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9 Total Abdominal Colectomy: Hand-Assisted Approach
Fig. 9.7 Mobilizing the
descending colon using
“lateral-to-medial” approach
107
Fig. 9.8 Taking down the
splenic fl exure by cupping both
the descending and transverse
colon in the palm and gently
retracting them caudally
obtained by pushing the operative fi eld, not by pulling back
the laparoscope (Video 9.4 ). In order to accomplish this
effectively, you must ensure you have adequate mobilization
to avoid tearing of the often-fragile tissues.
The transverse colon is mobilized from the duodenum
with blunt dissection using the 2nd fi nger and tip of
LigaSure™ device. The hepatic fl exure is then mobilized by
dissecting the hepato-colonic ligament. The dissection is
extended caudal and lateral to the ascending colon, till it
meets with the plane made previously at Step 1. The colonic
mobilization is completed when the cecum is freed and
secured in the surgeon’s palm.
Step 3. Mesenteric Division Under HALS
9.11 )
(Fig.
The mesenteric division is performed again in a counterclockwise fashion (from the left side to the right side). Using
the “palm-up” technique, the fi ngers are inserted onto the
108
K. Nakajima et al.
Fig. 9.9 Taking down the omentum from the transverse colon, using 2nd and 3rd fi ngers to pinch the omentum and 4th fi nger to displace the
transverse colon
Fig. 9.10 The concept of “move-the-ground” technique
colonic mesentery behind the descending colon (Fig. 9.12 ).
The mesentery is thus stretched laterally and is easily divided
with LigaSure™ device just proximal to the marginal vessels. All major colonic arteries should be positively palpated
with 1st and 2nd fi ngers and then sealed with LigaSure™
device.
As the division reaches to the transverse mesocolon, the
small-bowel loops escape from the mesenteric window and
might compromise surgical exposure. This can be prevented
by “palm-up” technique: the mesentery is pushed up with
2nd and 3rd fi ngers, while the small bowel is pushed down
with the dorsal surface of the hand (Fig. 9.13 ). Again, the use
of “move-the-ground” technique should be considered when
the directions of LigaSure™ device and dissecting line are
not matched. The entire abdominal colon is freed in the peri-
Fig. 9.11 Step 3 (mesenteric division under HALS)
toneal cavity when division of the right mesocolon is completed. If the small bowel continues to be a hindrance to clear
visualization, changing the position of the patient during this
step is often helpful.
Step 4. Resection, Specimen Extraction, and/or Anastomosis
The hand-access device is opened, and the abdominal colon
is exteriorized. Additional mobilization/division can be performed under direct vision when necessitated. The distal
colon is then staple transected at the level of the sacral promontory (Fig.
tomosis is completed in a usual fashion.
9.14 ). Brooke end ileostomy or ileorectal anas-
9 Total Abdominal Colectomy: Hand-Assisted Approach
Fig. 9.12 The mesenteric
division using “palm-up”
technique. The 2nd to 4th fi ngers
are inserted underneath the
mobilized colon, to stretch the
mesocolon laterally
Fig. 9.13 Dividing transverse
mesocolon using “palm-up”
technique. The small-bowel loops
are displaced from the operative
fi led using the dorsal surface of
the hand
109
Fig. 9.14 The remainder of mesenteric division is completed under
direct vision
Special Considerations
Theoretically HALS is suitable for operations that require
minilaparotomy for completion [ 1 , 2 ]. The recovery of
tactile sense further contributes to better exposure, easier
identifi cation of anatomy, and rapid control of bleeding.
HALS thus has been increasingly accepted as practical
alternative to straight laparoscopy for complex and extensive colorectal operations such as TAC. Several previous
studies including ours have suggested that HALS reduces
operative times of TAC, while retaining acceptable morbidity rates and recovery benefi ts of minimally invasive
surgery [
tile feedback can only be enjoyed by the operating surgeon, whereas the other members have to assist him/her
only through conventional laparoscopic visual cues [
1 , 2 , 4 , 7 ].
HALS is virtually a “solo surgery,” since regained tac-
2 ].
110
To make HALS procedure most effective and safe, the
operating surgeon should deliver his/her sense of palpation verbally to other surgical crew, making timely orientation and understanding possible. The authors believe
HALS is not a simple “bridge” for novice, but should be
performed by experienced surgeon, since abundant experience and profound understanding with both open and
laparoscopic surgery is necessary to give adequate feedback for coordinate performance of the surgical members
during the procedure.
Summary
HALS provides many things to surgeons, e.g., tactile
sensation, gentle tissue handling, blunt dissection, and
rapid hemostasis. Though these are the “lost items” in the
straight laparoscopic era, they are very helpful in performing complex and extensive colorectal procedures
such as TAC.
K. Nakajima et al.
References
1. Nakajima K, Lee SW, Cocilovo C, Foglia C, Sonoda T, Milsom
JW. Laparoscopic total colectomy: hand-assisted vs standard
technique. Surg Endosc. 2004;18:582–6.
2. Nakajima K, Nezu R, Hirota M, Nishida T. The role of hand-assisted
laparoscopic surgery in subtotal/total colectomy for Crohn’s colitis.
Surg Endosc. 2010;24:2713–7.
3. Fichera A, McCormack R, Rubin MA, Hurst RD, Michelassi
F. Long-term outcome of surgically treated Crohn’s colitis: a prospective study. Dis Colon Rectum. 2005;48:963–9.
4. Marcello PW, Fleshman JW, Milsom JW, Read TE, Arnell TD,
Birnbaum EH, Feingold DL, Lee SW, Mutch MG, Sonoda T, Yan Y,
Whelan RL. Hand-assisted laparoscopic vs. laparoscopic colorectal
surgery: a multicenter, prospective, randomized trial. Dis Colon
Rectum. 2008;51:818–26.
5. Nakajima K, Lee SW, Cocilovo C, Foglia C, Sonoda T, Milsom
JW. Hand-assisted laparoscopic colorectal surgery using GelPort.
Surg Endosc. 2004;18:102–5.
6. Nakajima K, Nezu R, Ito T, Nishida T. Hand-assisted laparoscopic
restorative proctocolectomy for ulcerative colitis: optimization of
instrumentation towards standardization. Surg Today. 2010;40:840–4.
7. Wilhelm TJ, Refeidi A, Palma P, Neufang T, Post S. Hand-assisted
laparoscopic sigmoid resection for diverticular disease: 100 consecutive cases. Surg Endosc. 2006;20:477–81.
Operative Details of Laparoscopic Rectal Resection for Cancer
Martin R. Weiser
10
K e y P o i n t s
• Preoperative considerations in the setting of rectal cancer
are extensive. Meticulous evaluation of the patient before
surgery will help identify potentially diffi cult aspects of
the operation.
• Proper radiographic imaging can demonstrate the local
extent of the tumor, facilitating a detailed operative plan.
• The single most important factor in optimizing outcomes
is complete excision of the tumor with negative macroscopic and microscopic margins.
• Total mesorectal excision (TME) for malignancy involves
sharp dissection in relatively avascular planes under direct
visualization.
Introduction
Surgical therapy for rectal cancer encompasses several different operations, ranging from local excision or TEM/
TAMIS to total mesorectal excision (TME) and abdominal
perineal resection. In properly selected patients, each can
provide standard of care for oncologic resection of rectal
cancer. A laparoscopic approach to rectal lesions, which is
the focus of this chapter, offers an oncologically sound solution to a complex problem, with the added benefi ts witnessed
in other minimally invasive procedures. When performed by
experienced surgeons facile in the laparoscopic TME technique, the potential morbidity associated with radical surgery (including major medical complications, impaired
sexual and urinary function, wound problems, and the need
for a permanent stoma) is in large part reduced compared to
an open approach. With the proper selection of appropriate
candidates, laparoscopic proctectomy stands as a useful and
valuable tool in the surgeon’s armamentarium.
Indications
Benign, premalignant, and cancerous lesions of the rectum
involving the various layers of the rectal wall may be
removed via a laparoscopic approach. This technique
depends in part upon accurate preoperative staging to
avoid inadequate resection of more advanced lesions (i.e.,
T4). Endorectal ultrasound has reported rates of up to
90 % accuracy for determining tumor depth of penetration,
along with sensitivity rates of 60–70 % and specifi city
rates of 70–80 % for nodal metastases. Similarly, MRI is
associated with accuracy rates of up to 85 % for primary
rectal wall involvement, nodal sensitivity rates of 60–70 %,
and specifi city rates of 70–80 % [ 1 ]. In general, radical
resection offers lower recurrence rates when compared to
local excision [ 2 ]. This is especially true for T2 tumors,
where local recurrence has been cited to be as high as 47 %
after standard transanal excision. Similarly, lesions possessing poor prognostic risk factors, such as lymphovascular invasion (LVI), poor differentiation, tumor budding,
and mucinous or signet cell adenocarcinoma, should typically be resected with a standard TME [ 3 ].
Patient Preparation
Electronic supplementary material: Supplementary material is
available in the online version of this chapter at
1581-1_10
com/videos/978-1-4939-1580-4
M. R. Weiser , M.D. (*)
Department of Surgery , Memorial Sloan Kettering Cancer Center ,
1275 York Avenue , New York , NY 10065 , USA
e-mail:
H.M. Ross et al. (eds.), Minimally Invasive Approaches to Colon and Rectal Disease: Technique and Best Practices,
DOI 10.1007/978-1-4939-1581-1_10, © Springer Science+Business Media New York 2015
. Videos can also be accessed at http://www.springerimages.
.
weiser1@mskcc.org
10.1007/978-1-4939-
Patients receive a full bowel preparation to allow for intraoperative endoscopy. Low molecular weight heparin is given in
the preoperative area, and antibiotics are administered within
an hour of incision. In the operating room, each calf is
wrapped in pneumatic compression stocking and then placed
in modifi ed lithotomy position, with legs in padded adjustable stirrups. The legs are positioned in a 20- to 25-degree
111
112
Fig. 10.1 Patient positioning.
With permission from Nakajima
K, Milsom JW, Böhm B. Patient
Preparation and Operating Room
Setup. In: Milsom JW, Böhm B,
Nakajima K, eds. Laparoscopic
Colorectal Surgery, 2nd ed.
Springer, New York 2006
M.R. Weiser
abducted position, with the thighs only minimally elevated
above the level of the abdomen; higher elevation may cause
the surgeon’s hands to collide with the thigh when mobilizing the splenic fl exure (Fig. 10.1 ). The patient is positioned
with the pelvis just above the break at the lower end of the
operating table. This facilitates free access to the perineum
for intraoperative endoscopy, pelvic manipulation, perineal
resection, or transanal anastomosis. A beanbag or other
securing device is used to help maintain position during table
rotation and tilt. The hands and arms are padded and tucked
at the patient’s sides. After the induction of general anesthesia, an indwelling ureteral catheter and orogastric tube are
inserted to decompress the bladder and reduce gastric
distension.
Operative Technique (Video 10.1 )
The author routinely utilizes the fi ve following ports: one
for the laparoscope, two for the operating surgeon, and two
for the assistant. A 10-mm infraumbilical port is initially
placed using an open technique. A balloon port—which
creates an airtight seal—is preferred, as this port is mostly
used for the camera. Five-millimeter ports are then placed
in the right upper, left upper, and left lower quadrants,
under direct laparoscopic vision. A 12-mm port is placed
in the right lower quadrant and ultimately utilized for
endoscopic stapling. A fascial suture (#0 Vicryl) is placed
at the 12-mm stapling port site, using a suture passing
technique for fascial closure at the end of the case. All
ports are placed at least 8 cm apart on each side to prevent the instrument shafts from crossing each other. I
generally use three monitors; however, two monitors are
sufficient. One monitor is placed at the patient’s left leg
and can swing to the left shoulder during splenic fl exure
mobilization; the other monitor is placed on the right and
can be maneuvered between the patient’s legs for pelvic
dissection (Fig. 10.2 ).
Surgeon, Assistant, and Nurse Positioning
Depending on the operative step, all team members will
stand in varying positions. It is important to adapt the position based on the patient’s body habitus and the particular
step of the operation, to maximize ergonomics. For dissection
of the mesocolon and mobilization of the splenic fl exure, the
surgeon and second assistant (camera person) stand on
the patient’s right side, and the fi rst assistant stands on the
patient’s left. The nurse is positioned at the patient’s left leg.
For mesocolon dissection, the surgeon views the monitor
positioned near the patient’s leg. For splenic fl exure mobilization, the second assistant moves between the patient’s legs;
all team members look at the left-sided monitor, which is
repositioned to the patient’s left shoulder. For pelvic dissection, the surgeon and second assistant stand on the patient’s
right side, and the fi rst assistant stands on the left side. All
team members view the monitor between the patient’s legs.
Dissection of the Mesocolon and Vascular Pedicle
Following initial inspection of the peritoneal cavity, including liver, omentum, and pelvis, the patient is positioned in
Trendelenburg for dissection of the mesocolon and vascular
pedicle. The omentum is placed superiorly above the colon
and onto the liver. The patient is tilted right-side down; this
allows placement of the small intestine in the right upper
quadrant, out of the area of dissection. Using 5-mm bowel
10 Operative Details of Laparoscopic Rectal Resection for Cancer
113
Fig. 10.2 One monitor is placed at the patient’s left leg and can swing
to the left shoulder during splenic fl exure mobilization; the other monitor is placed on the right and can be maneuvered between the patient’s
graspers through the left-sided cannulas, the assistant
holds the sigmoid ventrally under traction and to the left.
In a medial to lateral fashion, the inferior mesenteric artery
(IMA) is identifi ed and the retroperitoneum is incised, starting at the sacral promontory to the right of (i.e., under) the
vessel. Dissection is continued in a cephalad direction to the
base of the IMA. Using gentle blunt dissection, the mesentery is dissected off the retroperitoneum. Dissection proceeds
adjacent to and just below the IMA, which is swept ventrally,
to ensure that the preaortic hypogastric sympathetic nerves
are preserved and swept dorsally. Dissection beneath the
mesentery is continued laterally, until the left ureter and
gonadal vessels are identifi ed and swept posteriorly. Once
the origin of the IMA is identifi ed, the peritoneum is incised
anteriorly over the pedicle and away from the left colic
artery. A peritoneal window is made just lateral to the inferior mesenteric vein (IMV). This permits ligation of the IMA
legs for pelvic dissection. With permission from Memorial Sloan
Kettering Cancer Center
and IMV pedicle, generally distal to the left colic artery
10.3 ). We employ a bipolar device for vascular ligation,
(Fig.
but occasionally use endoscopic staplers or clips. Care is
taken to revisualize the left ureter before ligation and division of the IMA and IMV.
Splenic Flexure and Left Colon Mobilization
The second phase of the procedure is left colon mobilization.
Through the peritoneal window, the left mesocolon is bluntly
dissected from the underlying retroperitoneal structures,
including the gonadal vessels, ureter, Gerota’s fascia, and
pancreas (Fig.
sary, the sub mesenteric dissection is continued until the
spleen is visible and the lesser sac is entered. This can also be
performed in a medial to lateral fashion by dissection just
10.4 ). If splenic fl exure mobilization is neces-
114
under the IMV adjacent to the ligament of Treitz and the
pancreas. The IMV is divided adjacent to the pancreas,
before it joins the splenic vein to form the portal vein. This
enables full mobilization of the left colon and mesentery.
The greater omentum is then freed from the transverse colon
edge toward the midline, as far as necessary, to allow the
descending colon to reach to the pelvis. The left colon is then
mobilized by sharply dividing the lateral peritoneal attachments along the white line of Toldt (Fig.
10.5 ).
After the mobilization of the left colon, the sigmoid
mesocolon is divided to the appropriate area of the colon;
this will become the proximal resection line. The colon is
transected at this level with an endoscopic stapler (Fig. 10.6 ).
Fig. 10.3 A peritoneal window is made just lateral to the inferior mesenteric vein (IMV), permitting ligation of the IMA and IMV pedicle.
With permission from Memorial Sloan Kettering Cancer Center
M.R. Weiser
Pelvic Dissection
The next phase of the operation is mesocolic dissection. The
surgeon moves back to the right side of the table. The goal is
to completely remove the rectum with an intact mesorectum,
without injuring the pelvic autonomic nerves. The peritoneum is incised along both sides of the rectum down to and
around the anterior peritoneal refl ection. The dissection is
initiated posterior to the rectum, at the level of the sacral
promontory. The plane between the parietal and visceral layers of the endopelvic fascia is dissected sharply with cautery.
Care is taken to immediately identify the hypogastric nerves
as they travel anterolaterally across the aortic bifurcation,
approximately 2 cm medial to the ureters bilaterally.
Dissection along the visceral peritoneum (fascia propria of
the rectum) will maintain the plane of dissection above the
hypogastric nerves and avoid injury to these structures.
Dissection continues posterolaterally until the junction of
the mesorectum and pelvic autonomic nerve plexus is
encountered. This area is referred to as the lateral rectal
stalks, and care is taken to maintain sharp dissection along
the mesorectum to avoid parasympathetic nerve injury
(Fig.
10.7 ). The area of dissection may contain small blood
vessels emanating from the pelvic sidewall, which can generally be well controlled with cautery or—rarely—bipolar.
The surgeon must be wary of straying into the pelvic sidewall, as this can result in substantial bleeding and nerve
injury. The area of dissection is enhanced using the laparoscope, because of the magnifi cation it provides. Inferior to
the level of S3, the rectosacral ligament (Waldeyer’s fascia)
is divided sharply with cautery or bipolar. Blunt dissection
Fig. 10.4 Medial dissection.
( To p ): an avascular plane exits
between Toldt’s fascia and the
mesocolon, which is briefl y
dissected medial to lateral after
IMA and IMV ligation. ( Bottom ):
medial to lateral dissection
beneath the left mesocolon
provides excellent views of the
distal pancreas (P), the base of
the left transverse mesocolon and
retroperitoneum. With permission
from: Leroy J, Henri M, Rubino
F, Marescaux J. Sigmoidectomy.
In: Milsom JW, Böhm B,
Nakajima K, eds. Laparoscopic
Colorectal Surgery, 2nd ed.
Springer, New York 2006
10 Operative Details of Laparoscopic Rectal Resection for Cancer
115
Fig. 10.5 Mobilization of the left colon is achieved by sharply dividing
the lateral peritoneal attachments along the white line of Toldt. With
permission from Memorial Sloan Kettering Cancer Center
Fig. 10.7 Dissection posterolaterally to the junction of the mesorectum and pelvic autonomic nerve plexus. This area is referred to as the
lateral rectal stalks, and care is taken to maintain sharp dissection along
the mesorectum to avoid parasympathetic nerve injury. With permission
from Memorial Sloan Kettering Cancer Center
Fig. 10.6 Division of the sigmoid. ( Top ): proximal bowel division is per-
formed after dividing the mesocolon up to the chosen site. ( Bottom ):
specimen extraction at the suprapubic site involves double protection: (1)
wound protector. With permission from: Leroy J, Henri M, Rubino F,
Marescaux J. Sigmoidectomy. In: Milsom JW, Böhm B, Nakajima K, eds.
Laparoscopic Colorectal Surgery, 2nd ed. Springer, New York 2006
should be avoided to prevent tearing into the mesorectum or
presacral fascia and injuring the presacral venous plexus.
The angle of dissection follows the curves of the sacrum,
proceeding in an anterior direction to the pelvic fl oor.
Anterior dissection of the peritoneum in the pouch of
Douglas is usually performed last. For anterior tumors in
male patients, dissection is anterior to Denonvilliers’ fascia,
exposing the seminal vesicles bilaterally (Fig.
10.8 ).
In female patients, dissection occurs in the rectovaginal
septum. Anterior elevation of the vagina, by an assistant
holding a sponge stick in the vaginal vault, helps provide
appropriate tissue tension for dissection.
Fig. 10.8 Denonvilliers’ fascia
The precise point of distal resection is determined by sigmoidoscopy, which is performed at the time of resection.
The proximal bowel is closed with a laparoscopic bowel
clamp, and a fl exible sigmoidoscope/proctoscope locates the
116
M.R. Weiser
Fig. 10.9 Before stapling, the rectum is occluded below the level of the
tumor, and the distal rectum is irrigated with saline. With permission
from Memorial Sloan Kettering Cancer Center
lesion. By transillumination or palpation of the sigmoidoscope with a laparoscopic instrument, the lower edge of the
tumor in the rectum is identifi ed.
Division of the Rectum (Video 10.2 )
The rectum is then divided at least 2 cm below the mid- and
distal lesions and 5 cm below upper rectal lesions. If the pelvis is wide, an endoscopic stapler can be used under laparoscopic guidance to divide the rectum. Before stapling, the
rectum is occluded below the level of the tumor, and the distal rectum is irrigated with saline (Fig. 10.9 ). A laparoscopic
stapler is then deployed below the clamp on the bowel. After
enlarging the port site and placing a wound protector, the
specimen is usually removed at the umbilicus.
In the case of a narrow pelvis in which the endoscopic stapler
cannot be properly positioned, a low transverse incision with a
wound protector is usually employed. The rectum is occluded,
irrigated, stapled, and divided using an open technique.
Colorectal/Coloanal Anastomosis
The fi nal stage of the operation is the creation of an end-toend anastomosis with a circular stapler. If a low transverse
incision is utilized, the anastomosis can be performed using
an open technique. If the distal rectum was successfully stapled laparoscopically, the anastomosis is performed laparoscopically. The mobilized descending colon is delivered
through either the enlarged umbilical port site or the low
transverse incision (Fig. 10.10a ). The anvil of the circular
stapler is then placed into the descending colon lumen, and a
purse-string is tied around the center rod in the usual manner
(Fig.
10.10b ). The proximal bowel is then returned to the
peritoneal cavity, and the abdominal wall is closed by occluding the wound protector. Pneumoperitoneum is reestablished;
the shaft of the stapler is brought to the stapled end of the
rectum, and the pin is advanced through the rectal wall. The
groove in the center rod is held with an endoscopic clamp
through the right lower quadrant cannula and by locking the
center rod into the center post of the circular stapler
(Fig. 10.11 ). This locking action requires that the axes of the
center rod and the center post be in a perfect line. Because the
center rod protruding from the proximal colon is grasped with
an instrument from the right lower quadrant, its tip will be
slightly directed to the right side of the pelvis. Thus, the circular stapler head should be directed slightly to the left side.
After deploying the stapler, it is removed, and the tissue rings
are inspected. The anastomosis is tested for leaks by fi lling
the pelvis with saline, occluding the left colon, and insuffl ating air into the rectum via a proctoscope (Fig. 10.12 ). The
anastomosis is visualized for completeness and hemostasis.
When performing ultralow coloanal anastomosis with
intersphincteric dissection, the specimen is removed via the
perineum. The descending colon is then divided at the level
of the anal canal in preparation for a hand-sewn reconstruction. Full thickness colon is secured to the mucosa of the anal
canal, with the incorporation of muscle with interrupted
suture in a single layer technique.
A loop ileostomy is placed in patients with coloanal
anastomosis who have received preoperative chemoradiation.
This can be performed with laparoscopic assistance. It is
placed in the right lower quadrant, at a site ideally marked by
an enterostomal nurse preoperatively. A fl at drain is passed
through the 5-mm right upper quadrant cannula and guided
into the pelvis with a bowel grasper.
Pearls and Pitfalls
• When starting the dissection at the sacral promontory,
ensure that you have all of the redundant sigmoid colon
out of the pelvis. This will help you identify the IMA and
avoid getting in the wrong plane.
• When performing a medial approach to the left colon,
avoid tunneling after scoring the mesentery underneath
the IMA. Keep a broad plane of dissection as you work
toward the base of the IMA to allow for maximal visual-
ization and safe dissection.
• Dissection, aside from dealing with the major vascular
pedicles, should be relatively avascular. If you encounter
moderate-signifi cant bleeding, you are likely in the wrong
plane and need to stop and reassess.
• Applying perineal pressure will push the pelvic fl oor
superiorly and can aid in dissection.