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10 Operative Details of Laparoscopic Rectal Resection for Cancer
Fig. 10.10 Exteriorization. ( a , To p ): after specimen
extraction, the colon is drawn out through this site,
keeping the wound protector in place. ( b , Bottom ):
the anvil and center rod of the circular stapler are
introduced into the bowel lumen and secured with a
purse-string suture. 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
117
Fig. 10.11 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. With permission from
Memorial Sloan Kettering Cancer Center
Fig. 10.12 Air leak test
118
M.R. Weiser
Conclusion
A straight laparoscopic approach to rectal cancer can be
successfully utilized as the surgical procedure of choice by
those with appropriate expertise. While this approach can be
technically demanding and requires advanced laparoscopic
skills, in most cases, your patient will reap the benefi ts from
a minimally invasive approach.
References
1. Bipat S, Glas AS, Slors FJ, Zwinderman AH, Bossuyt PM,
Stoker J. Rectal cancer: local staging and assessment of lymph
node involvement with endoluminal US, CT, and MR imaging—a
meta- analysis. Radiology. 2004;232:773–83.
2. Paty PB, Nash GM, Baron P, et al. Long-term results of local exci-
sion for rectal cancer. Ann Surg. 2002;236:522–9.
3. Bretagnol F, Rullier E, George B, Warren BF, Mortensen NJ. Local
therapy for rectal cancer: still controversial? Dis Colon Rectum.
2007;50:523–33.
Laparoscopic Hand-Assisted Low Anterior Resection
Govind Nandakumar and Sang W. Lee
11
K e y P o i n t s
• The hand-assisted approach to LAR offers the same
benefi ts as a straight laparoscopic approach while providing the added advantage of tactile feedback and use of
the hand.
• A Pfannenstiel incision for the hand-assisted device is
ideally suited for a low anterior resection.
• After placing the hand-assisted device, use your hand
inside the abdomen to protect the intra-abdominal contents when placing your trocars.
• A sponge is extremely useful to aid in retraction, visualization, “drying” the operative fi eld and cleaning the camera. Have a method in place to keep track of your sponges
in addition to the routine counts.
• Ligation of the IMV near the ligament of Treitz provides additional length to help ensure a tension-free
anastomosis.
• The hand-assisted device can be used in several methods
to complete the total mesorectal excision (TME) from
placing trocars through it or using the hand to pull up the
specimen during posterior dissection.
Background
Laparoscopy has been increasingly adopted for surgical
resections of the colon and the rectum. While laparoscopy
for colon cancer has been well studied and the short and
long-term data have matured [ 1 ], rectal cancer surgery is
technically more challenging, and the data for a laparoscopic
Electronic supplementary material: Supplementary material is avail-
able in the online version of this chapter at
. Videos can also be accessed at http://www.springerimages.com/
1_11
videos/978-1-4939-1580-4
G. Nandakumar , M.D. (*) • S.W. Lee , M.D.
Division of Colon and Rectal Surgery, Department of Surgery ,
Weill Cornell Medical College , 525 East 68th Street ,
Box 172 , New York , NY 10065 , USA
doctorgovind@gmail.com; sal2013@med.cornell.edu
e-mail:
.
10.1007/978-1-4939-1581-
approach in rectal cancer is not as robust. In this gap,
hand- assisted laparoscopic colon surgery can offer several
advantages, while retaining many of the benefi ts of traditional laparoscopy. This chapter focuses on the technical
aspects of hand-assisted low anterior resection (HALAR) for
the treatment of rectal and rectosigmoid cancer.
Indications
A low anterior resection may be indicated for benign or
malignant disease processes. This chapter focuses on
HALAR for malignant disease. However, this technique
could be used for benign indications such as sigmoid colectomy for diverticulitis or Crohn’s disease, resection of large
polyps, treatment of intermittent sigmoid volvulus, and
resection with rectopexy for rectal prolapse.
Preoperative Planning
Patient History and Physical Findings
A complete history and physical focusing on the underlying
pathology is essential. For patients with colon cancer and/or
polyps, a detailed surgical history, personal cancer history,
and family history are essential. Preoperative genetic
counseling and testing may be considered based on age and
family history.
• Prior abdominal surgery, distension and obstruction are
important to elicit in the history and physical examination
prior to making a decision regarding pursuing an open
versus laparoscopic approach.
• History and physical examination should also evaluate the
cardiovascular and respiratory systems to assess the ability to tolerate pneumoperitoneum.
• Nutritional status and recent history of major weight loss
should be considered in the decision to perform a primary
anastomosis and/or a diverting ostomy.
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_11, © Springer Science+Business Media New York 2015
119
120
Imaging and Diagnostic Studies
• All patients with colon or rectal cancer and/or a polyp
should have a complete extent of disease workup including carcino embryonic antigen (CEA), computed tomography (CT) of the abdomen and pelvic, chest x-ray or
chest CT, colonoscopy and routine preoperative laboratory testing.
• The CT should be reviewed carefully to assess adjacent
organ involvement, metastatic disease, and obstructive
disease.
• An MRI of the pelvis or an endorectal ultrasound is
important in staging the tumor to make a decision regarding neoadjuvant chemotherapy and/or radiation. In addition, this can provide information regarding a threatened
circumferential margin and the need for an extended or en
bloc resection.
• A laparoscopic approach may not be feasible in the presence of massive distension, adjacent organ involvement
and obstruction.
• Advanced tumors, low rectal cancers, and adjacent organ
involvement generally require neoadjuvant treatment.
The hand-assisted approach is useful in these diffi cult
cases as it permits the use of a combination of laparoscopy for mobilization and open techniques to complete
the pelvic dissection.
• Colonoscopy and evaluation of the entire colon is important to ensure there are no synchronous lesions proximal
or distal to the area of resection. In large obstructing
tumors, preoperative colonoscopy may not be feasible.
On the table, CO 2 colonoscopy and colonoscopy after
neoadjuvant treatment are considerations. CO 2 rather than
conventional air colonoscopy should be used intraoperatively in order to avoid prolonged colonic distension,
which can hinder laparoscopy.
• We recommend endoscopic tattooing to be performed just
distal to the tumor and in three quadrants. Tattooing is
also important prior to neoadjuvant treatment as it identifi es the location of the tumor if there is a complete
response. Relying only on the distance from the anal
verge, especially for more proximal lesions is fraught
with the potential for error.
• A digital examination and proctoscopy by an experienced
surgeon are very important in assessing the rectal cancer.
The size of the tumor, distance from the dentate line, circumferential involvement, anterior versus posterior location, mobility, and tonicity of the sphincter are important
in operative planning.
• Preoperative marking by a trained enterostomal therapist
helps prevent common pouching diffi culties should the
patient need diversion.
G. Nandakumar and S.W. Lee
Surgical Management
Preoperative Planning
• The patient receives a mechanical bowel preparation to
facilitate handling of the colon and to facilitate intraoperative colonoscopy, if required. While the need for bowel
preparation is controversial, the consequences of a leak
may be more signifi cant without preparation.
• The patient is seen and evaluated by the surgical and anesthesia teams in the preoperative area on the day of surgery.
• Most patients are offered and elect to have an epidural or
intravenous catheter for patient-controlled anesthesia.
• A second- or third-general cephalosporin or ertapenem is
used for antibiotic prophylaxis within 1 h of skin incision
and re-dosed as needed. No antibiotics are administered
postoperatively.
• Venodyne boots and 5,000 U of subcutaneous heparin are
used for deep vein thrombosis prophylaxis.
• A Foley catheter is used in all patients and removed as
early as possible.
• Ureteral stents are used selectively in cases of recurrent
surgery, neoadjuvant chemoradiation therapy, and prior
infl ammatory conditions (i.e., abscess/leak).
Positioning
• The patient is positioned in a modifi ed lithotomy position
with both arms tucked to the sides. It is essential to ensure
that all pressure points, fi ngers, and calves are padded
adequately.
• The use of a beanbag and cloth tape allows extreme positioning with decrease in possibility of patient sliding.
• Alternatively, the use of Gel Pads makes routine taping of
patient not necessary.
• The practice of using shoulder braces should be avoided
as they can cause brachial plexus injury.
• Prior to draping, the patient is placed in steep
Trendelenburg and on either side to ensure that the patient
is secured well on the operating table.
• It is essential to ensure that both knees are in line with the
torso in order to avoid collision of instruments to patient’s
thighs when working in the upper quadrants of the
abdomen.
• The abdomen is prepped from the nipples to the mid-thigh.
• Access to the anus is always maintained for possible
intraoperative colonoscopy and assessment of the tumor
and extent of dissection, and to perform the anastomosis.
• Figure 11.1 shows one possible setup for use of the hand port.
11 Laparoscopic Hand-Assisted Low Anterior Resection
121
Fig. 11.1 OR setup with the teaching surgeon using his hand and
trainee operating. With permission from Carter J , Whelan RL. Hand
assisted laparoscopic anterior resection. In : Milsom JW , Bohm B ,
Nakajima K , eds. Laparoscopic colorectal surgery. Springer , New York
2006 ; pp : 255 - 273 . © Springer 2006
Procedure
Port Placement and Hand Device
The ideal features of a hand-assisted device have previously
been defi ned [ 2 ]. The device needs to be fl exible to allow for
a wide range of motion of the surgeon’s hand without permitting gas leakage. The device should also function as a wound
protector and retractor for portions of the operation that will
be performed through the hand-access device. The ergonomics of the device are also essential to ensure surgeon comfort
and appropriate circulation to the surgeon’s hand during long
operations.
For a low anterior resection, a Pfannenstiel incision,
opening the anterior fascia transversely and dividing the
posterior fascia longitudinally without dividing the rectus, is
well suited (Fig. 11.2 ). It is important to dissect the anterior
fascia off the rectus superiorly almost to the umbilicus and
inferiorly as far as possible. This maneuver is the key in
achieving adequate retraction and exposure. This incision
has a low incidence of hernia formation [ 3 ]. Perforating ves-
sels should be carefully controlled to prevent a rectus
sheath hematoma. One disadvantage of this incision is that
Fig. 11.2 Pfannenstiel incision showing muscle separation along the
midline. With permission from Yuko Tonohira
conversion to an open may require a midline incision that
will eventually lead to an inverted “T”-shaped incision. The
actual length of the incision is usually dependent on the
glove size of the surgeon. A general rule of thumb is to create an incision the same length as the surgeon’s glove size in
centimeters.
For cases where the likelihood of conversion to open surgery is high, a lower midline incision for the hand-access
device is better suited. This incision allows for easy conversion to a midline laparotomy, should it be necessary.
After induction of anesthesia, the abdomen is draped in
the usual fashion, and a Pfannenstiel incision is made 1–2
fi ngerbreadths above the top of pubis. After raising fl aps as
described earlier, the peritoneal cavity is entered with careful
attention to protecting the bowel and the urinary bladder.
Placing the patient in Trendelenburg position helps move the
small bowel away from the pelvis. The fl exible ring of the
wound protector is inserted and fl attened against the parietal
peritoneum.
A 10 mm port is placed at the umbilicus under manual
guidance through hand port. The lid of the hand-assisted
device is placed and pneumoperitoneum is established.
Exploratory laparoscopy is performed to rule out metastatic
disease. The feasibility of a laparoscopic approach can also
be established at this time.
Under direct visualization, two 5 mm ports are placed on
the right side—lateral to the rectus muscle to avoid the inferior epigastric artery. The trocars should be one palm breath
from each other and away from the anterior superior iliac
spine. If a stoma is planned on the right side, our preference
is to place trocars lateral and well away from stoma to avoid
pouching diffi culties with trocar sites. One or two 5 mm
trocars are also placed on the left side (Fig. 11.3 ).
122
G. Nandakumar and S.W. Lee
Technical Aspects
Mobilization
• Place the greater omentum in the upper abdomen over the
liver and the small bowel to the upper right quadrant of
the abdomen (Fig. 11.4 ).
• Expose the left colon mesentery and inferior mesenteric
artery and vein. The hand is used to identify and follow
the sacral promontory and put traction on the inferior
mesenteric artery (Fig.
11.5 ) by retracting the pedicle
superiorly and anteriorly.
Fig. 11.3 Suggested port placement. With permission from Yuko
Tonohira
The monitors are positioned on both sides of the patient,
with two monitors positioned on the left. The operating surgeon can stand on the right of the patient—using his/her
right hand through the hand-assisted device and the left hand
with a dissecting tool. A teaching surgeon may choose to
stand between the legs and use either hand to expose for a
trainee or operating surgeon.
The use of a moist laparotomy pad or a tagged towel
placed intracorporeally through the hand-access device can
facilitate retraction of the small intestines and cleaning of the
laparoscope [ 4 ].
Positioning and Alterations During Case
The patient is placed in the steep Trendelenburg position
and left side up. The omentum is positioned superior to the
transverse colon. The small bowel is moved to the right of
the abdomen. At this point, there should be clear visualization of the mesentery of the left colon, the ligament of Treitz
and the inferior mesenteric artery and vein. Placing the
patient in reverse Trendelenburg may facilitate takedown of
the splenic fl exure.
Fig. 11.4 Exposure is achieved by placing the omentum in the upper
abdomen and the small bowel in the right upper quadrant. With permis-
sion from Leroy J , Henri M , Rubino F , Marescaux J. Sigmoidectomy.
In : Milsom JW , Bohm B , Nakajima K , eds. Laparoscopic colorectal surgery. Springer , New York 2006 ; pp : 145 - 169 . © Springer 2006
Fig. 11.5 Lateral traction on the sigmoid colon exposes the inferior
mesenteric artery. With permission from Carter J , Whelan RL. Hand
assisted laparoscopic anterior resection. In : Milsom JW , Bohm B ,
Nakajima K , eds. Laparoscopic colorectal surgery. Springer , New York
2006 ; pp : 255 - 273 . © Springer 2006
11 Laparoscopic Hand-Assisted Low Anterior Resection
123
Fig. 11.6 A peritoneal window is created to start the retromesenteric
dissection. With permission from Yuko Tonohira
Fig. 11.8 Identifi cation of the ureter prior to dividing the vascular
pedicle With permission from Yuko Tonohira
Fig. 11.7 “Purple down” The retroperitoneal fascia ( purple ) is dis-
sected off the mesentery ( yellow )
• The peritoneum along the inferior aspect of the pedicle is
incised sharply, starting at the sacral promontory and
working toward the origin of the inferior mesenteric ves-
sels (Fig. 11.6 ).
• The inferior mesenteric artery is isolated at its origin.
Care is taken to protect the main trunks of the hypogastric
nerves that run posterior along the aortic plexus and must
be swept dorsally.
• Blunt retromesenteric dissection is started carefully
ensuring that the retroperitoneal fascia (purple) is not
lifted with the mesentery (Fig. 11.7 ).
• Using traction and countertraction, the retro-mesenteric
plain is developed laterally and superiorly.
• It is critical to identify the left ureter prior to dividing any
mesenteric vessels in order to avoid injury (Fig. 11.8 ).
Fig. 11.9 Division of the pedicle with an energy device preserving the
left colic With permission from Yuko Tonohira
The left ureter is located medial to the gonadal vessels at
this level and more distally at the level of the common
iliac bifurcation. If the left ureter cannot be identifi ed, a
different surgical exposure method such as lateral-tomedial mobilization can be utilized. Alternatively, the
ureter can be identifi ed more proximally near the origin of
the IMA. If all of the laparoscopic maneuvers fail to identify the ureter, open dissection through the Pfannenstiel
incision can be attempted.
• The inferior mesenteric artery (IMA) is isolated, and a
window is created around the vessel ensuring the ureter is
not lifted up with the mesentery. All vessels are divided
with a bipolar energy device with overlapping burns.
Leaving a stump helps control unexpected bleeding
(Fig.
11.9 ). In patients with calcifi ed mesenteric vessels,
either vessel loop ligator, clips, or laparoscopic stapler
should be used for vessel ligation.
124
G. Nandakumar and S.W. Lee
Fig. 11.10 High ligation of the IMA (proximal to the left colic) With
permission from Yuko Tonohira
Fig. 11.11 Retromesenteric dissection using traction and countertraction With permission from Carter J , Whelan RL. Hand assisted
laparoscopic anterior resection. In : Milsom JW , Bohm B , Nakajima K ,
eds. Laparoscopic colorectal surgery. Springer , New York 2006 ; pp : 255 -
273 . © Springer 2006
• Depending on the location of the tumor, the IMA can be
divided high on the aorta (Fig. 11.10 ) or can be ligated
distal to the take off of the left colic. Division distal to the
left colic theoretically provides an extra source of arterial
blood fl ow to the conduit without sacrifi cing oncological
principles.
• Division of the IMA facilitates completion of the retromesenteric dissection (Figs.
11.11 and 11.12 ).
– Medially to the root of the mesentery.
– Laterally to the white line.
– Superiorly to the inferior border of the pancreas.
• The inferior mesenteric vein (IMV) is divided. Of note,
the ligament of Treitz may need to be partially released to
Fig. 11.12 Retromesenteric dissection ensuring that the purple
retroperitoneal fascia is kept down and the ureter is protected. With per-
mission from Carter J , Whelan RL. Hand assisted laparoscopic anterior resection. In : Milsom JW , Bohm B , Nakajima K , eds. Laparoscopic
colorectal surgery. Springer , New York 2006 ; pp : 255 - 273 . © Springer
2006
obtain adequate exposure of the IMV, and there is an avascular plane just lateral (i.e., to the right) to its origin. The
duodenum needs to be protected from inadvertent thermal
injury. High division of the IMV at this location is critical
to achieve good mobilization and a tension-free anastomosis in the low-lying pelvis.
• An alternative approach is to perform the IMV dissection
fi rst followed by the IMA dissection. The lesser sac can
be entered anterior to the pancreas with this approach.
Care should be taken to ensure that the mesentery to the
transverse colon is protected.
• The lesser sac can also be entered by releasing the omentum from the transverse colon (Fig. 11.13 ). The gastro-
colic attachments need to be divided to achieve adequate
mobilization.
• The lateral attachments to the colon are taken down using
the dissecting tool through the left-sided port (Figs. 11.14
and 11.15 ).
• At this point, the splenic fl exure should be completely
mobilized with the ability to perform a colo-anal anastomosis, if required.
Total Mesorectal Excision (TME)
The principles of the total mesorectal excision remain the
same irrespective of the specifi c technique used to complete
this dissection. Some highlights include:
• Posterior dissection in the avascular plane preserving the
mesorectal envelope, along with identifying and preserving the hypogastric nerves.
11 Laparoscopic Hand-Assisted Low Anterior Resection
125
Fig. 11.13 The omentum is released from the transverse colon. With
permission from Carter J , Whelan RL. Hand assisted laparoscopic
anterior resection. In : Milsom JW , Bohm B , Nakajima K , eds.
Laparoscopic colorectal surgery. Springer , New York 2006 ; pp : 255 - 273 .
© Springer 2006
Fig. 11.15 Takedown of lateral attachments. With permission from
Yuko Tonohira
Fig. 11.14 The lateral attachments are released along the white line.
With permission from Sonoda T. Hand assisted laparoscopic total
abdominal colectomy. In : Milsom JW , Bohm B , Nakajima K , eds.
Laparoscopic colorectal surgery. Springer , New York 2006 ; pp : 274 - 294 .
© Springer 2006
• Lateral peritoneal attachments are divided, and the lateral
dissection is carried out close to the mesorectum while
preserving its envelope.
• Anterior dissection with or without excision of the anterior fascia, depending on the location and the extent of the
tumor.
The hand-assisted device offers multiple options in carry-
ing out these aspects of the dissection. The specifi c technique
used is dependent on the preference of the surgeon and the
Fig. 11.16 The lid of the hand-assisted device is removed, and the
TME is performed similar to open surgery with the help of “bright
tract” retractors With permission from Yuko Tonohira
specifi c characteristics of the patient and tumor. The
following techniques can be used to complete the TME.
1 . Open technique through the hand-assisted port
(a) The lid of the device is removed and the wound
retractor portion of it is retained for retraction
(Fig. 11.16 ).
(b) Laparotomy pads are used to pack the small bowel
out of the pelvis.
(c) The proximal colon is divided using a linear stapler
5–10 cm from the tumor ensuring that the point of
division has pulsatile blood fl ow.
(d) Two lighted retractors (long linear retractors with a
lip) are used to provide tension and counter-tension to
complete TME dissection as described above
(Fig. 11.17 ). These retractors are better suited than
the traditional St. Mark’s retractors as they are less
126
G. Nandakumar and S.W. Lee
Fig. 11.17 “Bright tract” retractors used to complete the TME With
permission from Yuko Tonohira
Fig. 11.18 Open stapler used to transect distal rectum With permission
from Yuko Tonohira
bulky and can be used as a pair through to provide
adequate exposure.
(e) Proctoscopy is performed to ensure that the dissec-
tion has progressed beyond the tumor.
(f) Transection of the rectum distal to the tumor can be
achieved with an open “TA” stapler through the
Pfannenstiel incision (Fig.
11.18 ). Using two staplers
can facilitate traction in diffi cult cases. The fi rst stapler is placed proximally and used to provide traction
to place the second stapler more distal. Staplers that
can staple on either side and divide in the middle are
Fig. 11.19 Laparoscopic stapler used to transect proximal bowel. With
permission from Leroy J , Henri M , Rubino F , Marescaux
J. Sigmoidectomy. In : Milsom JW , Bohm B , Nakajima K , eds.
Laparoscopic colorectal surgery. Springer , New York 2006 ; pp : 145 - 169 .
© Springer 2006
also available, but can be bulky to use in a narrow
pelvis. Prior to transection, the distal rectum may be
washed out with Betadine or sterile water to clear any
tumor cells that may have been dislodged during the
dissection.
(g) Transanal dissection preserving the external sphinc-
ter can be used for very low tumors followed by a
hand-sewn anastomosis. In this case, Gelpi retractors
and the Lonestar device (Cooper Surgical, Trumbull,
CT) are particularly useful.
2 . Laparoscopic TME
(a) The dissection is carried out laparoscopically with or
without (Chap.
10 ) hand assistance.
(b) The hand can be used as a retractor similar to the
hand held retractors used in open surgery.
(c) The proximal bowel can be divided with a laparo-
scopic linear stapler (Fig. 11.19 ) or performed more
expeditiously with an open stapler through the handassisted device (Fig. 11.20 ).
(d) An umbilical tape tied around the rectal stump can
serve as a useful retractor.
(e) A laparoscopic energy source is used to complete the
dissection as described with the open technique.
3 . Laparoscopic TME using the hand-access device as a
retractor (Video 11.1 )
(a) The colon is divided through the Pfannenstiel inci-
sion at the proximal margin.
(b) The divided colon stump is exteriorized through the
hand-access device (Fig.
11.21 ).
(c) The rectum is retracted out of the pelvis.