monthly focus

surgical intervention video

This educational video presents the case of a laparoscopic subtotal colectomy for severe acute colitis with a bottom-up approach to detach the right colon which requires the placement of a suprapubic optical port as in the laparoscopic ileocecal resection technique.



Bibliography:

1. Chebbi F, Ayadi MS, Rhaiem R, Daghfous A, Makni A, Rebaϊ W, Ksantini R, Ftirich F, Jouini M, Kacem M, Ben Safta Z. Laparoscopic ileo-cecal resection: the total retro-mesenteric approach. Surg Endosc. 2015 Jan;29(1):245-51. doi: 10.1007/s00464-014-3666-8. Epub 2014 Jul 10. PMID: 25007973.

2. Mege D, Stellingwerf ME, Germain A, Colombo F, Pellino G, Di Candido F, Maggiori L, Foschi D, Buskens CJ, Adegbola S, Spinelli A, Warusavitarne J, Bemelman WA, Sampietro G, D'Hoore A, Panis Y. Management of Rectal Stump During Laparoscopic Subtotal Colectomy for Inflammatory Bowel Disease: A Comparative Cohort Study from Six Referral Centres. J Crohns Colitis. 2020 Sep 16;14(9):1214-1221. doi: 10.1093/ecco-jcc/jjaa046. PMID: 32191295.

3. Antonino Spinelli, Stefanos Bonovas, Johan Burisch, Torsten Kucharzik, Michel Adamina, Vito Annese, Oliver Bachmann, Dominik Bettenworth, Maria Chaparro, Wladyslawa Czuber-Dochan, Piotr Eder, Pierre Ellul, Catarina Fidalgo, Gionata Fiorino, Paolo Gionchetti, Javier P Gisbert, Hannah Gordon, Charlotte Hedin, Stefan Holubar, Marietta Iacucci, Konstantinos Karmiris, Konstantinos Katsanos, Uri Kopylov, Peter L Lakatos, Theodore Lytras, Ivan Lyutakov, Nurulamin Noor, Gianluca Pellino, Daniele Piovani, Edoardo Savarino, Francesco Selvaggi, Bram Verstockt, Glen Doherty, Tim Raine, Yves Panis, ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment, Journal of Crohn's and Colitis, Volume 16, Issue 2, February 2022, Pages 179–189



Laparoscopic subtotal colectomy for severe acute colitis 

Colectomie subtotale laparoscopique pour colite aiguë grave

Colectomie gauche laparoscopique à trois trocarts pour une tumeur de l'angle colique gauche

This is the case of a 36-year-old woman with no relevant personal or family history. She presented with anemia and changes in bowel habits over a 3-month period. CT-scan revealed a marked concentric thickening of the colonic wall at the splenic flexure with an inflammation of the surrounding adipose tissue. Videocolonoscopy described a neoproliferative nipple-like ulcerated friable lesion located 30cm away from the anal margin. Biopsy was performed and the lesion was marked with Indian ink. 

Three 10mm trocars were placed in the epigastrium, right hypochondrium, and right iliac fossa, respectively. Medial and lateral approaches were used. Through an anterior trans-omental approach, the greater omentum was separated from the transverse colon. The dissection of the omentum was continued to the left and mobilization was completed. Once complete mobilization was achieved, the distal division was performed using a 60mm mechanical suture. A colorectal anastomosis was then performed using a circular mechanical suture. The pneumatic test was negative. 



Bibliography:

1. Roscio F, Bertoglio C, De Luca A, Frattini P, Clerici F, Scandroglio I. Totally laparoscopic resection of the splenic flexure for tumor. Updates Surg. 2012 Sep;64(3):185-90. doi: 10.1007/s13304-012-0162-3. Epub 2012 Jun 28. PMID: 22739994.

2. Cirocco WC. The optimal extent of colectomy for splenic flexure carcinoma - Extended vs segmental? Less is best! Am J Surg. 2023 Mar;225(3):452-453. doi: 10.1016/j.amjsurg.2022.10.054. Epub 2022 Nov 15. PMID: 36402619.

3. Hashida H, Kondo M, Kita R, Kitamura K, Uryuhara K, Kobayashi H, Kaihara S. Laparoscopic Colectomy for Splenic Flexure Cancer Approached from Four Directions. J Laparoendosc Adv Surg Tech A. 2021 Sep;31(9):1014-1018. doi: 10.1089/lap.2020.0709. Epub 2020 Nov 23. PMID: 33226876.

4. Rondelli F, Pasculli A, De Rosa M, Avenia S, Bugiantella W. Is routine splenic flexure mobilization always necessary in laparotomic or laparoscopic anterior rectal resection? A systematic review and comprehensive meta-analysis. Updates Surg. 2021 Oct;73(5):1643-1661. doi: 10.1007/s13304-021-01135-y. Epub 2021 Jul 24. PMID: 34302604.

Three-port laparoscopic left colectomy for splenic flexure tumor

There is evidence in the literature supporting that postoperative complications in colorectal surgery can be handled laparoscopically. Many cases of reoperative surgery will be described in the video. Most of them are due to anastomotic leakage evidenced during the early postoperative days. Depending on the size of the anastomotic defect, an anastomosis takedown or proximal ostomy may be performed. Lavage of the entire abdomen can be performed using a minimally invasive approach. Patients may keep the benefits of the initial laparoscopic surgery with the management of this potentially lethal complication using a reoperative laparoscopic surgery.

Bibliography:

1\. Rotholtz NA, Laporte M, Matzner M, Schlottmann F, Bun ME. "Relaparoscopy" to treat early complications following colorectal surgery. Surg Endosc. 2022 May;36(5):3136-3140. doi: 10.1007/s00464-021-08616-6. Epub 2021 Jun 22. PMID: 34159459.

2\. Rotholtz NA, Angeramo CA, Laporte M, Matzner Perfumo M, Schlottmann F, Bun ME. "Early" Reoperation to Treat Complications Following Laparoscopic Colorectal Surgery: The Sooner the Better. Surg Laparosc Endosc Percutan Tech. 2021 Aug 18;31(6):756-759. doi: 10.1097/SLE.0000000000000984. PMID: 34406166.

Laparoscopic reoperation for early postoperative complications after colorectal surgery

Réopération laparoscopique en cas de complications postopératoires précoces après chirurgie colorectale

Although complete mesocolic excision has oncological importance for colon cancer surgery, there are some difficulties in right hemicolectomy due to variations in the vascular anatomy around the gastrocolic trunk (1-3). Recently, in a study including 38,030 cases of right hemicolectomy from the Japanese national database, the 30-day postoperative mortality rate was 1.2% (4). In the video, we presented the advantages of the cranial-first approach for right-sided colon cancer. This procedure comprised three steps. First, the omentum was dissected and the transverse mesocolon was taken down. The right gastroepiploic vein and the anterior superior pancreaticoduodenal vein were preserved, and the accessory right colic vein (ARCV) was dissected at its root. The pancreatic head and the horizontal duodenal leg were exposed extensively. Secondly, the patient’s head was lowered, and the ileocecum was detached from the caudal side for complete mobilization of the right-sided colon. Finally, the patient was changed to a horizontal position, and lymphadenectomy was performed depending on the tumor’s location. In this case, the ileocolic artery (ICA) and ileocolic vein (ICV) and the right branches of the middle colic artery (MCA) and of the middle colic vein (MCV) were divided. The MCV was mostly divided from the cranial side. However, as the case could be easily treated from the medial side, the MCV was divided consistently using a medial approach. The major advantages of this technique were to safely dissect the ARCV at its origin while clearly visualizing the right gastroepiploic vein and the anterior superior pancreaticoduodenal vein and to recognize the dissection line around the gastrocolic trunk (GCT). Another advantage was to easily perform lymph nodes dissection in the dorsal side of the superior mesenteric vein (SMV), visualizing the right lateral border of the nerves around the superior mesenteric artery (SMA). 



Bibliography: 

1. Hohenberger, W., Weber, K., Matzel, K., Papadopoulos, T. and Merkel, S. (2009) Standardized surgery for colonic cancer: complete mesocolic excision and central ligation--technical notes and outcome. Colorectal Dis, 11: 354-364; discussion 364-355. doi: 10.1111/j.1463-1318.2008.01735.x

2. West, N. P., Hohenberger, W., Weber, K., Perrakis, A., Finan, P. J. and Quirke, P. (2010) Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon. J Clin Oncol, 28: 272-278. doi: 10.1200/JCO.2009.24.1448

3. De Simoni, O., Barina, A., Sommariva, A., Tonello, M., Gruppo, M., Mattara, G., et al. (2021) Complete mesocolic excision versus conventional hemicolectomy in patients with right colon cancer: a systematic review and meta-analysis. Int J Colorectal Dis, 36: 881-892. doi: 10.1007/s00384-020-03797-3

4. Yoshida, T., Miyata, H., Konno, H., Kumamaru, H., Tangoku, A., Furukita, Y., et al. (2018) Risk assessment of morbidities after right hemicolectomy based on the National Clinical Database in Japan. Ann Gastroenterol Surg, 2: 220-230. doi: 10.1002/ags3.12067

Advantages of the cranial-first approach in laparoscopic surgery for right-sided colon cancer

Avantages de l'abord supérieur premier dans la chirurgie laparoscopique du cancer du côlon droit

The patient was a 84-year-old woman with no history of perianal abscess and sigmoid diverticulosis. She had episodes of rectal bleeding, weight loss, and previous endoscopic resection for adenomatous polyps with high-grade dysplasia in the sigmoid and right colon. Her family history included colorectal cancer. She underwent an endoscopic dissection for an adenomatous polyp with low-grade dysplasia in the right colon and for a 15mm laterally spreading tumor (LST) in the transverse colon with a grade III (dysplasia?) according to Kudo’s classification and with SCAD-like (please clarify) inflammation in the descending and sigmoid colon. After 8 months, she underwent another endoscopic dissection for a recurrent LST on the distal transverse colon, which was positive for a pT1 adenocarcinoma, and for adenomatous tubular villous polyps in the ascending colon with low-grade dysplasia. CT-scan showed a concentric thickening of a 2.5cm tract near the splenic flexure. A laparoscopic total colectomy was performed to manage the pT1N0 colonic adenocarcinoma (please confirm). The transverse colon cancer can be treated with different kinds of colonic resections, but when it appears with multiple conditions such as colitis and recurrent dysplastic lesions, or with a strong family history of colon cancers, total colectomy should be considered. Laparoscopy in elderly patients is always carefully considered due to the increasing physiological demands. However, it is a feasible and safe approach with potential short-term benefits. The literature shows no significant differences in overall morbidity and mortality between laparoscopic and open surgery in old patients. However, some pooled analyses are starting to show a slightly reduced morbidity in the laparoscopic approach, even in elderly patients, with a reduced risk of surgical site infections, a faster recovery time inducing a shorter hospital stay, and less need for rehabilitation.



Bibliography:

1. Devoto L, Celentano V, Cohen R, Khan J, Chand M. Colorectal cancer surgery in the very elderly patient: a systematic review of laparoscopic versus open colorectal resection. Int J Colorectal Dis. 2017 Sep;32(9):1237-1242. doi: 10.1007/s00384-017-2848-y. Epub 2017 Jun 30. PMID: 28667498.

2. Passuello N, Polese L, Ometto G, Grossi U, Mammano E, Vittadello F, Frasson A, Tessari E, Bartolotta P, Gregori D, et al. Outcomes of Laparoscopic Surgery in Very Elderly Patients with Colorectal Cancer: A Survival Analysis and Comparative Study. Journal of Clinical Medicine. 2023; 12(22):7122. https://doi.org/10.3390/jcm12227122

3. Ueda, Y., Shiraishi, N., Kawasaki, T. et al. Short- and long-term outcomes of laparoscopic surgery for colorectal cancer in the elderly aged over 80 years old versus non-elderly: a retrospective cohort study. BMC Geriatr 20, 445 (2020). https://doi.org/10.1186/s12877-020-01779-2

4. Chern, YJ., Hung, HY., You, JF. et al. Advantage of laparoscopy surgery for elderly colorectal cancer patients without compromising oncologic outcome. BMC Surg 20, 294 (2020). https://doi.org/10.1186/s12893-020-00967-6



Laparoscopic total colectomy for transverse colon adenocarcinoma in an elderly woman

Colectomie totale laparoscopique pour adénocarcinome du côlon transverse chez une femme âgée

Laparoscopic surgery is a technically demanding procedure that requires a significant level of experience and expertise. Since surgery is the mainstay treatment of rectal cancer, comprehending the complexities of multilaminar structures and interfascial spaces is mandatory.

This is the case of a 68-year-old woman who was evaluated for a positive fecal occult blood test. Colonoscopy found a vegetative lesion 15cm away from the anal verge, occupying approximately half of the lumen. Biopsy and distal tattooing were performed. The biopsy study confirmed the presence of a moderately differentiated adenocarcinoma. CT-scan showed no lung nor liver metastasis. MRI revealed an upper rectal cancer, 11.4cm away from the anal verge, with no pathological lymph nodes. It was a T2 N0 Mx negative CRM tumor. Surgical treatment was decided upon along with a laparoscopic anterior rectal resection. This video demonstrates all the important technical steps to fasten the learning curve and master the procedure in a stepwise approach, without compromising the oncologic principles.

Bibliography:

1\. Park, Y. Y., & Lee, K. Y. (2021). Step-wise learning of laparoscopic low anterior resection. Journal of Minimally Invasive Surgery, 24(1), 56‑58. [https://doi.org/10.7602/jmis.2021.24.1.56](https://doi.org/10.7602/jmis.2021.24.1.56)

2\. Morino, M., Parini, U., Giraudo, G., Salval, M., Brachet Contul, R., & Garrone, C. (2003). Laparoscopic total mesorectal excision. Annals of Surgery, 237(3), 335‑342. [https://doi.org/10.1097/01.SLA.0000055270.48242.D2](https://doi.org/10.1097/01.SLA.0000055270.48242.D2)

3\. Mahmoud, A. M. A., & Moneer, M. M. (2017). Toward standardization of laparoscopic resection for colorectal cancer in developing countries : A step by step module. Journal of the Egyptian National Cancer Institute, 29(3), 135‑140. [https://doi.org/10.1016/j.jnci.2017.04.003](https://doi.org/10.1016/j.jnci.2017.04.003)

4\. Montroni, I., Mari, G., Boni, L., Maggioni, D., Crippa, J., Cocozza, E., Ferrari, G., Ugolini, G., Capelli, P., Berti, S., Pugliese, R., Spinelli, A., & AIMS Academy clinical research network. (2021). Surgical coaching applied to laparoscopic TME for continuous professional development in rectal surgery : Proof of concept. Updates in Surgery, 73(5), 1805‑1810. [https://doi.org/10.1007/s13304-021-01137-w](https://doi.org/10.1007/s13304-021-01137-w)

Laparoscopic low anterior resection (LAR): a stepwise approach

Résection laparoscopique antérieure basse : une approche par étapes

Biopsie ganglionnaire laparoscopique en cas de pathologie hématologique mal diagnostiquée : prélèvement du groupe de ganglions péri-aortiques

This video shows the case of a 73-year-old female patient who was admitted to the emergency department for abdominal pain. Through the anamnesis she did not report any past medical condition. CT-scan of the abdomen showed a diffuse lymphadenomegaly. Blood tests did not identify any significant changes that might be suggestive of a hematologic disease. A bone marrow biopsy was performed without any diagnostic finding. A full body 18F-FDG PET/CT-scan was performed and showed increased metabolism at the periaortic lymph node package and near the left renal vein. After a multidisciplinary case discussion, surgery was indicated. A laparoscopic lymph node sampling was decided upon. 

The patient was placed supine in a left lateral Trendelenburg position. Four 12mm trocars were placed according to the Hasson technique. The first trocar was placed supraumbilically. The second trocar was placed in the epigastric region. Two additional trocars were inserted in the left and right midclavicular line respectively.

The procedure began with the takedown of the hepatic flexure. As a result, a disconnection was performed between Toldt’s fascia and Gerota’s fascia, exposing the renal fascia and medializing the ascending colon. The upper knee of the duodenum was identified and mobilized according to the Kocher maneuver. This maneuver ended when the duodenal block was verticalized and the left margin of the aorta was uncovered. At the end of the maneuver, lymph nodes with potential pathological significance were discovered with 18F-FDG PET/CT imaging. The first lymph node identified on the aortic plane was sampled, and after discovering the left renal vein, the lymph node identified with 18F-FDG PET/CT imaging was harvested. 

The patient resumed oral feeding rapidly and was discharged home on POD 3. Histological and cytofluorimetric analyses confirmed the presence of a marginal-type low-grade B-cell non-Hodgkin lymphoma.

Immunophenotyping evidenced the following tumor markers as such: CD20 positive, PAX5 positive, BCL2 positive, CD10 negative, and CD200 negative B cells.



Laparoscopy usually plays a marginal role in the diagnosis of hematologic diseases.

The authors reported the clinical case of a female patient with a new-onset hematologic disease which could not be determined via classical diagnostic markers performed using serum chemistries and with bone marrow biopsy. Following a multidisciplinary case discussion, surgery was indicated and a diagnostic laparoscopy was performed with sampling of the periaortic lymph nodes. 



Bibliography:

1. Nevler, A., Har-Zahav, G., Abraham, A., Schiby, G., Zmora, O., Shabtai, M., Gutman, M., & Rosin, D. (2017). Laparoscopic lymph node biopsy : Efficacy and advantages. The Israel Medical Association Journal: IMAJ, 19(4), 231 233.



Laparoscopic lymph node biopsy in misdiagnosed hematologic disease: sampling of the periaortic lymph node group

Colorectal cancer is the third most common type of cancer in the world. Approximately 35 to 55% of patients will develop liver metastases in the course of the disease. Surgical resection is the only option for long-term survival. The laparoscopic approach for lesions located in the superior segments of the posterior liver is still challenging. 

This video aims to demonstrate a laparoscopic resection of the metastasis located in liver segment VII as performed at the authors’ institution. 

The authors present the case of a 65-year-old man diagnosed with a cancer of the splenic flexure of the colon, occlusive, and with a single synchronous metastasis in liver segment VII. 

Initially, the patient underwent a laparoscopic segmental colectomy for a cancer in the splenic flexure of the colon. It was then decided to perform a laparoscopic segment VII atypical resection. Five ports were placed. The procedure began with a complete abdominal exploration and no other lesions were observed macroscopically. The right triangular and coronary ligaments were divided. The left triangular ligament was also divided to medialize the right liver and to access liver segment VII. The extension of the lesion was identified via intraoperative ultrasound and the limits of the resection were marked. It was confirmed by fluoroscopy that the margins were free (indocyanine green (ICG) was administered 20 hours earlier). The hepatic pedicle was looped and the gastric antrum exited through the left flank. Hepatotomy was started and continued until the complete release of the lesion. Hemostasis was controlled with a bipolar irrigation forceps and clips on major vessels. The resection margins were confirmed using fluorescein and a small fragment was enlarged on the lower margins. Hemostasis and bilistasis were controlled. 

The postoperative course was uneventful, and the patient was discharged on postoperative day 5. Pathological findings confirmed a 2.2 by 1.5cm hepatic metastasis of adenocarcinoma compatible with colorectal primary cancer. 

Despite the various obstacles and challenges, the laparoscopic approach has obvious advantages: less tissue damage associated with lower levels of postoperative pain, fewer peritoneal adhesions, a shorter hospital stay, and an earlier return to daily activities. Recent studies also add to these advantages less blood loss and no differences in the recurrence rate or long-term survival rate in malignant conditions. 



Bibliography:

1. Gon, Hidetoshi et al. Suitability of Laparoscopic Liver Resection of Segment VII: a Retrospective Two-Center Study. J Gastrointest Surg. 2022 Nov;26(11):2274-2281. doi: 10.1007/s11605-022-05389-8. Epub 2022 Jun 17.

2. S R Coles et al. Total laparoscopic management of lesions involving liver segment 7. Surg Endosc. 2015 Nov;29(11):3190-5. doi: 10.1007/s00464-014-4052-2. Epub 2015 Jan 13.

3. Engstrand, Jennie et al. Colorectal cancer liver metastases - a population-based study on incidence, management and survival. BMC Cancer. 2018 Jan 15;18(1):78. doi: 10.1186/s12885-017-3925-x.



Laparoscopic resection of liver segment VII for metastatic colorectal cancer

Segmentectomie laparoscopique du segment hépatique VII pour cancer colorectal métastatique

video lecture

TaTME for complex rectal cancers beyond the learning curve

Essential surgical anatomy and step-by-step procedures in performing TaTME

Colectomie totale laparoscopique avec création d'une iléostomie terminale pour colite ulcéreuse réfractaire 

In this educational video, the authors demonstrate the laparoscopic total colectomy with end ileostomy formation in a patient refractory to medical treatment, with an acute flare-up of ulcerative colitis. The authors used the new LigaSure retractable L-hook laparoscopic sealer (Medtronic) with a Maryland tip, which allows effortless switch from fine sharp dissection to blunt dissection and vice versa. In this video, they demonstrate dissection of all inflamed colonic vessels, due to their prominence secondary to the pathophysiology of severe acute ulcerative colitis and provide tips and tricks on how to approach this common clinical situation. 

Bibliography:

1. Le Berre C, Honap S, Peyrin-Biroulet L. Ulcerative colitis. Lancet. 2023 Aug 12;402(10401):571-584. doi: 10.1016/S0140-6736(23)00966-2. PMID: 37573077. (https://pubmed.ncbi.nlm.nih.gov/37573077/)

2. Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H; IBD guidelines eDelphi consensus group; Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut. 2019 Dec;68(Suppl 3):s1-s106. doi: 10.1136/gutjnl-2019-318484. Epub 2019 Sep 27. Erratum in: Gut. 2021 Apr;70(4):1. PMID: 31562236; PMCID: PMC6872448. (https://pubmed.ncbi.nlm.nih.gov/31562236)

3. Spinelli A, Bonovas S, Burisch J, Kucharzik T, Adamina M, Annese V, Bachmann O, Bettenworth D, Chaparro M, Czuber-Dochan W, Eder P, Ellul P, Fidalgo C, Fiorino G, Gionchetti P, Gisbert JP, Gordon H, Hedin C, Holubar S, Iacucci M, Karmiris K, Katsanos K, Kopylov U, Lakatos PL, Lytras T, Lyutakov I, Noor N, Pellino G, Piovani D, Savarino E, Selvaggi F, Verstockt B, Doherty G, Raine T, Panis Y. ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment. J Crohns Colitis. 2022 Feb 23;16(2):179-189. doi: 10.1093/ecco-jcc/jjab177. PMID: 34635910. (https://pubmed.ncbi.nlm.nih.gov/34635910/)

4. Ippolito C, Colucci R, Segnani C, Errede M, Girolamo F, Virgintino D, Dolfi A, Tirotta E, Buccianti P, Di Candio G, Campani D, Castagna M, Bassotti G, Villanacci V, Blandizzi C, Bernardini N. Fibrotic and Vascular Remodelling of Colonic Wall in Patients with Active Ulcerative Colitis. J Crohns Colitis. 2016 Oct;10(10):1194-204. doi: 10.1093/ecco-jcc/jjw076. Epub 2016 Mar 19. PMID: 26995183. (https://pubmed.ncbi.nlm.nih.gov/26995183/)

Laparoscopic total colectomy with end ileostomy formation for refractory ulcerative colitis 

Excision mésorectale totale transanale (TaTME) pour adénocarcinome avancé du bas rectum

Colorectal cancer is the fourth most common malignancy and the second main cause of cancer-related mortality in the world. Transanal total mesorectal excision (TaTME) was first described by Lacy and Sylla in 2010. As this new surgical technique is increasingly adopted by surgeons (2), a comparable rate of intraoperative complications and a significantly lower incidence of postoperative complications were noted in the TaTME approach as compared with the laparoscopic TME (LaTME) approach (2). Indeed, many surgeons adopted the TaTME surgical technique because the use of LaTME is limited in low rectal cancer patients, who require surgeons with experience in ultralow sphincter-saving laparoscopic surgery, that has a high risk of leaving a positive circumferential resection margin. Aubert et al. confirmed that TaTME for low and middle rectal cancer is safe, feasible, and can lead to a high quality of rectal cancer resection specimen, with a shorter length of stay, and a lower readmission rate, as well as a lower rate of overall and major morbidities, anastomotic leakage, and circumferential resection margin involvement, as opposed to the standard laparoscopic total mesorectal excision (3).

This video presents the case of a 50-year-old man with a history of Parkinson’s disease who presented with proctorrhagia without any other symptoms. On medical exam, a rectal tumor was diagnosed 2cm away from the anal verge. It was decided to manage it with chemoradiotherapy. An assessment control was performed, and a complete tumor regression was observed. It was decided to perform a transanal total mesorectal excision.

Bibliography:

1\. Lei PR, Ruan Y, Yang X, Fang J, Chen T. Trans-anal or trans-abdominal total mesorectal excision? A systematic review and meta-analysis of recent comparative studies on perioperative outcomes and pathological result. Int J Surg. 2018;60(November):113- 119. doi:10.1016/j.ijsu.2018.11.003

2\. Ma B, Gao P, Song Y, et al. Transanal total mesorectal excision (taTME) for rectal cancer: A systematic review and meta-analysis of oncological and perioperative outcomes compared with laparoscopic total mesorectal excision. BMC Cancer. 2016;16(1). doi:10.1186/s12885-016-2428-5

3\. Aubert M, Mege D, Panis Y. Total mesorectal excision for low and middle rectal cancer: laparoscopic versus transanal approach—a meta-analysis. Surg Endosc. 2020;34(9):3908-3919. doi:10.1007/s00464-019-07160-8

Transanal total mesorectal excision (TaTME) for advanced low rectal adenocarcinoma

Perineal hernia after abdominoperineal resection (APR) is a complication caused by the herniation of intra-abdominal organs through the pelvic floor. Although most patients are asymptomatic, some patients have complaints that significantly impact their quality of life. Management of such hernias is challenging. 

The authors present the case of a 58-year-old female patient under surveillance after a laparoscopic abdominoperineal resection for rectal adenocarcinoma. She developed a symptomatic perineal hernia for which a correction was proposed. Laparoscopic surgery and the postoperative period were uneventful and the patient was discharged on the first postoperative day. Six months later, the patient reported a marked improvement in her life quality and showed no signs of hernia recurrence. 



Laparoscopic repair for a perineal hernia after an abdominoperineal resection (APR)

Cure de hernie périnéale par voie d'abord laparoscopique après résection abdominopérinéale

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the operation of choice for patients with ulcerative colitis (UC) (1). The most common type of IPAA is achieved with a J pouch, where the ileal pouch is anastomosed with the rectal cuff, a 2 to 3cm string of anal canal which can include a few millimeters of rectal mucosa. This tiny portion of the rectum and anal canal is necessary for the stapled anastomosis. The ileorectal anastomosis is a totally different procedure, where the rectum is kept in place (while it is removed in the IPAA) and connected to the ileum, with no creation of an ileal pouch. 

This video presents the case of a laparoscopic proctectomy with a J-pouch construction as the second stage of a modified two-staged procedure (subtotal colectomy with end ileostomy, proctectomy, and IPAA). The two-staged approach for the restoration of intestinal continuity in UC patients is one of the most used approaches, given its safety in terms of postoperative complications and overall quality of life for patients who are diagnosed with acute severe colitis and who undergo total colectomy as an emergency surgery, and after 3 to 6 months are fit and ready for intestinal reconstruction through the IPAA without a protective stoma (5, 6). 

The procedure was divided into two major steps. The first one was a laparoscopic proctectomy, performed with a close rectal dissection (CRD), also known as "incomplete TME approach", to minimize the risks of neuromuscular injury (2). An image at the beginning of the video compares the two approaches for laparoscopic proctectomy. 

The second step was the extracorporeal J-pouch construction using an endoscopic stapling device and an ileal pouch-anal anastomosis creation using a 31mm circular stapler. 

Randomized clinical trials results showed how an incomplete TME leads to a lower rate of severe complications and better short-term quality of life when compared to TME (3). This video presents the authors’ standardized approach. 

Close rectal dissection, or incomplete TME, is a safe approach for laparoscopic proctectomy given the good results obtained in terms of protecting autonomic nerve function (4). This technique may be more challenging than TME if the surgeon is used to oncological dissections. A standardized technique for CRD is crucial to have the best outcomes in terms of sexual and urinary functions. 



Bibliography:

1. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J. 1978 Jul 8;2(6130):85-8. doi: 10.1136/bmj.2.6130.85. PMID: 667572; PMCID: PMC1605901.

2. Reijntjes MA, de Jong DC, Bartels S, Wessels EM, Bocharewicz EK, Hompes R, Buskens CJ, d'Haens GR, Duijvestein M, Bemelman WA. Long-term outcomes after close rectal dissection and total mesorectal excision in ileal pouch-anal anastomosis for ulcerative colitis. Tech Coloproctol. 2023  Apr;27(4):297-307. doi: 10.1007/s10151-022-02713-x. Epub 2022 Nov 6. PMID: 36336745; PMCID: PMC10008209.

3. Capelli, G., De Simone, I., Spolverato, G. et al. Non-Operative Management Versus Total Mesorectal Excision for Locally Advanced Rectal Cancer with Clinical Complete Response After Neoadjuvant Chemoradiotherapy: a GRADE Approach by the Rectal Cancer Guidelines Writing Group of the Italian Association of Medical Oncology (AIOM). J Gastrointest Surg 24, 2150–2159 (2020). https://doi.org/10.1007/s11605-020-04635-1

4. Garcia-Granero A, Pellino G, Fletcher-Sanfeliu D, Millan M, Primo-Romaguera V, Garcia-Gausí M, Fernandez M, Gonzalez-Argente X, Spinelli A, Valverde-Navarro A, Garcia-Granero E. "Near-TME": proposed standardisation of the technique for proctectomy in male patients with ulcerative colitis. Tech Coloproctol. 2022 Mar;26(3):217-226. doi: 10.1007/s10151-022-02579-z. Epub 2022 Feb 1. PMID: 35103902; PMCID: PMC8857132.

5. Maspero, M., Hull, T.L. Clinical approach to patients with an ileal pouch. Abdom Radiol 48, 2918–2929 (2023). https://doi.org/10.1007/s00261-023-03888-z

6. Luo, W.Y., Singh, S., Cuomo, R. et al. Modified two-stage restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: a systematic review and meta-analysis of observational research. Int J Colorectal Dis 35, 1817–1830 (2020). https://doi.org/10.1007/s00384-020-03696-7



Completion proctectomy and J-pouch construction for ulcerative colitis (UC)

Proctectomie complète et création d'une poche en J pour colite ulcéreuse 

This video presents the case of a 39-year-old female patient with no relevant medical history. The symptoms appeared one week before rectal bleeding and weight loss. Upon physical examination, a 3cm indurated bleeding mass was found in the anal margin. Colonoscopy showed a friable exophytic-looking tumor lesion located 3 to 5cm away from the anal verge and covering 30% of the circumference. Histopathological exam revealed a grade II invasive adenocarcinoma without lymphovascular invasion. Magnetic resonance imaging showed an inferior rectal neoplasm located 2.8cm away from the anal margin with an extension to the middle rectum (4.6cm) without sphincter involvement. No lymph nodes or metastasis were observed, conclusive for a rectal T2N0M0. As a result, it was decided to perform a laparoscopic two-stage Turnbull-Cutait pull-through coloanal anastomosis with ultralow anterior resection. 

A conventional ultra low anterior resection was performed, externalizing the colon through the anus and fixing it proximally to the skin. One week later, the anastomosis was completed manually.

The postoperative period was uneventful. The patient resumed oral intake one day after the second surgery. She was discharged on postoperative day 8. Histopathological findings showed that the surgical margins were negative for neoplasia, and 16 lymph nodes proved negative for dysplasia. 

Bibliography:

1. Biondo S, Trenti L, Espin E, Bianco F, Barrios O, Falato A, De Franciscis S, Solis A, Kreisler E; TURNBULL-BCN Study Group. Two-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Low Rectal Cancer: A Randomized Clinical Trial. JAMA Surg. 2020 Aug 1;155(8):e201625. doi: 10.1001/jamasurg.2020.1625. Epub 2020 Aug 19. PMID: 32492131; PMCID: PMC7270870.

2. Biondo S, Trenti L, Galvez A, Espin-Basany E, Bianco F, Romano G, Kreisler E; Turnbull-BCN study group. Two-stage Turnbull-Cutait pull-through coloanal anastomosis versus coloanal anastomosis with protective loop ileostomy for low rectal cancer. Protocol for a randomized controlled trial (Turnbull-BCN). Int J Colorectal Dis. 2017 Sep;32(9):1357-1362. doi: 10.1007/s00384-017-2842-4. Epub 2017 Jun 30. PMID: 28667499.

3. La Raja C, Foppa C, Maroli A, Kontovounisios C, Ben David N, Carvello M, Spinelli A. Surgical outcomes of Turnbull-Cutait delayed coloanal anastomosis with pull-through versus immediate coloanal anastomosis with diverting stoma after total mesorectal excision for low rectal cancer: a systematic review and meta-analysis. Tech Coloproctol. 2022 Aug;26(8):603-613. doi: 10.1007/s10151-022-02601-4. Epub 2022 Mar 28. PMID: 35344150.

4. Melka D, Leiritz E, Labiad C, Blondeau M, Frontali A, Giacca M, Monsinjon M, Panis Y. Delayed pull-through coloanal anastomosis without temporary stoma: an alternative to the standard manual side-to-end coloanal anastomosis with temporary stoma? A comparative study in 223 patients with low rectal cancer. Colorectal Dis. 2022 May;24(5):587-593. doi: 10.1111/codi.16069. Epub 2022 Feb 10. PMID: 35094470.

Laparoscopic two-stage Turnbull-Cutait pull-through coloanal anastomosis for low rectal cancer

Anastomose colo-anale de Turnbull-Cutait en deux étapes par voie d'abord laparoscopique pour cancer du bas rectum



Bibliography:

1. Paquette, I. M., Madoff, R. D., Sigurdson, E. R., & Chang, G. J. (2018). Impact of proximal vascular ligation on survival of patients with colon cancer. Annals of Surgical Oncology, 25(1), 38‑45. https://doi.org/10.1245/s10434-016-5720-3 

2. Perrakis, A., Weber, K., Merkel, S., Matzel, K., Agaimy, A., Gebbert, C., & Hohenberger, W. (2014). Lymph node metastasis of carcinomas of transverse colon including flexures. Consideration of the extramesocolic lymph node stations. International Journal of Colorectal Disease, 29(10), 1223‑1229. https://doi.org/10.1007/s00384-014-1971-2 

3. Kotake, K., Mizuguchi, T., Moritani, K., Wada, O., Ozawa, H., Oki, I., & Sugihara, K. (2014). Impact of D3 lymph node dissection on survival for patients with T3 and T4 colon cancer. International Journal of Colorectal Disease, 29(7), 847‑852. https://doi.org/10.1007/s00384-014-1885-z 

Focus on colorectal surgery