laparoscopic tme richard l. whelan, md st. luke’s roosevelt hospital columbia university new york,...
TRANSCRIPT
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Laparoscopic TME
Richard L. Whelan, MDSt. Luke’s Roosevelt Hospital
Columbia UniversityNew York, N.Y.
2011 MISS Meeting, Salt Lake City
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Disclosures
• Olympus Corporation
• Applied Medical
• Gore Corporation
• Atrium Corporation
• Ethicon Endosurgery
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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
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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
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The mesorectal fascia is demonstrated as a low-signal intensity layer on MRI
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Heald’s “Holy Plane” surrounds the mesorectum*
- Easiest posteriorly
- Anteriorly more difficult
- Lateral dissection plane most difficult to find
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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
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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)
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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
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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
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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
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Laparoscopic-Assisted LAR Resection: Port Placement
Extraction site & possible stapling port
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Laparoscopic Abdomino-Perineal Resection
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Hand-assisted LAR
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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
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Medial to Lateral Starting at Right Sacral Promontory
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Initial Scoring in R Iliac Fossa
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Components of a TME (sphincter saving)
• Posterior mesorectal mobilization• Lateral mesorectal mobilization• Anterior mesorectal mobilization• Distal mesorectal division• Distal rectal division• Anastomosis
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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
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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
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Retraction of Uterus to Abdominal Wall
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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
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The Challenge of Transabdominal Closed Deep Pelvic Surgery
Rectal transection level
Pubis
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Pubis
Deep pelvis
Rectum
Front view
Side view
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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
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Retract With Open Grasper
Two point retractionSingle point of retraction
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Lateral Plane Exposure in Pelvis
Bony confines ofthe pelvis
Colon & Rectum
Pubis
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Exposing Left Lateral Plane
Bowel graspers
Tissue Cutting Device
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Exposing Right Lateral Pelvis
Tissue cutting device
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Retraction to Expose R Side
• Video clip 0002PowerPoint_Hi.wmv
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Importance of Cephalad Retraction Element
Video Clip: Gordon22Powerpoint_Hi.wmv:
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Scoring of Peritoneum Anteriorly
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Rectum
Pelvis
Anterior peritoneal reflection
Pubis
Anus
Leg
Head
Distal Rectal Retraction to Expose the Anterior Plane
Tucus
bladder
123
grasper
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Rectum
Pelvis
Anterior peritoneal reflection
Pubis
Anus
Leg
Head
Distal Rectal Retraction to Expose the Anterior Plane
Tucus
bladder
12
2nd grasper
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Early Anterior Dissection
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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
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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
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Pelvic Tissue Division & Dissection in Open & Closed LAR
• Monopolar cautery • Bipolar device• Ultrasonic shears• Avoid blunt dissection
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Early Right Lateral Dissection
• Video clip Cohen44PowerPoint_Hi.wmv
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Posterior Scoring
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Posterior Mobilization
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Sparing the Right Hypogastric Nerve in Mid-pelvis
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Initial Scoring Left Pelvis
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Proximal Left Dissection
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Initial Division of L lateral Attachments
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Minimally Invasive Strategies
Laparoscopic-assisted
Hand-assisted / Hybrid
Full Open Incision
Laparoscopic-assisted
Full Open Incision
Hand-assisted / Hybrid
Full Open Incision
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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.
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Extraction wound
SpecimenAbdominal cavity
Abdominal wall
Specimen Extraction
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Skin incision
Fascial incision
Peritoneal incision
Skin incision
Fascial incision
Peritoneal incision
Obesity
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Hand-Assist Posterior Mobilization
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Hand-assisted Right Lateral Dissection
Video clip: Gordon44Powerpoint_Hi.wmv
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Develop Plane Between Rectum & Mesorectum at Transection Level
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Distal Transection of Rectum
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Transecting the Distal Rectum With Endo GIA
Rectal transection level
Via RLQ 12 mmPort
OR
Via Suprapubic 12 mm Port
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Stapled EEA Anastomosis
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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
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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
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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
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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
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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
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Need to add video clips
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Laparoscopic TME: Summary
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Lateral Plane Exposure in Pelvis
Bony confines ofthe pelvis
Colon & Rectum
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Exposing Left Lateral Plane
Bowel graspers
Tissue Cutting Device
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Exposing Right Lateral Pelvis
Tissue cutting device
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Rectum
Pelvis
Abdomen
Distal resection point
Pubis
Anus
Leg
Head
Distal Rectal TransectionStapler
Tucus
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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)
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Distal Rectal Transection
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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
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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
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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