Minimally Invasive Transanal Total Mesorectal Excision in Laparoscopic Coloanal Anastomosis for Ultradistal Rectal Cancer

Introduction

: Transanal rectal excision and total mesorectal excision are challenging parts of laparoscopic coloanal anastomosis for ultradistal rectal cancers. The bottom-up transanal laparoscopic approach, a modification of the approach proposed for endorectal surgery, ¹ has demonstrated to allow for an adequate radical oncologic resection. ² The video shows how the transanal laparoscopic total mesorectal excision and coloanal anastomosis are performed on a 60-year-old man with a UT3N+ low rectal cancer. ³

Materials and Methods:

The anal canal is exposed using a Lone Star Retractor. The distal rectum is divided using a harmonic scalpel 1 cm above the dentate line, maintaining an adequate distance from the cancer, and is closed with a purse string. A single-incision laparoscopic trocar is inserted into the anal canal. Retropneumoperitoneum is insufflated at 12 mmHg. A 50-cm-long, 5-mm 30° camera, and two straight 5-mm laparoscopic instruments are used for the dissection. The rectum with its mesorectum is bluntly dissected circumferentially in an avascular plane from the presacral fascia, the prostate plan, and laterally, under laparoscopic view, following the rules of radical transanal total mesorectal excision (TME). The dissection is continued as far up as possible and allows for a complete dissection up to the level of upper rectum. Now the laparoscopic abdominal part of the operation is started. The inferior mesenteric vein is divided; the mesentery of the splenic flexure is dissected from the pancreas; the inferior mesenteric artery is divided at its origin; the splenic flexure is taken down. The upper rectum is mobilized and the plan of the transanal dissection is reached allowing for the complete detachment of the rectum and mesorectum and for the observation of the ultradistal part of the pelvis and of the transanal port. The specimen is extracted through a Pfannestiel incision. After reinsufflation of the pneumoperitoneum, the mobilized colon is transposed transanally through the single incision laparoscopic surgery port under laparoscopic vision and a standard hand-sewn coloanal anstomosis is made, protected by a loop ileostomy. Path report demonstrated a T3 N0 cancer with clear margins. Between March 2014 and November 2015, seven patients were operated with clear margins (range: 0.4 to 1.5 cm). Postoperative follow-up includes digital examination, CEA level, and abdominal and chest CT at close intervals. All patients are alive and disease free (follow-up 6 to 26 months).

Conclusions:

The video shows how the transanal minimally invasive approach allows for an oncologically radical TME under laparoscopic view and facilitates this challenging portion of the laparoscopic coloanal anastomosis for ultradistal rectal cancers, with minimal sphincter damage as demonstrated by preoperative and postoperative anorectal manometry.

No competing financial interests exist.

Runtime of video: 10 mins 3 secs

Part of this video was presented at the 2015 ACS meeting in Chicago.