Laparoscopic TME Richard L. Whelan, MD St. Luke’s Roosevelt Hospital Columbia University New York, N.Y. 2011 MISS Meeting, Salt Lake City
Laparoscopic TME
Richard L. Whelan, MDSt. Luke’s Roosevelt Hospital
Columbia UniversityNew York, N.Y.
2011 MISS Meeting, Salt Lake City
Disclosures
• Olympus Corporation
• Applied Medical
• Gore Corporation
• Atrium Corporation
• Ethicon Endosurgery
Total Mesorectal Excision (TME) for Rectal Cancer
• Articulated & popularized by William Heald• TME results: significantly < recurrence and >
survival • TME is the ‘gold standard’ world wide• Been widely implemented and vetted
(Sweden, Finland, Holland, etc)• Concentration of rectal cases at “centers of
excellence” in some countries
Pre-TME Situation• Local recurrence rates varied widely (3-42%)• Ratio of APR to LAR varied considerably• Recognition that results varied from surgeon to
surgeon (case volume and training)• + lateral mesorectal margins local
recurrences• 2 cm distal rectal margin policy “coning in” &
incomplete mesorectal excision• There was no standard well articulated method
The mesorectal fascia is demonstrated as a low-signal intensity layer on MRI
Heald’s “Holy Plane” surrounds the mesorectum*
- Easiest posteriorly
- Anteriorly more difficult
- Lateral dissection plane most difficult to find
Total Mesorectal Excision Method: Principal Elements
- Complete rectal & circumferential mesorectal mobilization to pelvic floor
- Resection of entire mesorectum
- 4-5 cm distal bowel margin
- Distal rectum(2-3cm) preserved
- Sharp dissection (scissor, cautery, etc)
- Sparing of hypogastric and deep pelvic autonomic nerves
Surgical Approaches
• Standard open approach• Laparoscopic (transanal removal specimen)
• Laparoscopic-assisted (extraction incision only)
• Hand-assisted laparoscopic• Hybrid Laparoscopic / Open method• TATA (Transanal – Transabdominal - Transanal)
Status of Laparoscopic TME & Rectal Resection for Cancer
• Laparoscopic methods have been proven to be safe and effective for colon cancer
• Far less data regarding rectal cancer resection• Randomized multi-center laparoscopic rectal cancer trials
– COLOR 2 in Europe (over 850 patients entered)– ACOSOG Study (over 120 patients enrolled)– MITT Group (lap vs Hand LAR, just starting)
• No long term prospective randomized results yet available• Single center data suggests lap TME possible
Rectal Resection For Cancer Only After Gaining Experience Doing Laparoscopic Colectomy
• Should do rectal cases early only after:– Learning open TME methods – Learning 2 handed skills– Doing many lap colectomies
• Do not attempt LAR early in your laparoscopic experience
Advantages of Laparoscopic Methods for TME
• Superior visualization• Improved ability to identify:
– Planes – Nerves – Vessels
• Better able to do the distal portion of the mobilization sharply
Laparoscopic-Assisted LAR Resection: Port Placement
Extraction site & possible stapling port
Laparoscopic Abdomino-Perineal Resection
Hand-assisted LAR
Straight Laparoscopic LAR: The Start
• Standard lateral to medial at left iliac fossa– Identify ureter & gonadal vessels– Mobilize main sigmoidal vessels – Enter posterior plane
• Medial to lateral – Right side– Base of rectosigmoid– Near sacral promontory– Score parallel to the main sigmoidal vessels
Medial to Lateral Starting at Right Sacral Promontory
Initial Scoring in R Iliac Fossa
Components of a TME (sphincter saving)
• Posterior mesorectal mobilization• Lateral mesorectal mobilization• Anterior mesorectal mobilization• Distal mesorectal division• Distal rectal division• Anastomosis
Deep Pelvic Surgery • The bony pelvis limits outward traction• Important adjacent anterior structures
– Bladder - Seminal vessicles– Prostate - Vagina
• Important posterior structures– Hypogastric nerves - Nervi erigente – Presacral veins
• Exposure is further limited in:– Males with narrow and long pelvis– Obese patients– Patients with large & bulky tumors
Retraction of the Giant Uterus
• #2 nylon suture on straightened retention needle passed through lower abdominal wall
• Once inside, needle passed through uterus near round ligament
• Passed back outside• Tied over small gauze• Identical suture on opposite side
Retraction of Uterus to Abdominal Wall
Other Methods of Uterine & Vaginal Retraction
• Uterine manipulator– Retractor placed transvaginally into cervix– Fixed in position either with cervical balloon or a
clamp– Downard traction on external end of device
retracts the uterus upwards
• Vaginal identification & retraction– Can use EEA sizers OR clean proctoscope
The Challenge of Transabdominal Closed Deep Pelvic Surgery
Rectal transection level
Pubis
Pubis
Deep pelvis
Rectum
Front view
Side view
Traction and Countertraction are Crucial ! The Assistant is the Key
• Need 4 hands to do deep mobilization• Assistant provides much of the exposure• Choose dissection target
– Posterior, anterior or lateral
• Open atraumatic grasper is the tool • Apply strong traction & countertraction• Then retract cephalad !!! CRITICAL
Retract With Open Grasper
Two point retractionSingle point of retraction
Lateral Plane Exposure in Pelvis
Bony confines ofthe pelvis
Colon & Rectum
Pubis
Exposing Left Lateral Plane
Bowel graspers
Tissue Cutting Device
Exposing Right Lateral Pelvis
Tissue cutting device
Retraction to Expose R Side
• Video clip 0002PowerPoint_Hi.wmv
Importance of Cephalad Retraction Element
Video Clip: Gordon22Powerpoint_Hi.wmv:
Scoring of Peritoneum Anteriorly
Rectum
Pelvis
Anterior peritoneal reflection
Pubis
Anus
Leg
Head
Distal Rectal Retraction to Expose the Anterior Plane
Tucus
bladder
123
grasper
Rectum
Pelvis
Anterior peritoneal reflection
Pubis
Anus
Leg
Head
Distal Rectal Retraction to Expose the Anterior Plane
Tucus
bladder
12
2nd grasper
Early Anterior Dissection
Anterior Deep Dissection
• In males:– Identify seminal vessicles– Leave Denonvillier’s fascia intact unless lesion is
anterior– Avoid vas deferens (shouldn’t see it)
• In females:– Find plane between vagina and anterior rectal
wall– More fat in this space than you think
Extraperitoneal Rectal Mobilization• Alter traction until plane exposed• Shift dissection target frequently
– Left lateral to anterior – Anterior to right lateral– Lateral to posterior– Pull back camera to get broader view
• Find the clearest dissection field• When confused, change exposure and/or shift
dissection target
Pelvic Tissue Division & Dissection in Open & Closed LAR
• Monopolar cautery • Bipolar device• Ultrasonic shears• Avoid blunt dissection
Early Right Lateral Dissection
• Video clip Cohen44PowerPoint_Hi.wmv
Posterior Scoring
Posterior Mobilization
Sparing the Right Hypogastric Nerve in Mid-pelvis
Initial Scoring Left Pelvis
Proximal Left Dissection
Initial Division of L lateral Attachments
Minimally Invasive Strategies
Laparoscopic-assisted
Hand-assisted / Hybrid
Full Open Incision
Laparoscopic-assisted
Full Open Incision
Hand-assisted / Hybrid
Full Open Incision
Hand and Hybrid Methods
• Offer patients much of the benefits of MIS• Avoids full laparotomy• Do not have to fully complete case
laparoscopically• Is a logical approach• If can take flexure down closed then patient
will benefit.
Extraction wound
SpecimenAbdominal cavity
Abdominal wall
Specimen Extraction
Skin incision
Fascial incision
Peritoneal incision
Skin incision
Fascial incision
Peritoneal incision
Obesity
Hand-Assist Posterior Mobilization
Hand-assisted Right Lateral Dissection
Video clip: Gordon44Powerpoint_Hi.wmv
Develop Plane Between Rectum & Mesorectum at Transection Level
Distal Transection of Rectum
Transecting the Distal Rectum With Endo GIA
Rectal transection level
Via RLQ 12 mmPort
OR
Via Suprapubic 12 mm Port
Stapled EEA Anastomosis
How To Judge Completeness of TME
• Circumferential Resection Margin (CRM)• Gross appearance of the specimen
– Bilobed shape of the extraperitoneal posterior mesorectum
– Extent of lateral resection– ? mesorectal defects
• Mesorectum should be “inked” prior to opening
Summary• Learn open TME method first
– Full mesorectal mobilization to levators– Wide lateral margins– Aim for 3-5 cm distal margin– Distal 1/3 rd lesions, divert
• Identify and preserve the hypogastric nerves• Understand vascular anatomy of each patient• Learn anterior deep pelvic anatomy• Inspect your specimens carefully
Summary• Routinely mobilize the splenic flexure• Practice MIS methods on prolapse patients
and sigmoid resections• Once mastered open TME MIS LAR/APR• Find good 1st assistant• Initially, take splenic flexure down &
devascularize proximally via closed methods• Initiate pelvic dissection laparoscopically
Summary
• Can complete case using hybrid (open) or hand method if need be
• As experience is gained, increase percentage of pelvic dissection done laparoscopically
• Traction and counter traction critical plus element of cephalad retraction
• Stick to the “Holy Plane”• As needed, shift operative field from posterior
to lateral to anterior to find best exposure
Summary
• Transect distal rectum intracorporeally provided can do it with 2 60 mm cartridges
• Alternative is to use open TA stapler via Pfannenstiel suprapubic incision
• Hand approach is logical if having difficulty OR if lesion is bulky or patient quite obese
Need to add video clips
Laparoscopic TME: Summary
Lateral Plane Exposure in Pelvis
Bony confines ofthe pelvis
Colon & Rectum
Exposing Left Lateral Plane
Bowel graspers
Tissue Cutting Device
Exposing Right Lateral Pelvis
Tissue cutting device
Rectum
Pelvis
Abdomen
Distal resection point
Pubis
Anus
Leg
Head
Distal Rectal TransectionStapler
Tucus
Distal Rectal Transection
• Angled staple line often obtained (spear shaped)
• Multiple staple cartridges often necessary• True transverse division with one cartridge
rarely obtained.• Use of suprapubic port to staple helps greatly
(alternate RLQ 12 mm port)
Distal Rectal Transection
Pelvic Exposure In Open LAR• Traction, countertraction critical• St. Marks, Dever, Sawyer retractors are critical
– Head light vs Lighted retractors (fiberoptic light cables)
– Bookwalter & similar self retaining retractors
• Single person provides exposure for deep lateral, anterolateral areas (2 St. Marks)– Sidewall and mesorectum retracted– Retraction is outward & cephalad
• Must work within the confines of the bony pelvis
Laparoscopic TME
• Exposure is of paramount importance• Closed methods pose different challenges
– Small bowel retraction – Uterine retraction
• Some challenges are the same for open & closed methods– Exposure obtained via traction & counter traction– Working in the deep pelvis– Confines of the bony pelvis are the same
Retraction & Counter traction Mandatory *
• Cannot do deep pelvic dissection alone• Need skilled 1st assistant • Decide area to be exposed (lateral rectum on
the right)– Retractor (via R sided port) retracts sidewall tissue
laterally and towards the head– 2nd grasper (open) retracts right side of rectum
medially and cephalad
* Especially in the obese patient