- Email: [email protected]
Transanal rectal dissection: A procedure to assist achievement of laparoscopic total mesorectal excision for bulky tumor in the narrow pelvis
The American Journal of Surgery (2009) 197, e46 – e50
How I Do It
Transanal rectal dissection: A procedure to assist achievement of laparoscopic total mesorectal excision for bulky tumor in the narrow pelvis Kimihiko Funahashi, M.D.*, Junichi Koike, M.D., Tatsuo Teramoto, M.D., Naoyasu Saito, M.D., Hiroyuki Shiokawa, M.S., Akiharu Kurihara, M.S., Tomoaki Kaneko, M.S., Kentaro Shirasaka, M.S., Hironori Kaneko, M.D. Department of General and Gastroenterological Surgery, Toho University Medical Center, Omori Hospital, Tokyo, Japan KEYWORDS: Transanal rectal dissection (TARD); Laparoscopic total mesorectal excision; Lower rectal cancer; Narrow pelvis; Bulky tumor
Abstract BACKGROUND: Laparoscopic approaches for colorectal surgery have been improved recently; however, it is often difficult to achieve total mesorectal excision (TME) for lower rectal cancer laparoscopically because of a narrow pelvis and a thickened mesentery. METHODS: TME was successfully performed in 6 patients (4 men, 2 women) with dissection of the rectum transanally from the anal side of the tumor. The preoperative stage was T3N1M0 in 1 patient and T3N0M0 in 5 patients. The mean body mass index was 29.8 kg/m2 (range, 28.7–31.2 kg/m2), and the mean tumor size was 46.5 mm (range, 30 – 60 mm). RESULTS: The mean duration of the anal portion of the operation was 64 minutes (56 minutes in women, 79 minutes in men). No complications occurred during surgery or postoperatively. CONCLUSION: This technique is a simple and effective procedure for successfully performing laparoscopic TME of lower rectal cancer in patients with bulky tumors, narrow pelvises, and thickened mesenteries. © 2009 Elsevier Inc. All rights reserved.
Laparoscopic approaches have been used in colorectal surgery for the past 10 years, and many researchers have recently demonstrated the feasibility of laparoscopic surgery for rectal cancer.1– 6 However, the use of laparoscopic surgery for rectal cancer, particularly lower rectal cancer, remains highly controversial. In a colorectal cancer clinical trial that compared conventional with laparoscopy-assisted surgery, a higher conversion rate and morbidity occurred in patients who underwent laparo-
* Corresponding author: Tel: 03-3762-4151; fax: 03-3298-4348. E-mail address: [email protected] Manuscript received February 28, 2008; revised manuscript July 17, 2008
0002-9610/$ - see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.07.060
scopic rectal excision compared with those who underwent laparoscopic colectomy.7 Although total mesorectal excision (TME) is the gold standard for the treatment of lower rectal cancer because of improved local control and survival, the presence of a narrow pelvis, a bulky tumor, and/or a thickened mesentery can cause an inadequate operative visual field, thereby limiting the ability to achieve successful laparoscopic TME. Incomplete TME, an inadequate surgical margin, and conversion to open surgery during laparoscopic surgery for lower rectal cancer because of technical difficulties may contribute to the local or anastomotic recurrence and high morbidity observed in clinical trials. Therefore, a simple and safe procedure is required to successfully achieve laparo-
K. Funahashi et al.
Laparoscopic TME with transanal rectal dissection
scopic TME for lower rectal cancer in patients with inadequate operative visual fields due to bulky tumors, narrow pelvises, and/or thickened mesenteries. The purposes of this paper are to introduce our simple and safe transanal rectal dissection (TARD) procedure combined with laparoscopic surgery for achieving complete laparoscopic TME in these patients and to report short-term outcomes.
Preoperative evaluation of tumor We planned to perform laparoscopic TME combined with TARD on 6 patients (4 men) with lower rectal cancer that was considered too difficult to remove with standard abdominal laparoscopic TME. In all patients, tumor size, location, circumferential margin, and lymph node involvement were evaluated using barium enema, colonoscopy, computed tomography, and magnetic resonance imaging. There was no evidence of tumor invasion to the pelvic wall and levator ani on magnetic resonance imaging or computed tomography, and this technique was applied to these patients.
Methods The operation is performed in the Lloyd-Davies position. Prior to the laparoscopic procedure, the anal portion of the operation is initiated. First, transanal ultrasound is performed to confirm the depth of invasion. If transanal ultrasound shows tumor invasion to the external sphincter and/or the levator ani, abdominoperineal resection should be chosen as the surgical procedure. The anal canal is exposed with a self-holding retractor (Lone Star Retractor; Lone Star Medical Products, Inc, Houston, TX). The distal side at the lower margin of the tumor is then closed with purse-string sutures under direct vision, followed by irrigation of the anal canal with 5% povidone-iodine. This procedure is important for preventing cancer cell dissemination in the surgical field. The division of the rectum is then initiated at the posterior side ⱖ2 cm distal to the tumor margin.8,9 A circular incision of the rectum is performed by closing the cut end of the rectum with an interrupted suture, and mobilization of the rectum, including the tumor, is continued proximally by exposing the levator ani. Although the rectum is able to be mobilized easily with a pusher, evaluation of the invasion of tumor cells is required on the dissected plane (the external sphincter and/or the levator ani) by microscopic examination of a frozen-section specimen histologically whenever mobilization of the rectum is difficult. If any findings of tumor invasion into the dissected plane are found, the procedure is immediately converted to abdominoperineal resection. Division and mobilization of the rectum, including the mesorectum, is performed until the peritoneal reflection is
e47
identified on the anterior side and until the sacral promontory beyond the rectosacral ligament is nearly reached on the posterior side. Finally, a Lap disc mini (HAKKO Group, Tokyo, Japan) is adapted to the anal canal to maintain pressure during laparoscopy (Fig. 1). For the laparoscopic procedure, a camera port is created in the paraumbilical zone with a trocar, and an operative port in the middle lower abdominal region and 2 additional operative ports in the left and right McBurney’s point are created. On routine intra-abdominal exploration, the gauze that is placed on the dissected plane as a landmark can be identified through the peritoneum on the anterior side of the rectum. The sigmoid and descending colon are mobilized completely from the subretroperitoneal fascia to ensure that the subsequent coloanal anastomosis is free of tension. The sigmoid colon and its mesentery are then removed, the lymph nodes around the inferior mesenteric artery are dissected with a harmonic scalpel, and the inferior mesenteric artery is ligated at a high level with an endoclip. It is relatively easy to dissect Denonvillier’s fascia and expose the seminal vesicles and prostate gland or the posterior wall of the vagina on the anterior side, and to mobilize the lower rectum with mesorectum from the sacrum as a landmark to gauge placement of the separated plane between the visceral and parietal endopelvic fascia through the anus (Fig. 2). The lateral ligaments of the rectum are gradually divided with a harmonic scalpel from the inner limit of the inferior hypogastric nerve fibers, and the rectum, including the total mesorectum, is completely removed from the pelvic floor (Fig. 3). The colon and rectum are pulled out of the umbilical wound and resected. A coloanal anastomosis is transanally performed by hand suturing. Finally, a diverting ileostoma is created. The diverting ileostoma is closed from 3 to 6 months after surgery.
Results Six patients (4 men, 2 women) with lower rectal cancer underwent laparoscopic TME combined with TARD. All tumors were located below the peritoneal reflection, as assessed by preoperative barium enema, and the mean tumor size was 46.5 mm (range, 30 – 60 mm). The mean body mass index was 29.8 kg/m2 (range, 28.7–31.2 kg/m2), and the presence of a narrow pelvis and a thickened mesentery was confirmed in all patients. Although lymph node metastases were demonstrated in a patient on preoperative computed tomography and magnetic resonance imaging, no patient had direct invasion to surrounding organs, the pelvic wall, or the levator ani. The preoperative stage was T3N1M0 in 1 patient and T3N0M0 in 5 patients. Therefore, preoperative chemoradiation was not performed for this series.
e48
The American Journal of Surgery, Vol 197, No 4, April 2009
Figure 1 A circular incision of the rectum is performed by closing the cut end of the rectum with an interrupted suture, and mobilization of the rectum, including the tumor, is continued proximally by exposing the levator muscle (A–C). Division and mobilization of the rectum, including the mesorectum, is performed until the peritoneal reflection on the anterior side and until the sacral promontory beyond the rectosacral ligament on the posterior side (D).
The mean duration of the anal portion of the operation was 64 minutes (56 minutes in women, 79 minutes in men). No complications occurred during surgery or postopera-
tively. The average distance from the rectal stump was 24 mm (range, 17–30 mm). The postoperative pathologic stage was T3N1M0 in 3 patients, T3N0M0 in 2 patients, and
K. Funahashi et al.
Laparoscopic TME with transanal rectal dissection
e49
Figure 3 The lateral ligaments of the rectum are gradually divided with a harmonic scalpel from the inner limit of the inferior hypogastric nerve fibers, and the rectum, including the total mesorectum, is completely removed from the pelvic floor.
T2N0M0 in 1 patient. The surgical margin was histologically free of tumor cells in all patients (Table 1). There were no postoperative recurrences during a mean 16 months of follow-up (range, 4 –35 months).
Table 1
Figure 2 A gauze that is placed on the dissected plane as a landmark can be identified through the peritoneum on the anterior side of the rectum (A,B).
Patients (n ⫽ 6)
Variable
Value
Age (y) Men/women Mean (range) body mass index (kg/m2) Mean (range) maximum size of tumor (mm) Preoperative diagnosis T3N0M0 T3N1M0 Postoperative diagnosis T2N0M0 T3N0M0 T3N1M0 Histologic type Well-differentiated adenocarcinoma Moderately differentiated adenocarcinoma Mean (range) distance from the rectal stamp (mm) Mean duration of the anal portion of surgery (min) Men Women
62.8 4:2 29.8 (28.7–31.2) 46.5 (30–60) 5 1 1 2 3 1 5 24 (17–30) 64 79 56
e50
The American Journal of Surgery, Vol 197, No 4, April 2009
Comments
References
We have been able to perform laparoscopic TME for bulky lower rectal cancer with a thickened mesentery simply and safely using a modified procedure. Some authors1–3,5,6 have reported good outcomes of laparoscopic TME for lower rectal cancer. However, for bulky tumors with a thickened mesentery located near a narrow pelvic floor, the ability to clamp the anal side of the tumor with an endocutter to perform double stapling is limited. Laurent et al10 reported that the rate of conversion was 15.5% because of intraoperative rectal fixity and difficulty with pelvic dissection and/or stapling and that anatomic and technical difficulties associated with lower rectal cancer with a stapled anastomosis caused a higher rate of conversion, particularly in men with stapled anastomoses. Although per anum rectal dissection11 and a prolapsing technique12,13 were reported to prevent many of the problems associated with laparoscopic low or ultralow anterior resection, these procedures are appropriate only for select patients with T1 or T2 carcinoma of the lower rectum.14 In our series, we performed our modified procedure in patients with pathologic T2 or T3 bulky tumors with a mean size of 46 mm. In conclusion, TARD resolves the problems associated with laparoscopic TME for bulky tumors in the lower rectum, including selection of the appropriate distal line of transection, securing the resection plane, and ensuring reliable rectal washout. We believe that this technique is useful particularly during laparoscopic TME for patients with lower rectal cancer with operative limitations due to the presence of bulky tumors, a narrow pelvis, and a thickened mesentery. For the preliminary oncologic results, no postoperative recurrences have yet been experienced. However, a larger number of patients need to be treated with this procedure before final conclusions about safety and longterm efficacy can be made.
1. Breukink SO, Pierie JP, Grond AJ, et al. Laparoscopic versus open total mesorectal excision: a case-control study. Int J Colorectal Dis 2005;20:428 –33. 2. Breukink SO, Grond AJ, Pierie JP, et al. Laparoscopic vs open mesorectal excision for rectal cancer: an evaluation of the mesorectum’s macroscopic quality. Surg Endosc 2005;19:307–10. 3. Zhou ZG, Hu M, Li Y, et al. Laparoscopic versus open total mesorectal excision with anal sphincter preservation for low rectal cancer. Surg Endosc 2004;18:1211–5. 4. Wu WX, Sun YM, Hua YB, et al. Laparoscopic versus conventional open resection of rectal carcinoma: a clinical comparative study. World J Gastroenterol 2004;15:1167–70. 5. Barlehner E, Benhidjeb T, Anders S, et al. Laparoscopic resection for rectal cancer: out comes in 194 patients and review of the literature. Surg Endosc 2005;19:757– 66. 6. Leory J, Jamail F, Forbes L, et al. Laparoscopic total mesorectal excision (TME) for rectal cancer surgery; long-term outcomes. Surg Endosc 2004;18:281–9. 7. Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomized controlled trial. Lancet 2005;365:1718 –26. 8. Ono C, Yoshinaga K, Enomoto M, et al. Discontinuous rectal cancer spread in the mesorectum and the optimal distal clearance margin in situ. Dis Colon Rectum 2002;45:744 –9. 9. Zhao GP, Zhou ZG, Lei WZ, et al. Pathological study of distal mesorectal cancer spread to determine a proper distal resection margin. World J Gastroenterol 2005;21:319 –22. 10. Laurent C, Leblanc F, Gineste C, et al. Laparoscopic approach in surgical treatment of rectal cancer. Br J Surg 2007;94:1555– 61. 11. Teramoto T, Watanabe M, Kitajima M. Per anum intersphinteric rectal dissection with direct coloanal anastomosis for lower rectal cancer; the ultimate sphincter-preserving operation. Dis Colon Rectum 1997; 40(suppl):S43–7. 12. Takatsuka J, Isogai M, Okamoto Y, et al. Low anterior resection using the prolapsing technique [in Japanese]. Syujyutu 2001;55:1965–72. 13. Fukunaga M, Kidokoro A, Iba T, et al. Laparoscopy-assisted low anterior resection with a prolapsing technique for low rectal cancer. Surg Today 2005;35:598 – 602. 14. Watanabe M, Teramoto T, Hasegawa H, et al. Laparoscopic ultralow anterior resection with per anum intersphinteric rectal dissection for lower rectal cancer. Dis Colon Rectum 2000;45(suppl):S94 –7.
How I Do It
Transanal rectal dissection: A procedure to assist achievement of laparoscopic total mesorectal excision for bulky tumor in the narrow pelvis Kimihiko Funahashi, M.D.*, Junichi Koike, M.D., Tatsuo Teramoto, M.D., Naoyasu Saito, M.D., Hiroyuki Shiokawa, M.S., Akiharu Kurihara, M.S., Tomoaki Kaneko, M.S., Kentaro Shirasaka, M.S., Hironori Kaneko, M.D. Department of General and Gastroenterological Surgery, Toho University Medical Center, Omori Hospital, Tokyo, Japan KEYWORDS: Transanal rectal dissection (TARD); Laparoscopic total mesorectal excision; Lower rectal cancer; Narrow pelvis; Bulky tumor
Abstract BACKGROUND: Laparoscopic approaches for colorectal surgery have been improved recently; however, it is often difficult to achieve total mesorectal excision (TME) for lower rectal cancer laparoscopically because of a narrow pelvis and a thickened mesentery. METHODS: TME was successfully performed in 6 patients (4 men, 2 women) with dissection of the rectum transanally from the anal side of the tumor. The preoperative stage was T3N1M0 in 1 patient and T3N0M0 in 5 patients. The mean body mass index was 29.8 kg/m2 (range, 28.7–31.2 kg/m2), and the mean tumor size was 46.5 mm (range, 30 – 60 mm). RESULTS: The mean duration of the anal portion of the operation was 64 minutes (56 minutes in women, 79 minutes in men). No complications occurred during surgery or postoperatively. CONCLUSION: This technique is a simple and effective procedure for successfully performing laparoscopic TME of lower rectal cancer in patients with bulky tumors, narrow pelvises, and thickened mesenteries. © 2009 Elsevier Inc. All rights reserved.
Laparoscopic approaches have been used in colorectal surgery for the past 10 years, and many researchers have recently demonstrated the feasibility of laparoscopic surgery for rectal cancer.1– 6 However, the use of laparoscopic surgery for rectal cancer, particularly lower rectal cancer, remains highly controversial. In a colorectal cancer clinical trial that compared conventional with laparoscopy-assisted surgery, a higher conversion rate and morbidity occurred in patients who underwent laparo-
* Corresponding author: Tel: 03-3762-4151; fax: 03-3298-4348. E-mail address: [email protected] Manuscript received February 28, 2008; revised manuscript July 17, 2008
0002-9610/$ - see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.07.060
scopic rectal excision compared with those who underwent laparoscopic colectomy.7 Although total mesorectal excision (TME) is the gold standard for the treatment of lower rectal cancer because of improved local control and survival, the presence of a narrow pelvis, a bulky tumor, and/or a thickened mesentery can cause an inadequate operative visual field, thereby limiting the ability to achieve successful laparoscopic TME. Incomplete TME, an inadequate surgical margin, and conversion to open surgery during laparoscopic surgery for lower rectal cancer because of technical difficulties may contribute to the local or anastomotic recurrence and high morbidity observed in clinical trials. Therefore, a simple and safe procedure is required to successfully achieve laparo-
K. Funahashi et al.
Laparoscopic TME with transanal rectal dissection
scopic TME for lower rectal cancer in patients with inadequate operative visual fields due to bulky tumors, narrow pelvises, and/or thickened mesenteries. The purposes of this paper are to introduce our simple and safe transanal rectal dissection (TARD) procedure combined with laparoscopic surgery for achieving complete laparoscopic TME in these patients and to report short-term outcomes.
Preoperative evaluation of tumor We planned to perform laparoscopic TME combined with TARD on 6 patients (4 men) with lower rectal cancer that was considered too difficult to remove with standard abdominal laparoscopic TME. In all patients, tumor size, location, circumferential margin, and lymph node involvement were evaluated using barium enema, colonoscopy, computed tomography, and magnetic resonance imaging. There was no evidence of tumor invasion to the pelvic wall and levator ani on magnetic resonance imaging or computed tomography, and this technique was applied to these patients.
Methods The operation is performed in the Lloyd-Davies position. Prior to the laparoscopic procedure, the anal portion of the operation is initiated. First, transanal ultrasound is performed to confirm the depth of invasion. If transanal ultrasound shows tumor invasion to the external sphincter and/or the levator ani, abdominoperineal resection should be chosen as the surgical procedure. The anal canal is exposed with a self-holding retractor (Lone Star Retractor; Lone Star Medical Products, Inc, Houston, TX). The distal side at the lower margin of the tumor is then closed with purse-string sutures under direct vision, followed by irrigation of the anal canal with 5% povidone-iodine. This procedure is important for preventing cancer cell dissemination in the surgical field. The division of the rectum is then initiated at the posterior side ⱖ2 cm distal to the tumor margin.8,9 A circular incision of the rectum is performed by closing the cut end of the rectum with an interrupted suture, and mobilization of the rectum, including the tumor, is continued proximally by exposing the levator ani. Although the rectum is able to be mobilized easily with a pusher, evaluation of the invasion of tumor cells is required on the dissected plane (the external sphincter and/or the levator ani) by microscopic examination of a frozen-section specimen histologically whenever mobilization of the rectum is difficult. If any findings of tumor invasion into the dissected plane are found, the procedure is immediately converted to abdominoperineal resection. Division and mobilization of the rectum, including the mesorectum, is performed until the peritoneal reflection is
e47
identified on the anterior side and until the sacral promontory beyond the rectosacral ligament is nearly reached on the posterior side. Finally, a Lap disc mini (HAKKO Group, Tokyo, Japan) is adapted to the anal canal to maintain pressure during laparoscopy (Fig. 1). For the laparoscopic procedure, a camera port is created in the paraumbilical zone with a trocar, and an operative port in the middle lower abdominal region and 2 additional operative ports in the left and right McBurney’s point are created. On routine intra-abdominal exploration, the gauze that is placed on the dissected plane as a landmark can be identified through the peritoneum on the anterior side of the rectum. The sigmoid and descending colon are mobilized completely from the subretroperitoneal fascia to ensure that the subsequent coloanal anastomosis is free of tension. The sigmoid colon and its mesentery are then removed, the lymph nodes around the inferior mesenteric artery are dissected with a harmonic scalpel, and the inferior mesenteric artery is ligated at a high level with an endoclip. It is relatively easy to dissect Denonvillier’s fascia and expose the seminal vesicles and prostate gland or the posterior wall of the vagina on the anterior side, and to mobilize the lower rectum with mesorectum from the sacrum as a landmark to gauge placement of the separated plane between the visceral and parietal endopelvic fascia through the anus (Fig. 2). The lateral ligaments of the rectum are gradually divided with a harmonic scalpel from the inner limit of the inferior hypogastric nerve fibers, and the rectum, including the total mesorectum, is completely removed from the pelvic floor (Fig. 3). The colon and rectum are pulled out of the umbilical wound and resected. A coloanal anastomosis is transanally performed by hand suturing. Finally, a diverting ileostoma is created. The diverting ileostoma is closed from 3 to 6 months after surgery.
Results Six patients (4 men, 2 women) with lower rectal cancer underwent laparoscopic TME combined with TARD. All tumors were located below the peritoneal reflection, as assessed by preoperative barium enema, and the mean tumor size was 46.5 mm (range, 30 – 60 mm). The mean body mass index was 29.8 kg/m2 (range, 28.7–31.2 kg/m2), and the presence of a narrow pelvis and a thickened mesentery was confirmed in all patients. Although lymph node metastases were demonstrated in a patient on preoperative computed tomography and magnetic resonance imaging, no patient had direct invasion to surrounding organs, the pelvic wall, or the levator ani. The preoperative stage was T3N1M0 in 1 patient and T3N0M0 in 5 patients. Therefore, preoperative chemoradiation was not performed for this series.
e48
The American Journal of Surgery, Vol 197, No 4, April 2009
Figure 1 A circular incision of the rectum is performed by closing the cut end of the rectum with an interrupted suture, and mobilization of the rectum, including the tumor, is continued proximally by exposing the levator muscle (A–C). Division and mobilization of the rectum, including the mesorectum, is performed until the peritoneal reflection on the anterior side and until the sacral promontory beyond the rectosacral ligament on the posterior side (D).
The mean duration of the anal portion of the operation was 64 minutes (56 minutes in women, 79 minutes in men). No complications occurred during surgery or postopera-
tively. The average distance from the rectal stump was 24 mm (range, 17–30 mm). The postoperative pathologic stage was T3N1M0 in 3 patients, T3N0M0 in 2 patients, and
K. Funahashi et al.
Laparoscopic TME with transanal rectal dissection
e49
Figure 3 The lateral ligaments of the rectum are gradually divided with a harmonic scalpel from the inner limit of the inferior hypogastric nerve fibers, and the rectum, including the total mesorectum, is completely removed from the pelvic floor.
T2N0M0 in 1 patient. The surgical margin was histologically free of tumor cells in all patients (Table 1). There were no postoperative recurrences during a mean 16 months of follow-up (range, 4 –35 months).
Table 1
Figure 2 A gauze that is placed on the dissected plane as a landmark can be identified through the peritoneum on the anterior side of the rectum (A,B).
Patients (n ⫽ 6)
Variable
Value
Age (y) Men/women Mean (range) body mass index (kg/m2) Mean (range) maximum size of tumor (mm) Preoperative diagnosis T3N0M0 T3N1M0 Postoperative diagnosis T2N0M0 T3N0M0 T3N1M0 Histologic type Well-differentiated adenocarcinoma Moderately differentiated adenocarcinoma Mean (range) distance from the rectal stamp (mm) Mean duration of the anal portion of surgery (min) Men Women
62.8 4:2 29.8 (28.7–31.2) 46.5 (30–60) 5 1 1 2 3 1 5 24 (17–30) 64 79 56
e50
The American Journal of Surgery, Vol 197, No 4, April 2009
Comments
References
We have been able to perform laparoscopic TME for bulky lower rectal cancer with a thickened mesentery simply and safely using a modified procedure. Some authors1–3,5,6 have reported good outcomes of laparoscopic TME for lower rectal cancer. However, for bulky tumors with a thickened mesentery located near a narrow pelvic floor, the ability to clamp the anal side of the tumor with an endocutter to perform double stapling is limited. Laurent et al10 reported that the rate of conversion was 15.5% because of intraoperative rectal fixity and difficulty with pelvic dissection and/or stapling and that anatomic and technical difficulties associated with lower rectal cancer with a stapled anastomosis caused a higher rate of conversion, particularly in men with stapled anastomoses. Although per anum rectal dissection11 and a prolapsing technique12,13 were reported to prevent many of the problems associated with laparoscopic low or ultralow anterior resection, these procedures are appropriate only for select patients with T1 or T2 carcinoma of the lower rectum.14 In our series, we performed our modified procedure in patients with pathologic T2 or T3 bulky tumors with a mean size of 46 mm. In conclusion, TARD resolves the problems associated with laparoscopic TME for bulky tumors in the lower rectum, including selection of the appropriate distal line of transection, securing the resection plane, and ensuring reliable rectal washout. We believe that this technique is useful particularly during laparoscopic TME for patients with lower rectal cancer with operative limitations due to the presence of bulky tumors, a narrow pelvis, and a thickened mesentery. For the preliminary oncologic results, no postoperative recurrences have yet been experienced. However, a larger number of patients need to be treated with this procedure before final conclusions about safety and longterm efficacy can be made.
1. Breukink SO, Pierie JP, Grond AJ, et al. Laparoscopic versus open total mesorectal excision: a case-control study. Int J Colorectal Dis 2005;20:428 –33. 2. Breukink SO, Grond AJ, Pierie JP, et al. Laparoscopic vs open mesorectal excision for rectal cancer: an evaluation of the mesorectum’s macroscopic quality. Surg Endosc 2005;19:307–10. 3. Zhou ZG, Hu M, Li Y, et al. Laparoscopic versus open total mesorectal excision with anal sphincter preservation for low rectal cancer. Surg Endosc 2004;18:1211–5. 4. Wu WX, Sun YM, Hua YB, et al. Laparoscopic versus conventional open resection of rectal carcinoma: a clinical comparative study. World J Gastroenterol 2004;15:1167–70. 5. Barlehner E, Benhidjeb T, Anders S, et al. Laparoscopic resection for rectal cancer: out comes in 194 patients and review of the literature. Surg Endosc 2005;19:757– 66. 6. Leory J, Jamail F, Forbes L, et al. Laparoscopic total mesorectal excision (TME) for rectal cancer surgery; long-term outcomes. Surg Endosc 2004;18:281–9. 7. Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomized controlled trial. Lancet 2005;365:1718 –26. 8. Ono C, Yoshinaga K, Enomoto M, et al. Discontinuous rectal cancer spread in the mesorectum and the optimal distal clearance margin in situ. Dis Colon Rectum 2002;45:744 –9. 9. Zhao GP, Zhou ZG, Lei WZ, et al. Pathological study of distal mesorectal cancer spread to determine a proper distal resection margin. World J Gastroenterol 2005;21:319 –22. 10. Laurent C, Leblanc F, Gineste C, et al. Laparoscopic approach in surgical treatment of rectal cancer. Br J Surg 2007;94:1555– 61. 11. Teramoto T, Watanabe M, Kitajima M. Per anum intersphinteric rectal dissection with direct coloanal anastomosis for lower rectal cancer; the ultimate sphincter-preserving operation. Dis Colon Rectum 1997; 40(suppl):S43–7. 12. Takatsuka J, Isogai M, Okamoto Y, et al. Low anterior resection using the prolapsing technique [in Japanese]. Syujyutu 2001;55:1965–72. 13. Fukunaga M, Kidokoro A, Iba T, et al. Laparoscopy-assisted low anterior resection with a prolapsing technique for low rectal cancer. Surg Today 2005;35:598 – 602. 14. Watanabe M, Teramoto T, Hasegawa H, et al. Laparoscopic ultralow anterior resection with per anum intersphinteric rectal dissection for lower rectal cancer. Dis Colon Rectum 2000;45(suppl):S94 –7.