TME for rectal cancer in a female patient: low rectal dissection

Total mesorectal excision (TME) has been established as a standardized radical surgical procedure in malignant tumors of the middle and lower rectal third. The objectives of TME are low rates of locoregional recurrences and good functional results. Total mesorectal excision in the radical surgical treatment of lower and middle third rectal carcinomas is the essential part of lymphatic dissection in these tumors. This film shows the low rectal dissection performed by a very experienced surgeon in a female patient presenting with cancer of the middle third of the rectum. Thanks to an adequate traction and counter-traction and thanks to the use of scissors (roticulator endo minishears), the rectum surrounded by its fascia propria is progressively divided.

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TME for rectal cancer in a female patient: low rectal dissection

Authors

J Leroy, J Marescaux

Abstract

Total mesorectal excision (TME) has been established as a standardized radical surgical procedure in malignant tumors of the middle and lower rectal third. The objectives of TME are low rates of locoregional recurrences and good functional results. Total mesorectal excision in the radical surgical treatment of lower and middle third rectal carcinomas is the essential part of lymphatic dissection in these tumors. This film shows the low rectal dissection performed by a very experienced surgeon in a female patient presenting with cancer of the middle third of the rectum. Thanks to an adequate traction and counter-traction and thanks to the use of scissors (roticulator endo minishears), the rectum surrounded by its fascia propria is progressively divided.

Classification

tips and tricks

Keywords

TME for rectal cancer, female patient, low rectal dissection

Media type

Surgical video

Duration

04'05''

Publication

2009-04

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E-publication

WeBSurg.com, Apr 2009;9(04).
URL: http://www.websurg.com/doi-vd01en2582.htm

TME for rectal cancer in a female patient: low rectal dissection

1. Introduction 00'09''

The objective of this film is to show the low rectal dissection in a female patient presenting with cancer of the middle third of the rectum. The upper rectum has been dissected. To do so, the dissection is performed anterior to the rectum.

2. Exposure 00'30''

The uterus is retracted anteriorly by the assistant standing between the patient’s legs. The retraction is maintained thanks to a grasper introduced in the suprapubic port.

3. Opening the Douglas\' pouch 00'46''

Then the recto-uterine pouch (Douglas’ pouch) is opened on the posterior aspect of the cervix, which allows to grasp the peritoneum on the anterior aspect of the rectum and to maintain the retraction between the vagina and the anterior rectum.

4. Division of the rectum from the Denonvilliers\' fascia 01'09''

Thanks to an adequate traction and counter-traction and thanks to the use of scissors (roticulator endo minishears) introduced into the right iliac fossa port, the rectum surrounded by its fascia propria is progressively divided from the Denonvilliers’ fascia on the posterior aspect of the vagina. The retraction must be performed bluntly thanks to the use of peanut swabs mounted on the forceps that retracts the rectum medially and posteriorly. This is done in conjunction with retraction of the vagina thanks to a 10mm retractor introduced in the suprapubic port. An H-shaped 10mm retractor is deployed back to vagina. It is a right-angled instrument, and helps to place an anterior traction, thus avoiding any increased intra-abdominal pressure.

5. Middle rectum dissection 02'41''

Thanks to traction and counter-traction that creates a two-directional retraction, and thanks to the use of articulated scissors (i.e., through a spatulated electrode), dissection is continued both on the anterior and the posterior aspect of the rectum, sliding between both pelvic and rectal fascias. The posterior dissection must be carried out underneath the mesorectum. Laterally this dissection is continued until the skeletonization of the rectal wall, making sure to avoid entering the rectum. The use of the retractor introduced on the posterior aspect of the rectum helps to gain a correct exposure and to place an adequate tension of the tissues. The dissection can then be continued underneath the mesorectum until skeletonization of the posterior aspect of the rectum thanks to the division of sacrorectal attachments.