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41 TaTME forAbdominoperineal Excision
421
Operative Procedure
A multimedia manuscript demonstrating our
technique for TpAPE has been published previously [5]. After positioning, the operation commences with a circumferential skin incision
around the anus, with appropriate margins away
from the tumor. Subcutaneous fat tissue is divided
using electrocautery so that the ring portion of
the GelPOINT-mini® device can be accurately
placed. When the skin incision becomes large
enough, a purse-string suture is applied, which is
benecial to prevent air leakage during surgery
(Fig. 41.3). Following the xation of the
GelPOINT-mini device, pneumoperitoneum is
maintained at 8–12 mmHg, and division of the
subcutaneous and ischioanal fat is performed
(Fig.41.4).
One can choose from among several dissection planes depending on the extent of tumor
invasion. This includes the intersphincteric, the
extralevator, or the ischioanal planes (Fig.41.5).
The tip of the coccyx is identied, and the levator
ani is widely exposed bilaterally (Fig.41.6). The
levator ani is divided posteriorly just anterior to
the tip of the coccyx. The hiatal ligament, a white
brous tissue connecting the coccyx and the rectum, is divided with special care so it does not
migrate into the mesorectum or posterior rectal
wall. Once the mesorectal plane is identied,
division of the levator muscle is extended bilaterally, and the endopelvic fascia covering the levator ani is also divided to enter the mesorectal
plane (Fig.41.7).
Posterior dissection is continued until this
plane is connected with the laparoscopic dissection. The level of division of the levator muscle
can be determined at the surgeon’s discretion,
mainly depending on the extent of tumor invasion. Here, the roots of the pelvic splanchnic
nerves are identied bilaterally, and special care
is taken to avoid injury to the autonomic nerves
of the pelvis (Fig.41.8).
Next, the anterior dissection is addressed. The
anterior dissection is more difcult in male
patients than in female patients because there is
the potential risk of urethral injury in males.
Therefore, we describe here the dissection in
male patients. The transverse perineal muscle is
an important landmark as it divides the anterior
c d
Fig. 41.3 Skin incision to GelPOINT placement. (a)
Skin incision can be minimal when skin is spared from
tumor invasion. (b) Subcutaneous fat is divided to some
extent to place the GelPOINT device. (c) Purse-string
suture is useful to keep the surgical eld air-tight. (d)
GelPOINT® placement
422
cd
Modified form Holm et al. Surg OncolClinN Am. 2014
S. Hasegawa et al.
a b
IRA
ACL
Fig. 41.4 Division of the ischioanal fat. (a) Left side. (b) Right side (IRA inferior rectal artery). (c) Posterior side
(ACL ano-coccygeal ligament). (d) Anterior side
Fig. 41.5 Perineal
dissection planes in
APE. (a) Ischioanal
APE. (b) Extralevator
APE. (c) Intersphincteric
APE. (Modied form
Holm etal. [7])
c)
a)
urogenital area and the posterior anorectal area.
We dissect just behind the transverse perineal
muscle, and here the bilateral puborectal sling,
which is oriented along the posterior-anterior
axis, is identied. There is no clear anatomical
b)
landmark at this point to divide the puborectalis
and levator ani muscles. The dissection line
should thus be determined based on the extent of
tumor inltration, from extralevator resection to
standard resection (Figs.41.9 and 41.10).
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cd
41 TaTME forAbdominoperineal Excision
LA
423
LA
TP
EAS
Fig. 41.6 Exposure of the levator ani muscle and
puborectal muscle. (a) Left side (LA levator ani). (b)
Right side (LA levator ani). (c) Anterior side (TP trans-
HL
MR
verse perineal muscle, EA external anal sphincter). (d)
Posterior side (PR puborectal muscle). Blue marker indicates the tip of the coccyx
LA
PR
MR
MR
PSN
EPF
Fig. 41.7 Division of the levator ani muscle and entering
into the posterior TME plane. (a) Division of the levator
muscle (HL hiatal ligament). (b) Exposure of the posterior
mesorectum (MR) (LA levator ani muscle). (c) Posterior
mesorectal dissection (MR mesorectum, EPF endopelvic
fascia). (d) Identication of the bilateral pelvic splanchnic
nerves (PSN) (MR mesorectum)
424
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cd
ab
cd
S. Hasegawa et al.
PSN
Fig. 41.8 Lateral extension of the dissection plane. (a)
Connection of the dissection plane with laparoscopic
team. (b) Extension of the division of the levator ani mus-
TP
LA
PSN
MR
cle (LA) to right side (MR mesorectum). (c) Dissection
between mesorectum and left pelvic splanchnic nerve
(PSN). (d) Dissection between mesorectum and right pelvic splanchnic nerve (PSN)
RUM
PR PR
PR
LA
Fig. 41.9 Right anterior-lateral dissection. (a) Surgical
eld after division of behind the transverse perineal muscle. (b) Division of the right puborectal sling (PR). (c)
Division of the right puborectal sling (PR) and levator ani
muscle (LA). (d) Surgical eld after division of the levator
ani muscle (LA) (EPF endopelvic fascia, MRA middle
PR
LA
EPF
MRA
MR
rectal artery, MR mesorectum)
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41 TaTME forAbdominoperineal Excision
425
RUM
LA
Fig. 41.10 Left anterior-lateral dissection. (a) Division
of the left puborectal sling (PR) (RUM rectourethral muscle). (b) Left puborectal sling (PR) and levator ani muscle
(LA). (c) Laparoscopic assistance (right upper window) is
helpful for better exposure and identication of the anat-
PR
SV
MR
Once the puborectal muscle sling is divided,
the perineal body or rectourethral muscle, which
MR
omy (LA levator ani muscle, MR mesorectum, SV seminal vesicle). (d) After division of the levator ani muscle
(LA), dissection between neurovascular bundle (NVB)
and mesorectum is performed under laparoscopic assistance (SV seminal vesicle)
specimen is extracted from below, and a permanent sigmoid colostomy is fashioned.
PR
LA
SV
LA
contains abundant smooth muscle bers and
brous connective tissue, is encountered. There
is no clear anatomical landmark here, and special
care should be taken not to injure the urethra,
How toAvoid Urethral Injury During
TpAPE
neurovascular bundle, and prostate (see “How to
avoid urethral injury” below). Laparoscopic
assistance to identify the contour of the prostate
is benecial to ensure safe and adequate dissection in this area (Fig.41.10). When the apex of
the prostate is identied, the following step is
almost identical with that of TaTME. Here, the
dissection plane is easy to distinguish between
the prostate and the rectum.
Dissection is widely commenced cranially
and connected to the space with laparoscopic
dissection. Finally, bilateral mesorectal dissection between the mesorectum and pelvic autonomic nerves is performed with the assistance
of the laparoscopic team (Figs. 41.11 and
41.12). The sigmoid mesentery and sigmoid
colon are divided laparoscopically. The resected
Urethral injury is a very important and serious
complication of this procedure. For male patients,
the risk of urethral injury is likely increased in
TpAPE procedures as compared with TaTME
because the dissection plane easily goes more
toward the lateral side of the prostate as compared with TaTME. Several methods have been
proposed to prevent this serious complication,
such as urethral lighted stent placement,
intraoperative ultrasonography, and stereotactic
navigation [6]. The key anatomic consideration
around this area is identication of the apex of
the prostate. Assistance with the laparoscopic
approach helps to predict the contour of the prostate even if it is just the level of the upper border
of the prostate.
NVB
MR
426
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cd
S. Hasegawa et al.
RUM
Pr
Pr
NVB
MR
Fig. 41.11 Dissection of the rectourethral muscle and
right neurovascular bundle. (a) Dissection between mesorectum and inferior part of the prostate (Pr). Rectourethral
muscle (RUM) can be identied as longitudinal whitish
a
RUM
Pr
NVB
MR
NVB
bers. (b) Division of the rectourethral muscle (RUM) (Pr
prostate). (c) Dissection between right neurovascular bundle (NVB) and mesorectum (MR). (d) Finally, right lateral attachment is divided, and TpAPE is completed
(NVB neurovascular bundle, MR mesorectum)
b
c
Fig. 41.12 Surgical eld after specimen extraction. (a) Transanal view. (b) Transanal view. (c) Laparoscopic view. (d)
Resected specimen
d
41 TaTME forAbdominoperineal Excision
427
Dissection Along theRectovaginal
Septum
For female patients, at the anterior aspect, the
perineal body can be divided under direct vision
at the most inferior part of the vagina, where
there is no clear dissection plane, under the guidance of digital examination and tactile feedback.
Once a clear dissection plane between the posterior vaginal wall and rectum is identied, it is
relatively easy to maintain this plane toward perineal reection. This can be assisted by tactile
feedback through digital palpation of the vaginal
vault during the process of dissection.
Pros andCons ofTpAPE
Pros
• Good exposure of the surgical eld, especially
along the anterior aspect.
• No air leakage when combined with the lapa-
roscopic approach.
• Skin incision can be minimized if perianal
skin is spared from tumor invasion.
• Operative time could be reduced with the two-
team approach.
Cons
• Because the surgical anatomy around the anal
canal is relatively complex, it is difcult to
identify an appropriate dissection line at the
anterior side, despite good visibility.
• Extra cost and resources are required for the
transperineal procedure.
References
1. Simillis C, Baird DL, Kontovounisios C, etal. A sys-
tematic review to assess resection margin status after
abdominoperineal excision and pelvic exenteration
for rectal cancer. Ann Surg. 2017;265:291–9.
2. den Dulk M, Putter H, Collette L, etal. The abdomi-
noperineal resection itself is associated with an
adverse outcome: the European experience based on a
pooled analysis of ve European randomised clinical
trials on rectal cancer. Eur J Cancer (Oxford, England:
1990). 2009;45:1175–83.
3. Martijnse IS, Dudink RL, West NP, et al. Focus on
extralevator perineal dissection in supine position
for low rectal cancer has led to better quality of
surgery and oncologic outcome. Ann Surg Oncol.
2012;19:786–93.
4. Palter VN, MacLellan S, Ashamalla S.Laparoscopic
translevator approach to abdominoperineal resection
for rectal adenocarcinoma: feasibility and short-term
oncologic outcomes. Surg Endosc. 2016;30:3001–6.
5. Hasegawa S, Okada T, Hida K, Kawada K, Sakai
Y. Transperineal minimally invasive approach for
extralevator abdominoperineal excision. Surg Endosc.
2016;30:4620–1.
6. Atallah S, Mabardy A, Volpato AP, Chin T, Sneider
J, Monson JRT. Surgery beyond the visible light
spectrum: theoretical and applied methods for
localization of the male urethra during transanal total mesorectal excision. Tech Coloproctol.
2017;21:413–24.
7. Holm T. Controversies in abdominoperineal excision.
Surg Oncol Clin N Am. 2014;23(1):93–111.
Hartmann’s Reversal
by a Combined TransanalTransabdominal Approach
Jean-Sébastien Trépanier, F. Borja de Lacy,
and Antonio M. Lacy
42
Introduction
Henri Hartmann rst described his eponymous
operation in 1921 at the 30th Congress of the
French Surgical Association [1]. It was initially
proposed for the treatment of rectal cancer, in an
attempt to lower the morbidity associated with
the abdominoperineal resection, developed by
William Ernest Miles at the beginning of the
twentieth century. Nowadays, the Hartmann’s
procedure is still commonly performed in various
benign and malignant conditions and both in
elective and emergent settings. After this operation, many patients will never undergo colostomy
closure (or Hartmann’s reversal– HR). In the literature, closure rates range between 28% and
60% [2, 3]. Restoring intestinal continuity is
often a technically challenging operation and has
signicant risks of mortality and morbidity,
respectively, up to 10% and 50% [3]. Quality of
life is often impaired in patients with a colostomy
J.-S. Trépanier (*)
Maisonneuve-Rosemont Hospital, General Surgery
Department, Montréal, Québec, Canada
e-mail: js.trepanier@umontreal.ca
https://www.aischannel.com
F. B. deLacy · A. M. Lacy
Gastrointestinal Surgery Department, Hospital Clinic,
University of Barcelona, Barcelona, Spain
e-mail: bdelacy@aischannel.com;
amlacy@aischannel.com
https://www.aischannel.com
for various reasons, and it could be improved
with a Hartmann’s reversal [4].
Interest in minimally invasive surgery (MIS)
has grown signicantly in the last decades and is
justied by diminished surgical trauma, resulting
in better outcomes for many patients who undergo
colorectal procedures. Thus, laparoscopic
approaches for reversal of Hartmann’s procedure
using multiport or single-port congurations
have been attempted [5–9]. They were shown to
be safe in trained hands and are associated with
faster postoperative recovery and fewer complications based on recent publications [10–14]. In
2014, a robotic approach to HR was described as
a case report [15].
Even with these different MIS approaches,
HR remains a challenging operation. The rates of
laparoscopic HR remain low (17.6%) according
to a study of the ACS-NSQIP data [16]. When a
laparoscopic approach is chosen, the conversion
rates to an open procedure are as high as 50%
[17]. Conicting data regarding the benets of
laparoscopy for HR was demonstrated by a recent
retrospective study of 276 patients: it failed to
demonstrate a difference regarding the length of
stay and complication rate [18]. Therefore, the
search for a different approach for HR remains
pertinent.
With the rapid development of advanced trans-
anal procedures, from transanal endoscopic
microsurgery (TEM) [19, 20] to transanal minimally invasive surgery (TAMIS) [21], and more
© Springer Nature Switzerland AG 2019
S. Atallah (ed.), Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal
Excision (taTME), https://doi.org/10.1007/978-3-030-11572-2_42
429
430
J.-S. Trépanier et al.
recently transanal total mesorectal excision
(taTME) [22–24], sound prociency in dissection
from a bottom-up approach was gained by various
surgeons around the world. In selected cases
where visualization from a transanal standpoint
would be deemed helpful, a combined transanallaparoscopic transabdominal Hartmann’s reversal
(taHR) was proposed as another approach. It has
been previously described by Dr. Antonio Lacy’s
team [25–27]. To date, it remains experimental. It
should be reserved to medical centers with thorough expertise in transanal surgery.
The expected advantages of this approach
include (a) transanal dissection through intact,
virgin planes, (b) improved ability to localize the
rectal stump (especially when short and covered
by peritoneum), (c) optimal visualization during
surgery in a narrow pelvis, and, nally, (d) the
advantage of performing a double purse- string
single-stapled anastomosis with rectal tissues
free of brosis or staple lines. This chapter is
intended to describe taHR and share various technical tips and pitfalls.
Preoperative Planning
ation is crucial for proper planning. Also, reoperative pelvic surgery can place the ureters at risk for
injury; therefore, consideration for preoperative
placement of ureteral stents should be given.
Operative Setup
For the taHR, we favor a two-team approach. It
allows for performance of the procedure with
assistance of a second team for plane dissection
using the two points of view. Thus, two complete
teams are operating simultaneously; each one
includes a surgeon, one or two assistants, a scrub
nurse, and a dedicated set of instruments.
Technique Description (Table 42.1)
taHR: Abdominal Aspects
Whenever possible, a laparoscopic approach is
favored for the abdominal portion of the taHR
operation. It should start with the colostomy takedown, placement of a single-port platform in the
Patients should be well informed on the innovative
aspect of this approach for intestinal continuity
reconstruction. Also, it is our opinion that every case
should be included in a prospective registry to measure outcomes, and, ideally, patients should be part of
a study protocol with internal review board approval.
Preoperatively, all patients are evaluated by
digital rectal examination and endoscopy of both
their rectal remnant and proximal colon. A contrast enema of the rectal stump is also performed
to measure its length and visualize its position in
the pelvis. Pre-colostomy, baseline anorectal
function is determined before proceeding, to provide realistic expectations of functional outcomes
after reconstruction and to exclude candidates for
whom HR would result in a poor quality of life. A
combined transanal-transabdominal approach is
considered when the rectal stump appears short
(less than 15cm). Knowledge of the indications
for which the initial Hartmann’s procedure was
performed and the circumstances of the rst oper-
Table 42.1 Steps of a taHR
Abdominal steps Transanal steps
1. Colostomy takedown. 1. Placement of the exible
2. Placement of an EEA
stapler anvil in the
proximal colon.
3. Single-port device in
stoma site.
4. Pneumoperitoneum. 4. Rectotomy.
5. Placement of trocars. 5. Dissection and
6. Lysis of adhesions. 6. Purse string on the open
7. Mobilization of the left
colon and splenic
exure.
8. Identication of the
rectal stump if
possible.
9. Anastomosis under
laparoscopic guidance.
transanal platform.
2. Evaluation of the rectal
stump.
3. Choice of the site
of rectotomy and
mucosa tattooing.
rendezvous. Extraction
of the resected portion
of rectal stump.
rectal stump.
7. Tying of the purse string
on the EEA anvil.
8. Double purse-string
single-stapled
anastomosis.
42 Hartmann’s Reversal by a Combined Transanal-Transabdominal Approach
431
colostomy site, and establishing pneumoperitoneum. The mucocutaneous junction is resected,
and a purse-string suture is performed on the colon
opening and tied around the anvil of an end-to-end
anastomosis stapler. The anvil is then delivered
back into the abdominal cavity. The platform is
secured in place at the former stoma site, and
pneumoperitoneum (set to 15mmHg) is created. A
5mm or ideally a 10mm 30° laparoscopic camera
is inserted through a trocar in the single-port platform, and the other trocars are then inserted under
direct vision as shown in Fig.42.1. Usually, some
degree of lysis of adhesions is necessary to allow
for safe placement of trocars. Often, the camera
trocar is placed more centrally and away from the
instruments trocars to avoid interference with their
movements. Alternatively, three trocars (or cannulas) can be introduced through the exible singleport platform in the colostomy wound to perform
a laparoscopic single-port abdominal dissection.
To allow for the performance of a tension-free
anastomosis, a mobilization of the left colon is
generally necessary. To gain signicant reach for
the proximal colon, a splenic exure takedown is
achieved if not previously done during the
Hartmann’s procedure.
Then, attention is directed toward the pelvis.
The rectal stump is often identied by blue polypropylene tag sutures placed during the Hartmann’s
procedure. If the rectal stump is long and easily
identiable, proceeding with a laparoscopic- only
HR is recommended. If the rectal stump is short or
there are many adhesions in the pelvis, the technique of taHR can be utilized.
taHR: Transanal Aspects
The transanal steps of taHR are similar to the
ones of a taTME.The main differences are that
with taHR, less importance is given to obtaining
a total mesorectal excision. In addition, the pursestring suture to occlude the lumen prior to the
rectotomy with taTME is a step that may be omitted during taHR.
Thus, the rst step for the transanal portion of
taHR is the positioning of the transanal platform.
We favor a exible (TAMIS) platform (Gelpoint
Path Transanal Access Platform; Applied Medical
Inc., Rancho Santa Margarita, CA) over a rigid
TEM platform (Fig.42.2). Then, we evaluate the
rectal stump under direct vision, looking for the
best suitable place for the anastomosis. Often, it is
Fig. 42.1 Proposed single-port platform and trocars
placement
Fig. 42.2 Transanal exible platform with an anal
retractor