymphadenectomy

AttentionisthenturnedtothesacralpromontoryandasharpTMEis performedinthebloodlessplane.Laparoscopically,theplaneis maximallyvisualizedvialateralmanipulationperformedwiththeaidof theleftlowerquadrantabdominalportsiteandcephalad-anterior retractionoftherectumperformedviatherightupperquadrantportsite. Robotically,thelateral-mostportfunctionsasastaticgrasperretractor forcephald-anteriorretractionoftherectosigmoidandthemoremedial left-abdominalportfunctionsasthedynamicretractor.Bothhypogastric nervesoverlyingthesacralpromontoryandproceedingdistallyalongthe pelvicsidewallsareidentifiedandpreserved(Fig.20-5).Dissectionis carriedoutinitiallyposteriorly,followedbylaterally,andfinally anteriorly.Careshouldbetakentofindthecorrectplaneofdissection, describedbyHealdasthe“holyplaneofrectalsurgery,”justoutsidethe fasciapropriaasthehypogastricnervespasstangentiallytoitandmedial totheureter.Thisismosteasilyappreciatedasawhite,loose,alveolar plane.Dissectiondistallyalongthisplaneiseasilyperformedsharply withelectrocauteryorenergydevices.

FIGURE20-5Initiationofthesharptotal

mesorectalexcisionwithmonopolarscissors.Theleft andrightsuperiorhypogastricnervesarevisualized (labeledlaterally)immediatelyadjacentandoutside

thefasciapropriainthepresacralspace.Thisplaneis maintainedandthewhiteloosealveolartissueis sharplydissectedposteriorlyandthenlaterallyand finallyanteriorlytothelevelofthelevatorplate.

Theinferiorhemorrhoidalplexus(IHP)sendsdelicatebranchestothe rectumthattravelinthelateralligaments.Theroutineuseoflarge clampstoligatethelateralligamentsinanattempttoavoidhemorrhage fromthemiddlerectalarteryisunnecessarybecausethisvesselisfound inonly20%ofthepatients.Utilizationoftheselargeclampsmayincrease theriskofdamagingtheIHP.Wedonotroutinelyincludetheentiretyof Denonvilliers’fascia(believedtobetheconglomerateoftwolayersofthe mostdistalpelvicperitoneumafterthespacewithinthelayersis obliteratedduringembryogenesis)inoursurgicalspecimen,unlessthere isareasontobelievethatitwouldberequiredtoobtainanR0resection— thatis,ananteriorlesion.

Careshouldbetakennottodamagethedelicatecavernosalfiberswhile performingtheanterolateralseparationofthedistalrectumfromthe prostateandtheseminalvesiclesduringboththeabdominalandperineal portionsofthisdissection(Fig.20-6).Thefibersareeasytodamageas evidencedbycasereportsofpatientssufferingfromneurogenic impotenceaftertheinjectionofsclerosantintoodeepofaplaneasan attemptedtherapyforanteriorlylocatedhemorrhoids.Thesefibers cannotbevisualized,makingknowledgeoftheirlocationandpathway particularlycrucial.Afterexitingfromtheirsacralroots,theypassfrom thepelvisanterolateraltotherectumontheirwaytopiercetheurogenital diaphragmbeforeenteringthecorpora.Damagecanbeavoidedby performingdelicateandavoidingoveraggressiverectaldissectionatthe2 and10o’clockpositions,asthisiswherethecavernosalfibersareat greatestrisk.Minimallyinvasivetechniquesandlaparorobotic visualizationaidsinthisdissectionbyaffordingahigh-definitionand magnifiedviewofthedissectionplaneswithminimaltractionartifact. Thisdissectioniscarrieddowntoandpastthelevatorplateandintothe intersphinctericspace.AtthecompletionoftheTME,thespecimen,with itsintactfasciapropriaencompassingthemesorectumandlymphnodes, hasbeendescribedasaglisteningbaby’sbottomposteriorlywithtwo lobes.

FIGURE20-6Leftanterolateraldistalpelvic

dissection.TheseminalvesiclesandDenonvilliers’ fasciaoverlyingtheanteriorrectum(anteriorbased tumor)areseenandthelevatorplateandpuborectalis musculatureisevidentattheinterfaceofthe rectum/mesorectumandpelvicfloor.

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Step5:IntersphinctericDissection

RoboticIntersphinctericDissection(Step5a)

Atthispoint,iftheanastomosisisdistalenoughthatthedissectionhas proceededwithintheintersphinctericplaneanddistaltothetumorwith sufficientmargin,twooptionsexist.Traditionally,perinealdissection frombelowwasperformedtocompletethedissection(seethefollowing).

Asecondtechnique,facilitatedbyroboticsystems,allowsforavoidance ofintersphinctericdissectionandhandsewnanastomosisfrombelow. Withtheaidoftheroboticsystem,dissectionfromtheabdominalphase hasimprovedtothepointthatperinealdissectionissignificantlyless commonlydone.WhenperformingtheTMEdissectionfromabove,the levatorplatesareencountered.Withimproved3Dvisualizationand wristedinstrumentation,thesurgeonisthenabletoidentifythe curvatureofthepuborectaliscircumferentiallyasitencirclesandwraps aroundthedistalanorectalcanal.Thisplanecanbevisualizedwithits peritonealreflectionline(athinwhitefilmylayer).Thisisappreciatedas theembryonicplanebetweenthevisceralstructuresoftheinternal sphinctermusculatureandthesurroundingsomaticskeletalmusclesof thepelvicfloorandexternalsphincters.Withcare,thedissectioncan proceeddistallyinthisintersphinctericplanecircumferentially.Oncean appropriatedistalmarginhasbeenachieved,asverifieddigitallyor

endoscopically,theanorectalcanalcanbedivided.Theroboticplatform forstaplingacrossthedistalrectal/analcanalisaffordedduetoimproved articulationandinstrumentation.Thisleavesaverydistal/short Hartmann’stypeanalbudorstump,typicallyatorjustabove(andif desired,below),thedentateline(Fig.20-7).Thedentatelinemaybe observedintheproximalcolorectalspecimen.

FIGURE20-7Thebareanorectalcanalhasbeen

transectedwiththeroboticstapler.Theanal transectionlineanddistalanalstumpisevidentafter ananterior–posteriordivision.Thepuborectalisand levatorplateareseenandthenmoremediallythereis achangeinorientationofthemusclefibers.The circularmusclefibersoftheexternalanalsphincter musclesareevidentencirclingtheanalstump.The observerwillnotethatthetransectionisdistal/caudad tothemidandupperexternalsphinctermusclefibers.

Atthispoint,astapledanastomosiscanthenbecreated—with accordantavoidanceanddependence/utilizationofahandsewn anastomosis.Toproceedatthispoint,ifnoperinealportionisrequired, thesiteofplannedileostomyisopenedupandawoundprotectoris insertedthroughtheabdominalwall.Thestapledendofthedistal anorectumandproximalrectumisthenextracorporealized.Thecolonis dividedbetweenclampsatthepreviousmesenterictransectionlineand whereappropriate,proximalvascularsupplyhasbeenassured.Frozen sectionpathologicalreviewshouldascertainandconfirmappropriate distalmargins.Ifthemarginisinadequate,thenthesurgeonshould proceedwithaperinealdissection(Step5b,below)orconvertittoan APR.

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Anappropriatecolonicconduitisthencreated(seeStep6inthe following).Thenotabledifferenceisthattheanviloftheend-to-end anastomotic(EEA)staplingdeviceisinsertedwithinthelumenofthe proximalcolonandbroughtoutontheantimesentericsurfaceatthe proposedsiteofanastomosistotheanalstump.Thecolotomyattheprior transectionisclosedusinganendomechanicalstaplingdevice.The colonicconduitisplacedbackwithintheperitonealcavity.Underdirect visualization,theEEAstapleriscarefullyandslowlyinsertedtoabutthe analstapleline.Withanteriorretractionofthevaginaorprostate,the spikeisthenslowlyadvancedthroughthewalloftheanalcanalposterior orimmediatelylateraltothedistaltransectionstapleline.Theanvilis thenmatedtothespikeandwhileassuringthatthereisnotwistingor kinkingofthecolonoritsmesentery,andsimilarlythatthereisno tensionontheproximalcolonconduit,thestapleristhenclosedand fired.Insomecases,carefulpathologicalreviewmayyieldobservationof thedentatelineinthedistalanastomoticringafteradouble-stapled intersphinctericcoloanalanastomosis(Fig.20-8).

FIGURE20-8Distalanastomoticringaftera

partialintersphinctericdissectionandsubsequent double-stapledside-to-endcoloanalanastomosis usingacircularend-to-endanastomoticstapling device.Thereisglandularepitheliumofthedistal rectumonleft(A),transitionaldentatelineinmiddle (B),andsquamousepitheliumoftheanusontheright (C).

Laparoscopicevaluationandtestingoftheanastomosiswhile

submergedundersterilesalineirrigationandproximalocclusionwith flexibleendoscopyhelpsdefineviability,patency,hemostasis,and absenceofanairleakattheanastomosisaswellasviabilityofthe proximalcolonandanus.Onceconfirmed,thesurgeonmayproceedto creationofadivertingloopileostomy(Step7).

(Step5b):PerinealDissection

DifferentdefinitionsregardingthetypesofISRsabound(Fig.20-9). Thereis,however,uniformityindescribingthetotalorcompleteISR.The distalresectionincludesthecompleteinternalanalsphinctercomplexby dissectionattheleveloftheintersphinctericgrooveandtheanalverge. ThesubtotalISRtransectstheinternalsphinctermusculatureby choosingadissectionlinebetweenthedentateandthelevelofthemore distalintersphinctericgroove.ApartialISRincorporatesadistallineof dissectionatorabovethedentate.Occasionally,dependingonthe size/locationofthetumor,anon-circumferential/partialinternaland evenexternalsphincterresectionmaybeperformed.Withverylimited singlequadrantexternalsphincterresection,qualityoflifemaybe acceptable.Pleaseseediscussionoffunctionaloutcomesbelow.

FIGURE20-9Classificationofintersphincteric

resections(ISR).ForatotalorcompleteISR(A),the distalresectionincludesexcisionofthecomplete internalanalsphinctercomplexbydissectionatthe leveloftheintersphinctericgrooveandtheanalverge. ThesubtotalISR(B)transectstheinternalsphincter musculaturebychoosingadissectionlinebetweenthe

dentateandthelevelofthemoredistal intersphinctericgroove.ApartialISR(C)incorporatesa distallineofdissectionatorabovethedentate. Occasionally,dependingonthesize/locationofthe tumor,anon-circumferential/partialinternaland/or evensinglequadrantlimitedexternalsphincter resectionmaybeperformed.

Atthebeginningoftheperinealdissection,adecisionshouldbemade astothedistalextentoftheresectionspecimen.Althoughcurrent literaturesuggeststhatanegativemarginoflessthan1cmdoesnot impaironcologicoutcomes,thesestudiesareabletomakesuchclaimsin patientswithlocallyadvancedcancersonly.Ifanattempttoperforma partialISRistobemade,thentheauthorpreferstostarthisplaneof dissectionatleast1cmdistaltothefurthestextentofthetumor,ifnot ideally2cm.Ifthisisnotpossibleorifthereispreoperativeevidenceof internalsphincterinvolvement,acomplete/totalISRisadvised.Insucha situation,thedistalplaneoftheresectionshouldbestartedatthelevelof theintersphinctericgroove,whichmaybemarkedbythewhitelineof Hilton,oreventheanalverge.

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Oncethisdecisionhasbeenmade,aself-retainingretractor(Lonestar Retractor,LonestarMedicalProducts,Inc.,Houston,TX)isutilizedfor effacementandretractionoftheanalcanal.Electrocauteryisutilizedto performacircumferentialmucosalexcisionatalevelatleast1cmdistal tothelesion.Thisisextendeddeeppasttheinternalsphinctermuscle untiltheintersphinctericplaneisencountered.Theanalorifice(orDRM) maybesuturedcloseandthedissectioniscontinuedproximallystaying intheplanewithinthesmoothinternalsphincterandstriatedexternal sphinctermuscles.Wefindithelpfultobeginthedissectionposteriorand lateralbeforedissectinganteriorlyastheintersphinctericplaneiseasier toidentifyintheselocations.Duringthispartofthedissection,care shouldbetakentoavoidcompromisingDenonvilliers’fasciabecause damagetothecavernosalfibersontheothersideusuallyleadtosexual dysfunction.Continueddissectionintheseplaneseventuallyleadsto communicationwiththeabdominaldissection.Atthispoint,therefore, thecolonandtherectumarecompletelyfreeandthespecimenisableto bebroughtoutpertheanus.Usingtwobowelclampstoavoidfecal contamination,thecolonisdividedatanareaproximaltothedivisionof theIMA.Thismesenterymayhavealreadybeendividedasdiscussed above(Step2).Therectalspecimenissentforfrozensectionanalysisto evaluateforappropriatedistalandcircumferentialmargins.Ifthe

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