Autonomic nerve-preserving laparoscopic total mesorectal excision in a male patient based on a new anatomical concept

The key to an oncologically resection of mid or low rectal cancer is the 'en bloc' resection of the rectum and its enveloping mesentery to the level of the pelvic floor with a negative distal and radial resection margin, the total mesorectal excision (TME). This video illustrates a laparoscopic low anterior resection in a 62-year-old female patient with T3 N0 mid-rectal carcinoma approximately 8 to 9cm from the anal verge.

This video describes a practical solution to total mesorectal excision using robotics. The patient is a 55-year-old female with a BMI of 32 and low rectal cancer localized 3cm above the anorectal ring. She also has large uterine fibroids.
The patient received preoperative chemoradiation and subsequently underwent a surgical procedure in form of ultra low anterior resection with colonic J pouch creation and protective ileostomy.
The concept of the procedure utilizes several surgical techniques which seem to be best suited for an obese patient with locally advanced low rectal cancer. The main emphasis during this presentation is placed on robotic total mesorectal excision. On the other hand, we would like to present a fairly universal approach to any low rectal cancer.
Several important issues in regards to the current robotic technology are discussed. These include the obvious advantage in the deep pelvis, hybrid concept, and the answer to the question “Why isn’t the entire procedure performed robotically?”

Background: Rectal resection with total mesorectal excision (TME) can be performed through the anus going up into the abdominal cavity. This approach has to be performed using a transanal device in order to create a retroperitoneum, allowing the surgeon to perform a TME similar to the one performed from the abdomen going down to the anus. A new reusable port named DAPRI Port or D-Port (Karl Storz Endoskope, Tuttlingen, Germany) has been developed, and a new platform together with curved reusable instruments according to DAPRI (Karl Storz Endoskope) has been created. The D-Port allows to maintain one of the rules of laparoscopy, which is the optical system in the middle of the two ancillary operative tools. In addition, the cost of the procedure is not increased, due to the reusable material.
Video: This video shows a down-to-up rectal resection assisted by single incision laparoscopy, in a 65-year old man presenting with a rectal adenocarcinoma 4cm away from the anal margin. Preoperative work-up showed a T2N0M0 tumor, after radiochemotherapy. The procedure was performed transabdominally for the vascular dissection and transanally for the TME. The abdominal single site was then used for the placement of the temporary ileostomy.
Results: Total operative time was 301 minutes, and partial transanal laparoscopy was 145 minutes. Perioperative bleeding was 50cc. The final scar length was 2.5cm, and the patient was discharged after 5 days. The pathological report confirmed a pT2N0M0 tumor (15 negative nodes).
Conclusions: Down-to-up rectal resection is an interesting procedure, and when associated with single incision laparoscopy, it offers the possibility to use the single site as the site for temporary ileostomy.

Background: Single incision laparoscopy is worth of interest during up-to-down rectal resection because it allows to use the single site as the site of temporary ileostomy placement at the end of the procedure.
Video: This video shows an up-to-down single incision laparoscopic rectal resection in a 49-year-old woman presenting with a rectal adenocarcinoma located 12cm away from the anal margin. Preoperative work-up showed a T2N0M0 tumor. The procedure was entirely performed with curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany), inserted in the right flank. The uterus and the peritoneal sheet covering the vagina were retrieved using percutaneous sutures. A circular mechanical colorectal anastomosis was performed and a final temporary ileostomy was placed at the site of the single access.
Results: The procedure duration was 297 minutes, and peroperative bleeding was unsignificant. The final scar length was 2.5cm, and the patient was discharged on postoperative day 5. The pathological report confirmed a pT2N0M0 tumor (20 negative nodes).
Conclusions: Up-to-down single incision laparoscopic rectal resection allows to place the temporary ileostomy at the single incision site, offering oncological results comparable to conventional laparoscopy.

This is the case of a 55-year-old man who presented with rectal bleeding. Colonoscopy detected a mass in the middle rectum, 6cm from the anal verge (AV). Biopsy results revealed the presence of an adenocarcinoma. Pelvic MRI and abdominal CT-scan showed no distant metastases, a T3N1M0 tumor 6cm from the anal verge, and an intact mesorectal fascia.
After 8 weeks of neoadjuvant chemoradiation therapy (CRT), a minimally invasive low anterior resection with transanal total mesolectal excision was performed.
A one-team abdomen-first approach is performed.