Laparoscopic anterior resection

Trick from Josh to use a Contour stapler to fire across the rectum in a laparoscopic case Laparoscopic use of the Contour Curved Cutter Stapler device via a glove port- a modified technique, page 1

In a appropriately consent and anaethatised patients

• Prep and drape
• Skin cover abx
• TEDs an SCDs
• Surgical time out

Entry

• Hasson entry in the midline
• RIF 10mm
• supra-pubic 5mm
• Sub-xiphoid 5mm

Diagnostic laparoscopy

• Check for the tattoo or tumour
• Confirm there is no liver or peritoneal disease

Step 1. Medial–lateral dissection under inferior mesenteric vein (IMV) and splenic flexure mobilisation

• The colorectal team I work for routinely mobilise the splenic flexure for all anterior resection regardless of tumour height. Step A
• The patient is placed head up +/- roll to the right
• The omentum is placed over the stomach/liver and the transverse colon is retracted cranially.
• The small bowel is swept to the patients right and the DJ flexure and IMV exposed as it heads under the lower boarder of the pancreas
• The assistant via the sub-xiphoid port tents the mesentery of the colon over the IMV
• Diathermy is used to open a plane under the IMV
• Blunt dissection laterally is performed separating the mesocolon from gerota’s fascia until the descending colon is identified
• This disssection plane is taken cranially to the level of the pancreas
• The IMV is then divided with a ligaure +/- Hem-o-lock at the lower border of the pancreas Step B
• The assistant is then grasps transverse colon mesentery just to the patients left of midline and the surgeons right hand is used to grasp the transverse colon mesentery at the splenic flexure - this tents it up
• The peritoneum is opened at the superior border of the pancreas
• The transverse colon mesentery is opened and the lesser sac is entered
• The transverse colon mesentery between the two windows is then incised. This is carried lateral using the superior boarder of the pancreas as the landmark. Step C
• The omentum is then held up by the assistant to the patients left of the mid-transverse colon. The surgeon grasps an epiploic appendage at a similar level to provide tension
• The omentum is then seperate from the transverse colon to enter the lesser sac.
• This is continued up to the splenic flexure Step D
• The descending colon and transverse colon are then both retracted caudally allowing identification of any remaining adhesions which are taken down to complete the mobilisation
• The descending colon attachment to the lateral wall (white line of Talt) are taken down towards the sigmoid colon until this becomes difficult.

Step 2. Mobilisation of the left colon and division of IMA

• Patient is then placed head down
• Small bowel is swept out of the pelvis to identify the IMA
• The assistant retracts the sigmoid colon anteriorly
• Diathermy is used to incise the peritoneum at the base of the sigmoid mesentery down to the pelvic brim and continue this up to meet the peritoneal dissection from step 1
• Blunt dissection is continued under the IMA
• The ureter and gonalds are identified
• The left colon is then grasped and retacted medially by the assisant and the white line of Talt incised to meet the medial diseastion - this will complete the moblsaition of the splenic flexure, descneding colon and sigmoid colon.
• The left colon is then once again retraced anterior and the the IMA pedicle is isolated and taken with a vascular stapler or haem-o-locks (first identify the ureter and gonadals again prior)
• The sigmoid colon mesentery is the taken down to the pelvic brim

Step 3 - Rectal mobilisation to division point

Left hemi-colectomy

• My routine practice is to take my distal margin at the rectosigmoid junction regardless of the location of the sigmoid lesion.
• To perform this adequately a limited amount of upper rectal dissection is required in the TME plane.

High anterior resection

Performed for distal sigmoid and rectosigmoid tumours and the final anastomosis is above the peritoneal reflection

• The posterior rectal mesentery is dissected in the total mesorectal excision (TME) plane down to the mid-rectum
• This dissection is continued to the right of the rectum/rectal mesentery.
• The dissection on the left (at the apex of the sigmoid mesocolon) is continued into the pelvis on the left of the rectum/rectal mesentery.
• A decision (based on the pathology) is made where to divide the rectum.
• The rectal mesentery at this point is divided with the Ligaure to leave a bare rectal tube at the point where it will be stapled.

Low anterior resection

Performed for upper rectal tumours and the final anastomosis is below the level of peritoneal reflection

Ultra low anterior resection

Performed for mid and low rectal tumours. A resection is said to be ultra-low if the colorectal anastomosis is within 2 cm from the anorectal junction. An Ultra-low can be performed with a colo-anal anastamosis.

Reconstruction

• Colonic J pouch of 5-6 cm preferred to end to end anastomosis – better function and lower leak rate.
• Side to end anastomosis an option

Anastomotic leakage after ultra-low anastomosis is common, with reports of an incidence ranging from 10% to 28%. A recent Swedish trial comparing patients after TME randomised to a defunctioning stoma or no stoma reported a reduction in leak rate from 28% to 10.3% in patients randomised to a stoma

Step 4 - Join

• The rectum is then stapled
  • Option 1: intracorporeally - at my institution we use Medtronic EndoGIA stapler with a 60cm purple load (alternative Signia Powered stapler with a 60cm Purple load - Tri-staple technology)
  • Option 2: a small lower pfanenstiel incision and a small Alexis retractor placed is made and a Echelon contour stapler is used to fire across the rectum
• The sigmoid colon is then delivered through the pfanenstiel incision (Alexis retractor)
• The planned proximal resection margin is identified and the mesocolon taken with a clips and ties to this point testing the margin artery on the way
• A purse-string applicator is placed across the bowel and and crushing clamp placed distal to this. Looped 1-0 PDS with straight needles is threaded through and the needles cut off and an artery clamp applied. The bowel is incised along the groove in the purse string applicator and the specimen sent for histology.
• The proximal bowel is opened and cleaned with savlon soaked gauze
• The Anvil of a Echelon (Ethicon) CDH 31mm powered stapler is placed and secured
• An assistant then performs a DRE, dilates the anal canal with rectal sizers if required, irrgates the rectum with dilute betadine if required then places the stapler and advances the spike in the middle of the staple line.
• The staple is connected and closed. The bowel is check to confirm it is not twisted. The stapler is fired. Donuts checked.
• Pelvis is washed out
• Drain is not routinely placed