Laparoscopic Transanal Total Mesorectal Excision: Rectal Cancer

Laparoscopic Transanal Total Mesorectal Excision

Mid or low Rectal Cancer and Benign Disease

Anal stricture, T4 or fixed tumor

GelPOINT Path

Patient is placed in the lithotomy position using Allen stirrups, the right arm is tucked and the patient is padded and well secured to the operating room table.
1. Transanal Access: Applied GelPOINT Path, Covidien SILS, Rigid platforms (Wolf and Storz)
2. AirSeal Insufflation System: Continuous carbon dioxide insufflation and smoke evacuation
3. Abdominal access: Four 5mm trocars

Computed tomography (CT) scan, Rectal Magnetic Resonance Image (MRI), colonoscopy, and Carcinoembryonic antigen (CEA) level

Following identification of the tumor, the rectal mucosa is marked 1 cm distally, and the rectal lumen is closed using a 2-0 Prolene purse string suture. Secure closure of the rectal lumen is required to maintain pneumorectum, and prevent proximal dilation of the colon, which may interfere with the abdominal exposure. The abdominal team works simultaneously, placing four 5mm trocars to gain access to the peritoneal cavity. The responsibilities of the abdominal surgeon are to mobilize the left colon and proximal rectum, divide the superior hemorrhoidal artery, and provide assistance with both the connection of the two operative fields and creation of the anastomosis.
A full thickness circumferential incision of the rectal wall is performed 1 cm distal to the purse string. The total mesorectal excision plane is identified and entered, initially focusing anteriorly and posteriorly. Intermittent cauterization with upward movement of the tissue maintains visualization of the tissue planes. The lateral quadrants are then mobilized, completing the circumferential mobilization of the rectum to the level of the peritoneal reflection. The peritoneal cavity is then entered and both teams retract for each other. Dissection proceeds based on which field has better exposure and visualization. This will complete the dissection and disconnect the specimen.
The specimen is removed transanally and an Ethicon 29mm EEA stapler is utilized to create a colorectal anastomosis. The proximal anvil of the stapler is placed in the standard fashion. An additional 2-0 Prolene suture is used to place a purse string around the distal rectal cuff and then tied down securely over a Jackson Pratt (JP) drain. The end of the drain is then secured to the stapler and used as a guide to advance the stapler through the access channel and distal rectal stump. The stapler ends are matched and the stapler is fired in the standard fashion. The anastomosis is can be visualized directly through the GelPOINT Path platform. The JP drain is brought through a trocar incision, secured to the skin, and a diverting loop ileostomy is then created.
The intraabdominal portion of the procedure can also be performed using the da Vinci Robotic platform or through an open approach. Specimen extraction can be through a limited abdominal incision with bulky tumors or limited bowel length.

The unique complication in this procedure, although uncommon, is an injury to the urethra. This structure is at risk in a male patient with a distal tumor if meticulous dissection is not used to mobilize the rectum off the prostate. Wrong plane surgery may lead to intramesorectal dissection or injury to the pelvic autonomic nerves or pelvic veins, including the internal iliac or presacral vessels.

The unique complication in this procedure, although uncommon, is an injury to the urethra. This structure is at risk in a male patient with a distal tumor if meticulous dissection is not used to mobilize the rectum off the prostate. Wrong plane surgery may lead to intramesorectal dissection or injury to the pelvic autonomic nerves or pelvic veins, including the internal iliac or presacral vessels.

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