Laparoscopic TME Rectum

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Essential equipment:













  • One (occasionally two) 5mm, two 12mm disposable trocars
  • Two 5mm fenestrated Johan grasping forceps 
  • 5mm Harmonic scalpel 
  • 5mm needle holder 
  • Medium (purple) Haem-o-Loc Clips 
  • 12mm linear stapler eg ATG 45 (Green cartridge)
  • Electric operating table 

We use gravity as much as possible (200steep head down and slight right lateral tilt).  A warming blanket and catheterisation (remove at end of procedure) are essential.  There should be minimal hip flexion.  We always use a 300 scope.

In the case of a female patient with a uterus in situ, insert a Sprakman retractor after having dilated the cervix.  This is the best way to elevate it out of the pelvis.




Site the laparoscopy port approx. 3cm above/lateral to the umbilicus in a "short" abdomen (short distance from umbilicus to the symphysis pubis) or through the umbilical tube (as shown).  We use 5mm and 12mm RIF ports for the vast majority of our surgery. 

If you go for 4 12mm operating ports and two 5mm exposure ports you need very good assistants!  Inexperienced assistants cant manage a 300 scope as well as holding an instrument.


Use a medial or lateral approach as findings dictate – if there is very little space/too much small bowel/very large tumour we would always start the dissection laterally.  If the tumour is fixed/tethered start medially.  DO NOT GET FIXED ON ONE APPROACH as it will limit what you can do.  Sometimes you will need to approach in a caudal to cranial mannner and vice versa.
 
Do not attempt an ultra low tumour below the prostate unless you are prepared to make a pfannenstiel to transect the gut tube with a TX30G.  An alternative is to continue the dissection in the intersphincteric plane from above then from below, through the anus, divide the gut tube at the dentate line.  Next deliver the specimen through the anus, resect, create a J colopouch, reduce it into the pelvis and finaly complete a colo-anal anastomosis.
 
The first landmark in dissection of the IMA is the sacral prominentry; opening the peritoneum here medial to the left ureter correctly exposes the neuro/vascular elements of the mesentery.  Remember, it is easy to dissect behind the hypogastric nerves. Retract the rectum upward and forward, identify the loose areolar plane between the mesorectum and the presacral fascia (with the hypogastric nerves lying on it).  The right and left nerves should now be clearly visualised on the presacral fascia.  Follow this plane as far as you can dissecting the mesorectum as you would at open operation. Rotate the 30 degree scope through 180 degrees to see the lower reaches of the rectum, gut tube and pelvic floor.
 
The dissection then turns to the right and the Denonvillier's fascia anteriorly.  Pull the rectum cephalad to expose the rectovesical or rectouterine pouch.  In a female an assistants finger retracting upwards from below can help.  In hysterectomised women  try an Amiele Vaginal trainer.  Next, divide the lateral ligament and continue dissecting inferiorly.

(A left-sided Endoretract II (fan) retractor can help in holding the small bowel out of the pelvis; usually un-necessary.  An assistant with a 5mm retractor introduced from the LIF can help with the pelvic dissection).

Once the posterior, right and anterior dissection has been completed, mobilise the sigmoid colon and the left side of the rectum (up to this point the left lateral attachments are rather useful "natural retractors".  the end point of the TME is the pelvic floor muscles.  A fist against the perineum helps elevate the levators into laparoscopic view. 

Use an atraumatic forceps to occlude the rectal lumen just below the tumour to allow distal cytocidal rectal washout from below.  after that, divide the rectum with an endostapler just above the pelvic floor.  To faciitate a low transection and to avoid an oblique transection line, retract the rectum cephalad and approach the rectum anteriorly with the endo-stapler.

When dissecting behind the sigmoid mesentery, watch out for the gonadal vein as much as the ureter.  If you make a hole in it reduce the venous pressure with steep head down tilt and clip it. 

Adapt the level of transection of the IMA (preserving the LCA) to the individual anatomical circumstance and quality of colonic vascularisation.

Put the patient in reverse -Trendelenburg position whilst maintaining a right-side-down tilt to bring the stomach and transverse colon into view.

The medial approach to the splenic flexure uses an initial dissection, after division of the IM vein through the transverse mesocolon and so enter the lesser sac.  The next step is to divide the posterior attachments of the transverse mesocolon at the lower border of the pancreas.  Potential dangers include, dissecting behind the pancreas (don't follow the IMV too far and make the hole through the TV mesocolon early).  Do not mistake the splenic vein for the IMV and don't stray into the mesentery and damage the marginal vessels.  It is rare to damage the spleen; you only really see it when you dissect the lateral peritoneal attachments.

The lateral approach is the same as in open surgery ie mobilised off Gerota's fascia.  As in open surgery it sometimes help to first mobilise the omentum from the transverse colon.
Open the lesser sac or mobilise the Gt. Omentum to allow easier resection of retroperitoneal attachments of the splenic flexure.  Divide the IMV as high as possible just blow the pancreas.
 
Practice intraoperative liver U/S.
 
Retrieve the specimen through a TV L upper quadrant incision lateral to the rectus in bad Diverticulosis (sufficient length to avoid a diverticulum in the anastomosis).  Alternately use the 12mm LIF port site or as we now prefer, bring it out via the umbilicus (as shown - TME with uterus en block and obstructed colon).

Use a pfannenstiel for low rectal cancers.  Pfanninsteil incisions are prone to incissional hernias if not closed correctly.



Return the bowel with staple head inserted, close the umbilical incision and insert a 12mm camera port through the suture line.  Pull the suture tight (no need to tie at this stage.  Staple the two ends of the bowel together, the assistant lifting the vagina upward with a finger whilst closing the staple gun.

Ensure that all the small bowel has been removed from behind the mobilised colon.

Close the 12mm port site and skin incisions.

The TME specimen should look no different than one obtained through an ope dissection.




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SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051
claire.TRENBERTH@spirehealthcare.com
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