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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_861_Библиотеки_им_академика_М_И_Перельмана.pdf
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usuallytechnicallydifficult.Completingastapledcolorectalanastomosis followingtaTME,5cmfromtheanalverge,requiresmultipleadditional stepsthatrenderthisproceduretechnicallychallenging.Pursestring closureoftheopenrectalstumpmustbeperformedthroughthe transanalplatform.Theanvilintheproximalcolonmustbeguided laparoscopicallytowardthecenteroftherectalpursestring.Finally,the distalrectalpursestringmustbetiedaroundtheproximalanvil.
PREOPERATIVEASSESSMENTAND PLANNING
PreoperativeStaging
Preoperativeevaluationincludesmultidisciplinarytumorboardreviewof eachrectalcancercase,withconsensusonthebesttherapeuticstrategy, includingtheneedforneoadjuvanttreatmentandmostappropriate surgicalapproachbasedontumorstaging,predictedCRMstatus,and relationshipofthetumortotheanalsphinctersandanorectalring. Patientswhoareeligibleforlowanteriorresection(LAR)withTMEare extensivelycounseledabouttheneedforatemporaryfecaldiversion,and theexpectedoutcomeswithtaTMEversusotherTMEapproaches, particularlywithregardtointraoperativeandpostoperativerisks, expectedlengthofhospitalstayandoverallrecovery,short-andlong­termoncologicoutcomes,andanticipateddefecatorydysfunction.Thisis particularlyimportantinpatientswithlowrectaltumorswhoare candidatesforTMEwithISRandhand-sewncoloanalanastomosis,and whoarehighlymotivatedtoavoidAPR.
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PreoperativePreparation
Fulloralmechanicalandantibioticbowelpreparationisrecommended fortaTME,withenemasintheeveningbeforesurgery.Apoorlyprepped rectummustbeavoidedbecauseitwillcompromisetumoridentification andaccurateendoscopicplacementoftheoccludingpursestringsuture. Preoperativedeepvenousthrombosisandantibioticprophylaxisis providedasperroutineprotocols.Strategiesforpaincontrolinclude transversusabdominisplaneblock,epiduralcatheter,and/orstandard patient-controlledanesthesia.Abladdercatheterisinsertedandpatients arepositionedinlithotomypositionusingstirrups,witharmstuckedto theside,andboththeabdomenandtheperineumpreppedanddraped.

SURGERY

OperatingRoomandTeamSetup
AlthoughitisstronglyrecommendedthattaTMEproceduresbe performedasatwo-teamapproach,withbothabdominalandtransanal teamsworkingsimultaneously,atleastduringthetransanalendoscopic portion,manysurgeonsperformthisprocedureasasingle-team approachandperformbothabdominalandtransanaldissection sequentially.Theabdominalandtransanalteamsshouldbeprovided withavideofeedoftheotherteam’soperativefieldsothatsurgicalsteps caneasilybesynchronized.ORswithamplespaceshouldbeutilizedso thatthereissufficientspacetoaccommodatetablesandequipmentfor bothteams,includingtherobotincasetheabdominalteamplanson dockingtherobotfortheabdominaldissection.
WhentaTMEisperformedusingrigidtransanalplatforms,asingle transanaloperatorisusuallyseatedinbetweenthepatient’slegs,because thevideoscopeisanchoredtotheplatformwhichisinturnanchoredto theORtable.However,whenperformedusingTAMISplatforms,a dedicatedcameraoperatorisneeded,inadditiontothetransanal surgeon,fortheentiredurationoftransanalprocedure.
Equipment
CombinedCO2insufflationandsmokeevacuationprovidesasteady-state pressurewithoutcollapseoftheoperativefield.TheTEMplatformis
equippedwithanintegratedautomaticpressure-controlledCO
2
insufflationsystem.AirSealSystem(SurgiQuest,Inc,Milford,CT)has becomethemostcommonlyusedinsufflationandfilteringsystemduring taTMEprocedures,andcaneasilybecombinedwithTAMISplatforms. ThesystemprovidesacontinuousflowcircuitthatevacuatesCO2and
smokeandquicklyrecirculatesfilteredandhigh-pressureCO2,thereby maintainingastablepneumorectumatalltimes.
Theuseofbipolarenergyduringtransanaldissectionshouldbe minimized.Nerveinjuryfromexcessiveheatfromdissectinginstruments shouldbeavoided.Transanaldissectionshouldbeprimarilyperformed usingmonopolarenergy.
ThelistofrecommendedequipmentfortaTMEtakesintoaccountthe useofeithertheTEOrigidplatformortheGelPOINTPathTAMIS platform(AppliedMedical,RanchoSantaMargarita,CA).
SURGICALPROCEDURE
One-VersusTwo-TeamApproach
Whenpossible,atwo-teamapproachshouldbeused,wherethe abdominalandtransanalteamsworksimultaneouslyduringtheentire durationofthetransanaldissectiontoshortentheoperativetime.The improvedvisualizationofdeeppelvicstructuresbycombiningtheview fromtheabdominalandtransanalvantagepointsmayincreasethe accuracyofthedissection.Table21-1includesalistofrecommended equipmentfortaTME.
TABLE21-1 SuggestedAbdominalandTransanalEquipmentList
fortaTME
ABDOMINALEQUIPMENT
Standardlaparoscopicbowelresectiontray
Fourtofive5-mmtrocarsandone12-mmtrocar
Monopolarcautery
Bipolardevice
Pelvicdrain
Stomaappliance
Smallwoundprotector
TRANSANALEQUIPMENTUSINGTEOPLATFORM
Headlight
Standardanorectaltray
LoneStarretractorwithspikes
Monopolarcautery
Standardinsufflationsystem
Standardhigh-flowinsufflatorunit(UHI-4,OlympusMedicalSystems,Tokyo,Japan)
Plasticanoscope(graduatedplasticanoscopethatispartoftheMedtronic (Minneapolis,MN)PPHstaplerset)
TEOset(proctoscope,camera,andangled-tipinstruments)
Flexibletiphookdissector(Medtronic,Mansfield,MA)
EEAstaplers(28or31mm)
3-0Vicryland2-0Prolenesutures
Indocyaninegreenfluorescenceimaging
Angled-tiplaparoscopicinstruments
TRANSANALEQUIPMENTUSINGTAMISPLATFORM
Headlight
Standardanorectaltray
LoneStarretractorwithspikes
Monopolarcautery
Insufflationandsmokeevacuationsystem(AirSealSystemConMedUtica,NY)
Plasticanoscope(preferenceisthegraduatedplasticanoscopethatispartofthe MedtronicPPHstaplerset)
TAMISplatform(GelPOINTAppliedMedical,RanchSantaMargarita,CAPathorSILS Medronic,Minneapolis,MN)
Bariatriclength5-mm30-degreescopewithanangledlightcordforTAMIS
Circularstaplers(28or31mm)
3-0Vicryland2-0Prolenesutures
Indocyaninegreenfluorescenceimaging
Angled-tiplaparoscopicinstruments
EEA,end-to-endanastomosis;TAMIS,transanalminimallyinvasivesurgery;taTME,transanaltotal mesorectalexcision;TEO,transanalendoscopicsurgery.
Thetwo-teamapproachusuallystartswiththeabdominalportion,with placementoflaparoscopictrocarsperstandardforlaparoscopicLAR (Fig.21-1).TheabdominalteamproceedswithhighligationoftheIMA andinferiormesenteryvein,followedbysharpmobilizationofthe sigmoidandrectosigmoidmesentery.Transanaldissectionisthen initiatedwhiletheabdominalteamcontinuesmobilizingtheleftcolon andperformsacompletesplenicflexuretakedown.Caremustbetakento reducethetotalCO2insufflationpressuresandavoidCO2retentionand
embolism.Typically,abdominalpressuresarereducedfrom15downto
10mmHg,whereastransanalpressuresaremaintainedat10–12mmHg. LegpositioninstirrupsandthedegreeofTrendelenburgmustbe adjustedtooptimizeexposureforthetransanalteamandavoid obstructingtheabdominalteamfrommaneuvering.
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p.192
FIGURE21-1Trocarpositionforthelaparoscopic
portionoftransanaltotalmesorectalexcision(TME) withdivertingloopileostomy.Excellentcosmetic resultsareachievedwhentransanalspecimen extractionispossible.
p.192
p.193
Astransanaldissectionproceedscephaladandapproachesthelevelof theperitonealreflectionanteriorly,theabdominalteamshouldhave completedleftcolonicmobilizationandstartedmobilizingtheupper portionoftherectumandmesorectum.Theabdominalteamusually providesthemostassistancewiththeposterioraspectoftheTME, namely,mobilizationoftheposteriormesorectum,whichisusually challengingtocompletetransanally.Thesteepangleofthesacral promontoryusuallyprecludesproximaldissectionofthemesorectumby thetransanalteam,andtheabdominalteamshouldpreferentiallydissect themesorectumposteriorlytowardthepelvicfloor.Ontheotherhand, anteriormesorectalmobilizationshouldbepreferentiallyperformed entirelytransanally,whichiswheretaTMEhasauniqueadvantageover anyothersurgicalapproach.Anteriormobilizationendswithperitoneal entry.Incisionofthecul-de-sacisperformedbythetransanalteamunder visionbytheabdominalteam,andfollowedbythecombinedtransanal andabdominaldissectiontocompletetheTME.Therendezvous approachtocompletetheTMEisamajoradvantageoftaTME.It
combinescomplementaryviewswithanglesofretractionanddissection fromtheabdominalandtransanalperspective.
Thecolonmustbedeliveredtransanallyforcolorectalorcoloanal anastomosis.Thisisfacilitatedbytheabdominalteam.
Aone-teamapproachiswidelyusedwithexcellentoutcomes,andis particularlyattractiveforsurgeonswhoprefercompletingtheabdominal dissectionrobotically.Atwo-teamapproachisnotalwayspractical.The transanalteamemploysabdominalassistanceduringcriticaltimes;atthe timeoftransanalperitonealentry,duringtherendezvousportionofthe case,whencompletingrectalandmesorectalmobilization,during specimenextraction,andespeciallyduringdeliveryofthecolonicconduit transanally.Thisallowsvisualconfirmationofthelackoftensionand ischemiabeforecolorectalorcolonanalanastomosis.
AlthoughsomecenterswillinitiatetaTMEprocedureswiththe transanaldissectionportionfirst,especiallywhenattemptingpure NOTEStaTME,thereisconsensusamongexpertsthatwhetheraone­teamortwo-teamapproachisused,abdominalaccessshouldbe establishedfirst,beforetransanaldissection.Thisisbasedonstandard oncologicprinciplesestablishedbyHealdetal.,whichapplytoopenand minimallyinvasiveTMEandincludehighligationoftheinferior mesentericvesselsbeforemesorectaldissectionandrectaltumor manipulation.
Theextentofpelvicdissectiondependsonthesurgeon’spreference; butasageneralrule,itisusuallycarriedoutuntilmoredistalrectaland mesorectaldissectionbecomesdifficultbecauseofpoorexposure.Most one-teamoperatorsmaintainlaparoscopicorroboticTMEuntilthe peritonealreflectionisreachedanteriorlyandextendtheposterior mesorectaldissectionuntilitbecomesobstructedorcomplicatedby limitedexposure.Atthatpoint,theone-teamoperatorwilldesufflatethe abdomenandwillinitiatetaTME.Upontransanalcompletionofthe TME,assistancemaybeprovidedbyanabdominaloperatorforthe rendezvousdissection,specimenextraction,andcompletionofthe anastomosis.Alternatively,thesameteamwillreturntotheabdominal approachtocompleteanyadditionalsteps,includingloopileostomy creation,pelvicdrainplacement,andabdominalwoundclosure.
TransanalTotalMesorectalExcisionwithLowAnterior Resection
Thepatientispositionedinhighlithotomyposition.Whetheraone-team ortwo-teamapproachisutilized,thestepsoftransanaldissectionare dependentontheexactlocationoftherectalcancerrelativetothe dentatelineandanorectalring,becauseitwillaffectwhetherornotISR isneeded.Followingconfirmationoftheexactlocationofthetumorby
digitalrectalexamination,anoscopy,and/orproctoscopy,adecisionis madewithrespecttotheexactlevelofdistalrectaltransectionneededto ensureanegativedistalmargin.
Themostimportantfirststepofthetransanaldissectionisthe occlusionoftherectumwithapursestringsuturebelowthetumor.For tumorsthatare>2cmabovethedentateline,or≥1cmabovethe anorectalring,thatis,whenISRisnotneeded,thepursestringsutureis placedtooccludetherectum0.5–1cmbelowthetumor.Ifthetumoris located<5cmfromtheanalverge,thepursestringcanbeplaceddirectly afterexposureisachievedwithaLoneStarretractorandanoscope.This isfollowedbyinsertionofthetransanalplatform.Itisourpreferenceto useadisposablegraduatedplasticanoscope,partofastapled hemorrhoidectomykit(Fig.21-2).Ifthetumorislocated≥5cmfromthe analverge,thetransanalplatformisinsertedfirst,followedby endoscopicplacementofthepursestringsuturetooccludetherectum. Ourpreferenceistousea2-0Vicrylpursestring,butasutureof2-0 Prolenemaybeused(Fig.21-3).Thepursestringsuturemustbeairtight toavoiddistensionoftheproximalcolonwithCO2,andspillageoffecal
materialortumorcellsintotheoperativefield.IfuponCO2insufflation to10–15mmHgthroughtherectum,thepursestringisleaking,itmust
beredoneorreinforced.
FIGURE21-2ALoneStarretractor(Cooper
Surgical,Trumbull,CT)andplasticanoscopy(A)are usedtofacilitatetransanalplacemementofa pursestringsuturetooccludetherectumbelowlow­lyingrectaltumors(B).
FIGURE21-3Pursestringocclusionoftherectum
forarectaltumorlocated>5cmabovetheanorectal ring(A).Pursestringocclusionoftherectumfora rectaltumorlocated<5cmbelowtheanorectalring (B),closetothedentateline.
p.193
p.194
Followingpursestringocclusionoftherectum,therectalmucosais incisedwithmonopolarcautery,followedbyfull-thickness circumferentialincisionoftherectalwall(Fig.21-4).Full-thicknessrectal andmesorectalmobilizationiscarriedoutusingmonopolarcautery,with effortstolimittheuseofbipolarenergytocontroltroublesomebleeding. Posteriormesorectaldissectionmustbecarriedoutalongtheavascular planebetweentheposteriormesorectumandpresacralfascia(Fig.21-5), andisusuallytheeasiesttoachievebecauseoftheeasilyidentifiable anatomiclandmarks.Thepresacralfascia,theshinymesorectalfascia andtheangelhairplaneinbetween,guidesthedissection.Caremustbe takentoavoiddissectiontooclosetothesacrumandinjurytothe presacralplexus.WesuggeststartingthetaTMEdissectionposteriorly andthenfollowingtheTMEplanelaterallyandanteriorly.Anteriorly, dissectioniscarriedoutbetweentherectovaginalfasciaorrectoprostatic fascia(Fig.21-6).Laterally,caremustbetakentoavoiddissectionofthe pelvicsidewallduringmesorectalmobilization,topreservethenervi erigente.Duringtheanterolateraldissectionoftherectumand mesorectum,caremustbetakentoavoidinjurytotheneurovascular bundlesbilaterally.Italsoservesasalandmarkforthelocationofthe prostate,ifdifficultiesareencounteredduringanteriormobilizationand identificationoftheposterioraspectoftheprostate.Itisimportantto emphasizethatdissectionshouldbecarriedoutcircumferentiallyandin asequentialpattern,andeveryeffortismadetoavoidunevendissection tocircumventplanedistortion,whichcandisorientandleadtheoperator astray.Ofnote,oneofthekeyadvantagesofthetransanalapproachisthe effectofthepneumorectum,whichdissectsavasculartissueplanes
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