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59. Robotic nerve-sparing total mesorectal excision for rectal cancer
ABSTRACTS
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29 October 2014 14:30 e 16:55 Video Session II 58. Down-to-up transanal total mesorectal excision F. Alba Mesa1, J.M. Romero Fernandez1, A. Amaya Cortijo1, V. Gomez Cabeza de Vaca2, A. Azevedo3, M. Carral Freire2, A.L. Komorowski4 1 Consorcio Sanitario Publico de Aljarafe, Department of General Surgery, Bormujos-Seville, Spain 2 Hospital Nisa Sevilla Aljarafe, Department of General Surgery, AljarafeSeville, Spain 3 Centro de Cirugia Minima Invasion, Department of Laparoscopy, Caceres, Spain 4 Maria Curie Sklodowska Institute, Department of Surgical Oncology Cancer Centre, Krakow, Poland Background: Laparoscopic total mesorectal excision in rectal cancer is a technically demanding operation especially in patients with large tumours, narrow pelvis and obesity. A relatively new approach combining laparoscopy and transanal endoscopy aims at overcoming these problems. Materials and methods: In this video we present a technique of Transanal Total Mesorectal Excision in a 82 years old female patient with a T3N2M0 rectal cancer localised 5 cm from the anal verge operated after neoadjuvant radio and chemotherapy. Abdominal part of operation is performed laparoscopically. The Lonestar anal retractor is placed in ano. The complete circular incision of the whole thickness of the intestinal wall under direct vision is performed. The purse-string suture is placed at the distal end of the specimen and the GelPort is placed in the anal position to obtain pneumorectum. The mesorectal dissection is done in the endoscopic way starting with the posterior part of the mesorectum. Anterior mesorectum is dissected afterwards since the peritoneal reflexion at this side is reached easily and pneumorectum can be lost after its inadvertent aperture. After completing the mesorectal dissection the specimen is extracted with ViDrape protective bag. Protective ileostomy concludes the surgery. Results: The postoperative course was uneventfull and the patient has been discharged home on 4th postoperative day. Postoperative pain was below 3 on VAS pain score (1-10), with Paracetamol as a sole analgesic agent. From the 21cm long specimen 12 lymphnodes have been isolated and the mesorectal excision has been judged as complete by pathologist. Conclusion: The Down-to-up Transanal Mesorectal Excision is feasible in patients with relatively advanced rectal cancers. No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.055
59. Robotic nerve-sparing total mesorectal excision for rectal cancer D. Santos1, P. Fernandes1, M. Silva1, E. Mello1, J. Jesus1 1 Instituto Nacional do Cancer, Abdomen e Pelve, Rio de Janeiro, Brazil Background: Urinary and sexual dysfunctions are recognized complications of rectal cancer surgery. In recent decades, the introduction of total mesorectum excision (TME) and the concept of nerve sparing dissection has decreased urogenital dysfunction. However, despite the advantages of a minimally invasive approach, laparoscopic rectal surgery is associated with a rate of sexual and urinary dysfunction that is similar or higher when compared with the open approach. This may be due to the proximity between the pelvic nerves and the mesorectum, and the difficulty in identifying small anatomical structures, specially in obese patients and those treated with neoadjuvant chemoradiotherapy. The aim of this video is to demonstrate that robotic TME facilitate the
preservation of the inferior hypogastric nerve, allowing decrease of urinary and sexual dysfunction. Methods: A fully robotic TME was performed in a 54 years old female patient with T2N0M0 rectal cancer. She was placed in a lithotomy position with 30 Trendelenburg and 20 right lateral inclination. The robot was docked at the patients left hip in 45 angle. Four robotic trocars were placed in a semi-lunar fashion. After small bowel loops mobilization, the inferior mesenteric artery and vein was dissected and divided. The left colon, splenic flexure and the sigmoid were mobilized. The mesorectum was approached only after dissection, identification and preservation of the hypogastric nerves. Then the TME was carried out with sacral, lateral and anterior rectal dissection in this order. The rectum was then divided using an endo-roticulator stapler, the robotic arm 1 was undocked and the extraction of the specimen was performed by a left inguinal incision. A circular-stapled coloanal anastomosis was done under robotic assistance. Results: The operative time was 280 min, blood-loss estimation was 150ml. The patient was discharged on the fourth postoperative day without any complications. Urinary catheter was removed in the first post-operative day and the patient had spontaneous voiding and without any urinary symptoms. No sexual dysfunction was noted according to the Female Sexual Function Index questionnaire. Conclusion: Robotic assistance provides better nerve-sparing TME due to the magnified view allied with the wide range of motion of the instruments that facilitates the identification and dissection of the anatomical planes and the smaller neural component of the inferior hypogastric plexus. No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.056
60. Laparoscopic total mesorectal excision: Step-by-step technique P. Alves1, N. Rama1, R. Bra´sio1, R. Malaquias1, I. Gil1, I. Sales1, D. Jord~ao1, O. Andril1, V. Faria1 1 Hospital de Santo Andre Leiria, General Surgery, Leiria, Portugal Background: Laparoscopic total mesorectal excision for rectal cancer is safe and feasible, with sound oncological outcomes and improved quality of life. Notwithstanding, laparoscopic proctectomy remains a challenging procedure. Our colorectal group emphasizes the relevancy of a standard laparoscopic procedure, and presents an embedded didactic video demonstrating a step-by-step laparoscopic total mesorectal excision for a low rectal cancer. Materials and methods: The group describes a four to five-trocar technique for laparoscopic low anterior resection (LLAR). The key steps demonstrated are: high division of the inferior mesenteric artery and vein, medial-to-lateral mobilization of the descending colon, takedown of the splenic flexure, total mesorectal excision with division of the rectum at the pelvic floor, and side-to-end colorectal anastomosis. Principles of a good anastomosis and potential pitfalls are described, including protection of the ureter, pelvic autonomic nerves and anastomosis. Results: The didactic video demonstrates the several steps of a total mesorectal excision down to the pelvic floor, performed in different patients of the colorectal group. A diverting ileostomy protected all low colorectal anastomosis. The short-term outcomes are also reported. Conclusions: Laparoscopic total mesorectal excision for low rectal cancer is safe and effective, allowing surgical and oncologic outcomes similar to those reported for open surgery. Nevertheless the high conversion rate and the long operation time, patient selection and advanced laparoscopic skills are paramount. The author hope that this didactic
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29 October 2014 14:30 e 16:55 Video Session II 58. Down-to-up transanal total mesorectal excision F. Alba Mesa1, J.M. Romero Fernandez1, A. Amaya Cortijo1, V. Gomez Cabeza de Vaca2, A. Azevedo3, M. Carral Freire2, A.L. Komorowski4 1 Consorcio Sanitario Publico de Aljarafe, Department of General Surgery, Bormujos-Seville, Spain 2 Hospital Nisa Sevilla Aljarafe, Department of General Surgery, AljarafeSeville, Spain 3 Centro de Cirugia Minima Invasion, Department of Laparoscopy, Caceres, Spain 4 Maria Curie Sklodowska Institute, Department of Surgical Oncology Cancer Centre, Krakow, Poland Background: Laparoscopic total mesorectal excision in rectal cancer is a technically demanding operation especially in patients with large tumours, narrow pelvis and obesity. A relatively new approach combining laparoscopy and transanal endoscopy aims at overcoming these problems. Materials and methods: In this video we present a technique of Transanal Total Mesorectal Excision in a 82 years old female patient with a T3N2M0 rectal cancer localised 5 cm from the anal verge operated after neoadjuvant radio and chemotherapy. Abdominal part of operation is performed laparoscopically. The Lonestar anal retractor is placed in ano. The complete circular incision of the whole thickness of the intestinal wall under direct vision is performed. The purse-string suture is placed at the distal end of the specimen and the GelPort is placed in the anal position to obtain pneumorectum. The mesorectal dissection is done in the endoscopic way starting with the posterior part of the mesorectum. Anterior mesorectum is dissected afterwards since the peritoneal reflexion at this side is reached easily and pneumorectum can be lost after its inadvertent aperture. After completing the mesorectal dissection the specimen is extracted with ViDrape protective bag. Protective ileostomy concludes the surgery. Results: The postoperative course was uneventfull and the patient has been discharged home on 4th postoperative day. Postoperative pain was below 3 on VAS pain score (1-10), with Paracetamol as a sole analgesic agent. From the 21cm long specimen 12 lymphnodes have been isolated and the mesorectal excision has been judged as complete by pathologist. Conclusion: The Down-to-up Transanal Mesorectal Excision is feasible in patients with relatively advanced rectal cancers. No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.055
59. Robotic nerve-sparing total mesorectal excision for rectal cancer D. Santos1, P. Fernandes1, M. Silva1, E. Mello1, J. Jesus1 1 Instituto Nacional do Cancer, Abdomen e Pelve, Rio de Janeiro, Brazil Background: Urinary and sexual dysfunctions are recognized complications of rectal cancer surgery. In recent decades, the introduction of total mesorectum excision (TME) and the concept of nerve sparing dissection has decreased urogenital dysfunction. However, despite the advantages of a minimally invasive approach, laparoscopic rectal surgery is associated with a rate of sexual and urinary dysfunction that is similar or higher when compared with the open approach. This may be due to the proximity between the pelvic nerves and the mesorectum, and the difficulty in identifying small anatomical structures, specially in obese patients and those treated with neoadjuvant chemoradiotherapy. The aim of this video is to demonstrate that robotic TME facilitate the
preservation of the inferior hypogastric nerve, allowing decrease of urinary and sexual dysfunction. Methods: A fully robotic TME was performed in a 54 years old female patient with T2N0M0 rectal cancer. She was placed in a lithotomy position with 30 Trendelenburg and 20 right lateral inclination. The robot was docked at the patients left hip in 45 angle. Four robotic trocars were placed in a semi-lunar fashion. After small bowel loops mobilization, the inferior mesenteric artery and vein was dissected and divided. The left colon, splenic flexure and the sigmoid were mobilized. The mesorectum was approached only after dissection, identification and preservation of the hypogastric nerves. Then the TME was carried out with sacral, lateral and anterior rectal dissection in this order. The rectum was then divided using an endo-roticulator stapler, the robotic arm 1 was undocked and the extraction of the specimen was performed by a left inguinal incision. A circular-stapled coloanal anastomosis was done under robotic assistance. Results: The operative time was 280 min, blood-loss estimation was 150ml. The patient was discharged on the fourth postoperative day without any complications. Urinary catheter was removed in the first post-operative day and the patient had spontaneous voiding and without any urinary symptoms. No sexual dysfunction was noted according to the Female Sexual Function Index questionnaire. Conclusion: Robotic assistance provides better nerve-sparing TME due to the magnified view allied with the wide range of motion of the instruments that facilitates the identification and dissection of the anatomical planes and the smaller neural component of the inferior hypogastric plexus. No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.056
60. Laparoscopic total mesorectal excision: Step-by-step technique P. Alves1, N. Rama1, R. Bra´sio1, R. Malaquias1, I. Gil1, I. Sales1, D. Jord~ao1, O. Andril1, V. Faria1 1 Hospital de Santo Andre Leiria, General Surgery, Leiria, Portugal Background: Laparoscopic total mesorectal excision for rectal cancer is safe and feasible, with sound oncological outcomes and improved quality of life. Notwithstanding, laparoscopic proctectomy remains a challenging procedure. Our colorectal group emphasizes the relevancy of a standard laparoscopic procedure, and presents an embedded didactic video demonstrating a step-by-step laparoscopic total mesorectal excision for a low rectal cancer. Materials and methods: The group describes a four to five-trocar technique for laparoscopic low anterior resection (LLAR). The key steps demonstrated are: high division of the inferior mesenteric artery and vein, medial-to-lateral mobilization of the descending colon, takedown of the splenic flexure, total mesorectal excision with division of the rectum at the pelvic floor, and side-to-end colorectal anastomosis. Principles of a good anastomosis and potential pitfalls are described, including protection of the ureter, pelvic autonomic nerves and anastomosis. Results: The didactic video demonstrates the several steps of a total mesorectal excision down to the pelvic floor, performed in different patients of the colorectal group. A diverting ileostomy protected all low colorectal anastomosis. The short-term outcomes are also reported. Conclusions: Laparoscopic total mesorectal excision for low rectal cancer is safe and effective, allowing surgical and oncologic outcomes similar to those reported for open surgery. Nevertheless the high conversion rate and the long operation time, patient selection and advanced laparoscopic skills are paramount. The author hope that this didactic