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Laparoscopic anterior rectopexy for rectal prolapse
This video demonstrates the technique and steps required to perform a laparoscopic anterior rectopexy for the successful treatment of rectal prolapse. The treatment of rectal prolapse with a laparoscopic trans-abdominal approach is well-established and has resulted in reduced morbidity and shorter hospital stay. It is also well-tolerated in the elderly and shows an improvement in incontinence and a low recurrence rate. This procedure can be enhanced by using a purely anterior (ventral) approach. The dissection is kept anterior to the rectum, by opening the rectovaginal septum and then continuing down to the pelvic floor where a mesh rectopexy is then performed. This avoids posterior rectal dissection and spares the autonomic pelvic nerves; it keeps morbidity low and improves constipation.
J Saunders, P Thomas, K Badrinath
Surgical intervention
8 years ago
14021 views
233 likes
0 comments
06:56
Laparoscopic anterior rectopexy for rectal prolapse
This video demonstrates the technique and steps required to perform a laparoscopic anterior rectopexy for the successful treatment of rectal prolapse. The treatment of rectal prolapse with a laparoscopic trans-abdominal approach is well-established and has resulted in reduced morbidity and shorter hospital stay. It is also well-tolerated in the elderly and shows an improvement in incontinence and a low recurrence rate. This procedure can be enhanced by using a purely anterior (ventral) approach. The dissection is kept anterior to the rectum, by opening the rectovaginal septum and then continuing down to the pelvic floor where a mesh rectopexy is then performed. This avoids posterior rectal dissection and spares the autonomic pelvic nerves; it keeps morbidity low and improves constipation.
Laparoscopic indirect ventral rectopexy with sigmoidectomy for rectal prolapse in a young female patient
The aim of surgical treatment of rectal prolapse is to anatomically restore prolapse and functionally remedy fecal incontinence and disorder of rectal emptying. There is not yet sufficient evidence-based knowledge of the advantages and disadvantages of various surgical methods. In practice, trans-abdominal surgery is recommended for patients in good conditions and perineal surgery for elderly and frail patients suffering from associated diseases. The progress of laparoscopic surgery has, however, made the trans-abdominal operation possible also for those in increasingly poor condition. With this procedure a significant improvement of defecation disorder is achieved in over 80% of patients. This video demonstrates the laparoscopic management of a rectal prolapse associated with constipation and a posterior enterocele.
J Leroy, J Marescaux
Surgical intervention
10 years ago
3483 views
142 likes
0 comments
15:44
Laparoscopic indirect ventral rectopexy with sigmoidectomy for rectal prolapse in a young female patient
The aim of surgical treatment of rectal prolapse is to anatomically restore prolapse and functionally remedy fecal incontinence and disorder of rectal emptying. There is not yet sufficient evidence-based knowledge of the advantages and disadvantages of various surgical methods. In practice, trans-abdominal surgery is recommended for patients in good conditions and perineal surgery for elderly and frail patients suffering from associated diseases. The progress of laparoscopic surgery has, however, made the trans-abdominal operation possible also for those in increasingly poor condition. With this procedure a significant improvement of defecation disorder is achieved in over 80% of patients. This video demonstrates the laparoscopic management of a rectal prolapse associated with constipation and a posterior enterocele.
Laparoscopic sigmoidectomy with ventral and posterior indirect rectopexy for rectal prolapse in a female patient
Rectal prolapse is an uncommon disease mainly seen in patients of advanced age.
In the last few years, the laparoscopic route has been shown to be feasible and has the advantage of being a minimally invasive technique. The objective of this film is to demonstrate a technique for the repair of rectal prolapse with sigmoidectomy. This is the case of a 72-year-old woman with a previous history of hysterectomy presenting also with dyschezia and moderate incontinence and a grade III rectal prolapse. Defecography showed a prolapse of the upper rectum with an enterocele without any associated rectocele in spite of the hysterectomy.
J Leroy, D Mutter, F Costantino, J Marescaux
Surgical intervention
10 years ago
2636 views
137 likes
0 comments
10:26
Laparoscopic sigmoidectomy with ventral and posterior indirect rectopexy for rectal prolapse in a female patient
Rectal prolapse is an uncommon disease mainly seen in patients of advanced age.
In the last few years, the laparoscopic route has been shown to be feasible and has the advantage of being a minimally invasive technique. The objective of this film is to demonstrate a technique for the repair of rectal prolapse with sigmoidectomy. This is the case of a 72-year-old woman with a previous history of hysterectomy presenting also with dyschezia and moderate incontinence and a grade III rectal prolapse. Defecography showed a prolapse of the upper rectum with an enterocele without any associated rectocele in spite of the hysterectomy.
Acute small bowel obstruction two months after laparoscopic rectal prolapse surgery: laparoscopic management
Acute small bowel obstruction (SBO) is an ever-increasing clinical problem. In this video, the authors demonstrate the laparoscopic management of acute small bowel obstruction. Its successful management depends on a comprehensive knowledge of the etiology and pathophysiology of obstruction, familiarity with imaging methods, good clinical judgment, and sound technical skills. The adoption of laparoscopy in the treatment of SBO has been slow because of concerns for iatrogenic bowel injury and working space issues related to bowel distension.
In this film, the authors demonstrate that it is essential to rapidly manage the patient after the first acute attack.
Although there is an inherent appeal for laparoscopy in its potential to minimize short- and long-term wound complications and perioperative laparotomy-related morbidity and to theoretically induce fewer subsequent adhesions than a traditional laparotomy incision would.

Small bowel obstruction is a pathology commonly found in the current practice of surgical emergencies. The main cause stems from surgical history with a variable onset of symptoms. The introduction of laparoscopic surgery helped to slightly reduce the number of patients presenting with occlusive syndromes. The rapid management of occlusive patients is one of the keys to success. Consequently, once diagnosis has been evoked, imaging studies must be performed, and especially CT-scan, in order to determine the type of obstruction, its mechanism and its severity. After work-up, either a conservative medical treatment or surgery will be decided upon.
L Marx, J Leroy, J Marescaux
Surgical intervention
6 years ago
3010 views
20 likes
0 comments
04:19
Acute small bowel obstruction two months after laparoscopic rectal prolapse surgery: laparoscopic management
Acute small bowel obstruction (SBO) is an ever-increasing clinical problem. In this video, the authors demonstrate the laparoscopic management of acute small bowel obstruction. Its successful management depends on a comprehensive knowledge of the etiology and pathophysiology of obstruction, familiarity with imaging methods, good clinical judgment, and sound technical skills. The adoption of laparoscopy in the treatment of SBO has been slow because of concerns for iatrogenic bowel injury and working space issues related to bowel distension.
In this film, the authors demonstrate that it is essential to rapidly manage the patient after the first acute attack.
Although there is an inherent appeal for laparoscopy in its potential to minimize short- and long-term wound complications and perioperative laparotomy-related morbidity and to theoretically induce fewer subsequent adhesions than a traditional laparotomy incision would.

Small bowel obstruction is a pathology commonly found in the current practice of surgical emergencies. The main cause stems from surgical history with a variable onset of symptoms. The introduction of laparoscopic surgery helped to slightly reduce the number of patients presenting with occlusive syndromes. The rapid management of occlusive patients is one of the keys to success. Consequently, once diagnosis has been evoked, imaging studies must be performed, and especially CT-scan, in order to determine the type of obstruction, its mechanism and its severity. After work-up, either a conservative medical treatment or surgery will be decided upon.
Laparoscopic ventral mesh rectopexy in a male patient
Introduction
Ventral rectopexy, with or without mesh, has a lower recurrence rate than a perineal approach for rectal prolapse treatment. One of the techniques which are gaining a wider acceptance is the laparoscopic ventral mesh rectopexy, also called D'Hoore rectopexy. The unique feature of this technique is that it avoids any posterolateral dissection of the rectum. Clinical outcomes demonstrate that this technique present good results in terms of recurrence, a low rate of constipation induced by the procedure, as well a low risk of sexual dysfunction.

Clinical case
A 43-year-old man was admitted to our hospital with a one-year evolution of rectal prolapse with complaints of sporadic rectal bleeding and soiling. He reports daily bowel movements with a necessity of manual prolapse reduction. His past medical history includes follicular lymphoma. He has no history of previous surgeries.
After preoperative investigation with colonoscopy, a barium enema and anorectal function tests, a laparoscopic D’Hoore rectopexy was proposed to the patient.
In this video, we present the critical steps of the procedure with special attention to the preservation of the hypogastric nerves.
The postoperative outcome was uneventful. In the follow-up period, the patient reports a significant improvement of symptoms, without rectal prolapse at defecation, no constipation, and no change in sexual function.
M Manzanera Díaz, C Moreno Sanz, J De Pedro Conal, A Goulart, F Cortina Oliva
Surgical intervention
4 years ago
4963 views
248 likes
0 comments
07:35
Laparoscopic ventral mesh rectopexy in a male patient
Introduction
Ventral rectopexy, with or without mesh, has a lower recurrence rate than a perineal approach for rectal prolapse treatment. One of the techniques which are gaining a wider acceptance is the laparoscopic ventral mesh rectopexy, also called D'Hoore rectopexy. The unique feature of this technique is that it avoids any posterolateral dissection of the rectum. Clinical outcomes demonstrate that this technique present good results in terms of recurrence, a low rate of constipation induced by the procedure, as well a low risk of sexual dysfunction.

Clinical case
A 43-year-old man was admitted to our hospital with a one-year evolution of rectal prolapse with complaints of sporadic rectal bleeding and soiling. He reports daily bowel movements with a necessity of manual prolapse reduction. His past medical history includes follicular lymphoma. He has no history of previous surgeries.
After preoperative investigation with colonoscopy, a barium enema and anorectal function tests, a laparoscopic D’Hoore rectopexy was proposed to the patient.
In this video, we present the critical steps of the procedure with special attention to the preservation of the hypogastric nerves.
The postoperative outcome was uneventful. In the follow-up period, the patient reports a significant improvement of symptoms, without rectal prolapse at defecation, no constipation, and no change in sexual function.
Low rectal resection with transanal total mesorectal excision (TaTME) performed with standard laparoscopic instrumentation
This is the case of a 62-year-old woman with rectal bleeding. She underwent a colonoscopy which showed a low rectal adenocarcinoma, 6cm from the anal margin. A CT-scan revealed the absence of metastasis and pelvic MRI showed a cT3N1 tumor.
The patient was treated with neoadjuvant radiochemotherapy. She received 50 Gray and capecitabine after which a new MRI showed a partial tumor response. The patient underwent surgery 10 weeks after finishing neoadjuvant therapy.
We started the operation with a laparoscopic abdominal approach. Four ports were placed. Two 10mm ports were introduced in the umbilicus and the right iliac fossa. Two 5mm ports were inserted in the left and right lower quadrant. Transanal total mesorectal excision (TaTME) was performed with a 5mm, 30-degree scope, monopolar hook, and bipolar forceps. The rectum was dissected 1cm distally from the neoplasia. The specimen was extracted transanally. Anastomosis was carried out transanally using a 33mm EEA™ circular stapler, after examination of the frozen section margin. A protective ileostomy was performed through the 10mm port site in the right iliac fossa and a drainage was put in place in the pelvis through the 5mm port entry site into the left flank.
The patient resumed food intake on postoperative day 2 and she was discharged on postoperative day 7. A complete mesorectal excision was confirmed on pathological examination. Fifteen negative nodes were removed. Distal and circumferential margins were negative.
The coloanal anastomosis was controlled with colonoscopy one month later. No sign of leakage was detected, and the ileostomy was subsequently closed.
The patient reports an adequate continence to gas and feces with one or two bowel movements per day. After 15 months of follow-up, the patient is still disease-free.
Our video shows that TaTME is a technique which can be performed by surgeons who have experience in laparoscopic and colorectal surgery.
In our operation, we did not use any energy devices, 3D or 4K technology. This procedure can be performed without expensive equipment.
L Taglietti, G Baronio, L Lussardi, R Cazzaniga, S Dester, A Zanoletti
Surgical intervention
9 months ago
2708 views
9 likes
1 comment
09:56
Low rectal resection with transanal total mesorectal excision (TaTME) performed with standard laparoscopic instrumentation
This is the case of a 62-year-old woman with rectal bleeding. She underwent a colonoscopy which showed a low rectal adenocarcinoma, 6cm from the anal margin. A CT-scan revealed the absence of metastasis and pelvic MRI showed a cT3N1 tumor.
The patient was treated with neoadjuvant radiochemotherapy. She received 50 Gray and capecitabine after which a new MRI showed a partial tumor response. The patient underwent surgery 10 weeks after finishing neoadjuvant therapy.
We started the operation with a laparoscopic abdominal approach. Four ports were placed. Two 10mm ports were introduced in the umbilicus and the right iliac fossa. Two 5mm ports were inserted in the left and right lower quadrant. Transanal total mesorectal excision (TaTME) was performed with a 5mm, 30-degree scope, monopolar hook, and bipolar forceps. The rectum was dissected 1cm distally from the neoplasia. The specimen was extracted transanally. Anastomosis was carried out transanally using a 33mm EEA™ circular stapler, after examination of the frozen section margin. A protective ileostomy was performed through the 10mm port site in the right iliac fossa and a drainage was put in place in the pelvis through the 5mm port entry site into the left flank.
The patient resumed food intake on postoperative day 2 and she was discharged on postoperative day 7. A complete mesorectal excision was confirmed on pathological examination. Fifteen negative nodes were removed. Distal and circumferential margins were negative.
The coloanal anastomosis was controlled with colonoscopy one month later. No sign of leakage was detected, and the ileostomy was subsequently closed.
The patient reports an adequate continence to gas and feces with one or two bowel movements per day. After 15 months of follow-up, the patient is still disease-free.
Our video shows that TaTME is a technique which can be performed by surgeons who have experience in laparoscopic and colorectal surgery.
In our operation, we did not use any energy devices, 3D or 4K technology. This procedure can be performed without expensive equipment.
Laparoscopic total mesorectal excision (TME) for rectal cancer: live procedure
This video of a live surgery performed by Professor Chen (Associate Professor, China Medical University Taichung, Taiwan) during an IRCAD Taiwan course very clearly demonstrates the stepwise execution of a laparoscopic total mesorectal excision (TME) with all its tips and tricks.
This is the case of a 65-year-old woman, with a low rectal tumor (4cm) is operated on after a short chemoradiation course (2 weeks before) for a stage IIA cancer (cT3N0M0).
Professor Chen’s surgical skills and experience and the beauty of the procedure, associated with a dynamic Q&A and expert comments coming from the auditorium, make of this video a must see.
WTL Chen, J Verde
Surgical intervention
9 months ago
3425 views
14 likes
0 comments
47:24
Laparoscopic total mesorectal excision (TME) for rectal cancer: live procedure
This video of a live surgery performed by Professor Chen (Associate Professor, China Medical University Taichung, Taiwan) during an IRCAD Taiwan course very clearly demonstrates the stepwise execution of a laparoscopic total mesorectal excision (TME) with all its tips and tricks.
This is the case of a 65-year-old woman, with a low rectal tumor (4cm) is operated on after a short chemoradiation course (2 weeks before) for a stage IIA cancer (cT3N0M0).
Professor Chen’s surgical skills and experience and the beauty of the procedure, associated with a dynamic Q&A and expert comments coming from the auditorium, make of this video a must see.
Transanal minimally invasive surgery (TAMIS) for rectal cancer with transabdominal and transrectal ICG-guided sentinel node
Transanal minimally invasive surgery (TAMIS) for rectal cancer is gaining interest, with the objective of maximum sparing for physiological functions. Although this approach may be considered appropriate for treating stage T1m tumors, a large proportion of T1sm and T2 tumors could well benefit from this. The greatest limitation to the application of TAMIS is represented by the difficulty of obtaining an adequate lymph node sample of the mesorectum. The use of indocyanine green (ICG) has recently been suggested as a possible lymph node marker after peritumoral injection. The case described in this video presents an innovative proposal for the detection and removal of lymph nodes draining a tumor of the lower rectum, with the aim of obtaining an adequate lymph node staging. After endoscopic peritumoral ICG injection, we proceeded to the search and removal of sentinel lymph nodes both with a laparoscopic transabdominal approach and with a transrectal approach (after specimen removal). If validated in a prospective series, this technique could represent the best lymph node harvesting strategy during TAMIS for early stage rectal cancer.
G Baiocchi, R Nascimbeni, N Vettoretto, N de Manzini, M Morino
Surgical intervention
11 months ago
1953 views
7 likes
0 comments
09:24
Transanal minimally invasive surgery (TAMIS) for rectal cancer with transabdominal and transrectal ICG-guided sentinel node
Transanal minimally invasive surgery (TAMIS) for rectal cancer is gaining interest, with the objective of maximum sparing for physiological functions. Although this approach may be considered appropriate for treating stage T1m tumors, a large proportion of T1sm and T2 tumors could well benefit from this. The greatest limitation to the application of TAMIS is represented by the difficulty of obtaining an adequate lymph node sample of the mesorectum. The use of indocyanine green (ICG) has recently been suggested as a possible lymph node marker after peritumoral injection. The case described in this video presents an innovative proposal for the detection and removal of lymph nodes draining a tumor of the lower rectum, with the aim of obtaining an adequate lymph node staging. After endoscopic peritumoral ICG injection, we proceeded to the search and removal of sentinel lymph nodes both with a laparoscopic transabdominal approach and with a transrectal approach (after specimen removal). If validated in a prospective series, this technique could represent the best lymph node harvesting strategy during TAMIS for early stage rectal cancer.
LIVE INTERACTIVE SURGERY: robotic low anterior resection for a local recurrence of rectal cancer
In this live interactive surgery, Dr. Parra-Davila demonstrates a robotic low anterior resection for a local recurrence of transanally excised rectal cancer. The operative technique shown includes a robotic oncological ‘en bloc’ resection and intracorporeal anastomosis. In the patient’s history, an ulcerated villous polyp too large for endoscopic removal was addressed to surgery. Preoperative biopsies had failed to detect malignancy. The surgical procedure consisted in a transanal full-thickness resection including partial TME for lymph node sampling. Since the operative specimen revealed a pT2N1a (1/8) rectal adenocarcinoma, the patient underwent adjuvant radiochemotherapy. The following year, a single hepatic metastasis was resected, complemented by postoperative chemotherapy. After 7 years of uneventful follow-up, an anastomotic recurrence was diagnosed. Following oncologic committee discussion, the patient was advised to undergo surgery.
E Parra-Davila, M Ignat, L Soler, B Seeliger, D Mutter, J Marescaux
Surgical intervention
1 year ago
1837 views
3 likes
0 comments
32:48
LIVE INTERACTIVE SURGERY: robotic low anterior resection for a local recurrence of rectal cancer
In this live interactive surgery, Dr. Parra-Davila demonstrates a robotic low anterior resection for a local recurrence of transanally excised rectal cancer. The operative technique shown includes a robotic oncological ‘en bloc’ resection and intracorporeal anastomosis. In the patient’s history, an ulcerated villous polyp too large for endoscopic removal was addressed to surgery. Preoperative biopsies had failed to detect malignancy. The surgical procedure consisted in a transanal full-thickness resection including partial TME for lymph node sampling. Since the operative specimen revealed a pT2N1a (1/8) rectal adenocarcinoma, the patient underwent adjuvant radiochemotherapy. The following year, a single hepatic metastasis was resected, complemented by postoperative chemotherapy. After 7 years of uneventful follow-up, an anastomotic recurrence was diagnosed. Following oncologic committee discussion, the patient was advised to undergo surgery.
Laparoscopic rectal resection with ICG-guided nodal navigation
The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of a 66-year-old woman with a sigmoid-rectal junction early stage cancer submitted to laparoscopic resection. Before surgery, the patient was submitted to endoscopy with the objective to mark the distal margin of the neoplasia, and 2mL of ICG were injected into the mucosa of the rectum, 2cm distal to the inferior border of the tumor.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588 camera system), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
It was possible to verify the good perfusion of the proximal stump of the anastomosis before the Knight-Griffen anastomosis was performed, thanks to an intravenous injection of ICG.
This technique could allow for a more precise and radical nodal dissection, a safer work respecting vascular and nerve structures, and could be related with a lower risk of anastomotic fistula, controlling the adequate perfusion of the stump.
G Baiocchi, S Molfino, B Molteni, A Titi, G Gaverini
Surgical intervention
1 year ago
3203 views
9 likes
0 comments
11:48
Laparoscopic rectal resection with ICG-guided nodal navigation
The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) testifies to a developing interest in many fields of surgical oncology. The technique seems to be promising, also during nodal dissection in gastric and colorectal surgery in the so-called “ICG-guided nodal navigation”.
In this video, we present the clinical case of a 66-year-old woman with a sigmoid-rectal junction early stage cancer submitted to laparoscopic resection. Before surgery, the patient was submitted to endoscopy with the objective to mark the distal margin of the neoplasia, and 2mL of ICG were injected into the mucosa of the rectum, 2cm distal to the inferior border of the tumor.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588 camera system), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
It was possible to verify the good perfusion of the proximal stump of the anastomosis before the Knight-Griffen anastomosis was performed, thanks to an intravenous injection of ICG.
This technique could allow for a more precise and radical nodal dissection, a safer work respecting vascular and nerve structures, and could be related with a lower risk of anastomotic fistula, controlling the adequate perfusion of the stump.
Combined abdominal - transanal laparoscopic approach (taTME) for low rectal cancers
Objective: to describe the TaTME surgical technique for the treatment of low rectal cancers.
Methods: The procedure was performed in two phases: first, by an abdominal laparoscopic approach consisting in the high ligation of the inferior mesenteric artery and vein, and complete splenic flexure mobilization. The pelvic dissection was continued in the Total Mesorectal Excision (TME) plane to the level of the puborectal sling posteriorly and of the seminal vesicles anteriorly.
Secondly, the procedure continued by transanal laparoscopic approach: A Lone Star® retractor was placed prior to the platform insertion (Gelpoint Path®). Under direct vision of the tumor, a purse-string suture was performed to obtain a secure distal margin and a completed closure of the lumen. It is essential to achieve a complete circumferential full-thickness rectotomy before facing the dissection cranially via the TME plane. Both planes, transanal and abdominal, are connected by the two surgical teams. The specimen was then extracted through a suprapubic incision. A circular end-to-end stapled anastomosis was made intracorporeally. Finally, a loop ileostomy was performed.
Results: A 75-year-old man with low rectal cancer (uT3N1-Rullier’s I-II classification), was treated with neoadjuvant chemoradiotherapy and TaTME. Operative time was 240 minutes, including 90 minutes for the perineal phase. There were no postoperative complications and the patient was discharged on postoperative day 5. The pathology report showed a complete mesorectum excision and free margins (ypT1N1a).
Conclusions: The TaTME technique is a safe option for the treatment of low rectal cancers, especially in male patients with a narrow pelvis. It is a feasible and reproducible technique for surgeons with previous experience in advanced laparoscopic procedures and transanal surgery.
S Qian, P Tejedor, M Leon, M Ortega, C Pastor
Surgical intervention
1 year ago
4358 views
6 likes
1 comment
06:45
Combined abdominal - transanal laparoscopic approach (taTME) for low rectal cancers
Objective: to describe the TaTME surgical technique for the treatment of low rectal cancers.
Methods: The procedure was performed in two phases: first, by an abdominal laparoscopic approach consisting in the high ligation of the inferior mesenteric artery and vein, and complete splenic flexure mobilization. The pelvic dissection was continued in the Total Mesorectal Excision (TME) plane to the level of the puborectal sling posteriorly and of the seminal vesicles anteriorly.
Secondly, the procedure continued by transanal laparoscopic approach: A Lone Star® retractor was placed prior to the platform insertion (Gelpoint Path®). Under direct vision of the tumor, a purse-string suture was performed to obtain a secure distal margin and a completed closure of the lumen. It is essential to achieve a complete circumferential full-thickness rectotomy before facing the dissection cranially via the TME plane. Both planes, transanal and abdominal, are connected by the two surgical teams. The specimen was then extracted through a suprapubic incision. A circular end-to-end stapled anastomosis was made intracorporeally. Finally, a loop ileostomy was performed.
Results: A 75-year-old man with low rectal cancer (uT3N1-Rullier’s I-II classification), was treated with neoadjuvant chemoradiotherapy and TaTME. Operative time was 240 minutes, including 90 minutes for the perineal phase. There were no postoperative complications and the patient was discharged on postoperative day 5. The pathology report showed a complete mesorectum excision and free margins (ypT1N1a).
Conclusions: The TaTME technique is a safe option for the treatment of low rectal cancers, especially in male patients with a narrow pelvis. It is a feasible and reproducible technique for surgeons with previous experience in advanced laparoscopic procedures and transanal surgery.
Robotic abdominoperineal resection (APR) with intraperitoneal puborectalis incision
The da Vinci™ surgical robotic system with its increased instrument stability, tridimensional view, and dexterity with 7 degrees of wristed motion offers a distinct surgical advantage over traditional laparoscopic instruments. This advantage is mainly in the deep pelvis where the limited working space and visibility makes distal rectal dissection extremely challenging. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.

An abdominoperineal resection (APR) involves the excision of the rectum with a total mesorectal excision (TME), and excision of the anus with an adequate circumferential resection margin (CRM). In a conventional open or laparoscopic approach, the rectal dissection is performed down to the level of the pelvic floor, after which the perineal approach is used to excise the anus and to cut the pelvic floor muscles circumferentially to allow for ‘en bloc’ tumor removal. However, as the pelvic floor is frequently very deep from the skin surface, dissection is technically challenging due to poor visualization, often leading to blind dissection. As a result, many APR specimens suffer from the problem of “waisting” and a positive CRM at the level of the levator ani muscle. In order to solve this problem, some units practice extralevator APR – however, in those cases, the patient ends up with a large perineal defect which frequently needs to be closed with either mesh or flap reconstruction.
With the da Vinci™ robotic system, this problem can potentially be minimized. The robotic system can be used to access deep into the pelvic cavity and make an incision in the puborectalis sling down to the ischiorectal fat. This incision, once completed, allows for easy access from the perineal approach to enter the pelvic cavity and complete the dissection, preventing any blind dissection and facilitating a CRM-clear specimen to be excised.
This video features a totally robotic approach to an abdominoperineal resection for a poorly differentiated anorectal adenocarcinoma, with intraperitoneal incision of the puborectalis sling to facilitate subsequent perineal dissection and specimen extraction.

Clinical case
A 79-year-old female patient presented with a perianal lump and discomfort. Colonoscopy revealed a 2cm mobile adenomatous polypoid lesion at the anorectal junction. Excision biopsy showed a poorly differentiated adenocarcinoma.

CT-scan of the thorax, abdomen and pelvis did not show any distant metastases, and MRI of the rectum did not show any significant locoregional disease. A robotic abdominoperineal resection was performed.

Patient set-up
The da Vinci™ Si™ robotic system was used, and a dual docking approach was chosen.
The patient was placed in a Lloyd-Davies position. Robotic ports (8mm) were placed in the epigastrium, left flank, suprapubic region, and in the right iliac fossa respectively. A 12mm trocar is inserted into the right flank for assistance and stapling.
SAE Yeo
Surgical intervention
1 year ago
764 views
4 likes
0 comments
11:27
Robotic abdominoperineal resection (APR) with intraperitoneal puborectalis incision
The da Vinci™ surgical robotic system with its increased instrument stability, tridimensional view, and dexterity with 7 degrees of wristed motion offers a distinct surgical advantage over traditional laparoscopic instruments. This advantage is mainly in the deep pelvis where the limited working space and visibility makes distal rectal dissection extremely challenging. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.

An abdominoperineal resection (APR) involves the excision of the rectum with a total mesorectal excision (TME), and excision of the anus with an adequate circumferential resection margin (CRM). In a conventional open or laparoscopic approach, the rectal dissection is performed down to the level of the pelvic floor, after which the perineal approach is used to excise the anus and to cut the pelvic floor muscles circumferentially to allow for ‘en bloc’ tumor removal. However, as the pelvic floor is frequently very deep from the skin surface, dissection is technically challenging due to poor visualization, often leading to blind dissection. As a result, many APR specimens suffer from the problem of “waisting” and a positive CRM at the level of the levator ani muscle. In order to solve this problem, some units practice extralevator APR – however, in those cases, the patient ends up with a large perineal defect which frequently needs to be closed with either mesh or flap reconstruction.
With the da Vinci™ robotic system, this problem can potentially be minimized. The robotic system can be used to access deep into the pelvic cavity and make an incision in the puborectalis sling down to the ischiorectal fat. This incision, once completed, allows for easy access from the perineal approach to enter the pelvic cavity and complete the dissection, preventing any blind dissection and facilitating a CRM-clear specimen to be excised.
This video features a totally robotic approach to an abdominoperineal resection for a poorly differentiated anorectal adenocarcinoma, with intraperitoneal incision of the puborectalis sling to facilitate subsequent perineal dissection and specimen extraction.

Clinical case
A 79-year-old female patient presented with a perianal lump and discomfort. Colonoscopy revealed a 2cm mobile adenomatous polypoid lesion at the anorectal junction. Excision biopsy showed a poorly differentiated adenocarcinoma.

CT-scan of the thorax, abdomen and pelvis did not show any distant metastases, and MRI of the rectum did not show any significant locoregional disease. A robotic abdominoperineal resection was performed.

Patient set-up
The da Vinci™ Si™ robotic system was used, and a dual docking approach was chosen.
The patient was placed in a Lloyd-Davies position. Robotic ports (8mm) were placed in the epigastrium, left flank, suprapubic region, and in the right iliac fossa respectively. A 12mm trocar is inserted into the right flank for assistance and stapling.
Laparoscopic rectal shaving for rectocervical endometriotic nodule
This is the case of a 32-year-old G0P0 woman presenting with severe dysmenorrhea, severe dyspareunia, and constipation. Pelvic examination showed a normal vagina, a fixed uterus, and mobile adnexae. Transvaginal ultrasonography (TvUSG) showed that the uterus and both ovaries were normal. A left parasalpingeal endometrioma (15mm), an obliterated Douglas pouch, as well as rectocervical and infiltrated rectal nodules (18mm and 0.6mm respectively) were also evidenced. Since bilateral ovaries were fixed to the pelvic sidewall, the operative strategy included bilateral ureterolysis and dissection of the hypogastric nerve and the pararectal fossa. Finally, the rectocervical nodule was mobilized by performing cervical and rectal shaving. The rectum was controlled by means of a methylene blue test. The final pathology was endometriosis.
H Altuntaş
Surgical intervention
1 year ago
6055 views
490 likes
0 comments
06:58
Laparoscopic rectal shaving for rectocervical endometriotic nodule
This is the case of a 32-year-old G0P0 woman presenting with severe dysmenorrhea, severe dyspareunia, and constipation. Pelvic examination showed a normal vagina, a fixed uterus, and mobile adnexae. Transvaginal ultrasonography (TvUSG) showed that the uterus and both ovaries were normal. A left parasalpingeal endometrioma (15mm), an obliterated Douglas pouch, as well as rectocervical and infiltrated rectal nodules (18mm and 0.6mm respectively) were also evidenced. Since bilateral ovaries were fixed to the pelvic sidewall, the operative strategy included bilateral ureterolysis and dissection of the hypogastric nerve and the pararectal fossa. Finally, the rectocervical nodule was mobilized by performing cervical and rectal shaving. The rectum was controlled by means of a methylene blue test. The final pathology was endometriosis.
Laparoscopic anatomy of the pelvic floor involved in laparoscopic surgery for pelvic organ prolapse (POP) and urinary incontinence
In this key lecture, Professor Jean-Bernard Dubuisson delineates the laparoscopic pelvic floor anatomy involved in surgical procedures for the management of pelvic organ prolapse (POP) and urinary incontinence. Traditional anatomy considers three levels: pelvic and perineal muscles, ligaments, and the space between all fascias covering the organs. Visceral ligaments occupy an anteroposterior axis (pubovesical ligaments, bladder pillars, and uterosacral ligaments) and a transverse axis (lateral bladder ligaments, cardinal ligaments, paracervix and rectal pillars). The four attachment sites which may be used by the surgeon for fascia and pelvic organ attachment in POP surgery are discussed-- Cooper’s ligament, white line, ischial spine, and sacral promontory. Approximately 90 laparoscopic anatomy pictures are presented in this authoritative lecture. The dissection planes and the different pelvic spaces used for surgery are explained, insisting on the main vessels, nerves, plexus, ureters which are obstacles to bear in mind and to avoid.
JB Dubuisson
Lecture
2 years ago
5279 views
615 likes
0 comments
24:09
Laparoscopic anatomy of the pelvic floor involved in laparoscopic surgery for pelvic organ prolapse (POP) and urinary incontinence
In this key lecture, Professor Jean-Bernard Dubuisson delineates the laparoscopic pelvic floor anatomy involved in surgical procedures for the management of pelvic organ prolapse (POP) and urinary incontinence. Traditional anatomy considers three levels: pelvic and perineal muscles, ligaments, and the space between all fascias covering the organs. Visceral ligaments occupy an anteroposterior axis (pubovesical ligaments, bladder pillars, and uterosacral ligaments) and a transverse axis (lateral bladder ligaments, cardinal ligaments, paracervix and rectal pillars). The four attachment sites which may be used by the surgeon for fascia and pelvic organ attachment in POP surgery are discussed-- Cooper’s ligament, white line, ischial spine, and sacral promontory. Approximately 90 laparoscopic anatomy pictures are presented in this authoritative lecture. The dissection planes and the different pelvic spaces used for surgery are explained, insisting on the main vessels, nerves, plexus, ureters which are obstacles to bear in mind and to avoid.
Colorectal resection in deep endometriosis: multidisciplinary laparoscopic approach (colorectal and gynecologic surgical teams)
In this video, we present the clinical case of a 42-year-old woman with deep pelvic endometriosis with rectal infiltration. After hormone therapy, the patient was operated on due to chronic pain. A laparoscopic approach was performed by a multidisciplinary team including colorectal and gynecologic surgeons having a wide experience in this field.
A CT-scan, MRI, and colonoscopy were performed before the surgery showing a deep infiltrating endometriosis with anterior rectal bowel involvement in the images and normal colorectal mucosa in the endoscopy.
Under general anesthesia, the laparoscopic approach was performed with 4 trocars. Deep infiltrating endometriosis (DIE) required a hysterectomy and rectal resection to clean all the pelvic space. An end-to-end colorectal anastomosis was performed and the extraction of the specimen (uterus and rectum) was carried out transvaginally. The patient was discharged on postoperative day 4 without complications.
JF Noguera, MD, PhD, J Gilabert-Estelles, J Aguirrezabalaga, B López, J Dolz
Surgical intervention
2 years ago
3338 views
304 likes
1 comment
09:55
Colorectal resection in deep endometriosis: multidisciplinary laparoscopic approach (colorectal and gynecologic surgical teams)
In this video, we present the clinical case of a 42-year-old woman with deep pelvic endometriosis with rectal infiltration. After hormone therapy, the patient was operated on due to chronic pain. A laparoscopic approach was performed by a multidisciplinary team including colorectal and gynecologic surgeons having a wide experience in this field.
A CT-scan, MRI, and colonoscopy were performed before the surgery showing a deep infiltrating endometriosis with anterior rectal bowel involvement in the images and normal colorectal mucosa in the endoscopy.
Under general anesthesia, the laparoscopic approach was performed with 4 trocars. Deep infiltrating endometriosis (DIE) required a hysterectomy and rectal resection to clean all the pelvic space. An end-to-end colorectal anastomosis was performed and the extraction of the specimen (uterus and rectum) was carried out transvaginally. The patient was discharged on postoperative day 4 without complications.
Stomal prolapse and parastomal incisional hernia treatment using laparoscopic Sugarbaker modified technique with intraperitoneal onlay mesh repair
Introduction: Prolapse stands for one of the most common complications of colostomy (>10%). Parastomal incisional hernia also represents 10 to 50% of complications. When both are present, the Sugarbaker technique represents a good indication due to mesh repair and pseudo-subperitonization, which can manage both prolapse and hernia. The laparoscopic modified Sugarbaker technique can be performed laparoscopically even in case of multiple previous laparotomies.
Clinical case: We report the case of a 71-year-old male patient presenting with parastomal incisional hernia and stomal prolapse after multiple abdominal procedures for ulcerative colitis, including rectosigmoidectomy, Hartmann procedure for anastomotic leak, left extended colectomy and stomal transposition for ischemic necrosis. An intra-abdominal proctectomy was attempted to manage the recurrence of colitis on the rectal stump. However, this attempt proved unsuccessful, and a local abdominoperineal resection was performed. Due to symptomatic hernia and prolapse, the laparoscopic Sugarbaker modified surgical technique with intraperitoneal onlay mesh (IPOM) repair is performed to manage prolapse by pseudo-subperitonization and to manage hernia using an IPOM repair. As shown in this video, this technique is safe, reproducible, and effective.
J Leroy, HA Mercoli, S Tzedakis, A D'Urso, D Mutter, J Marescaux
Surgical intervention
4 years ago
2440 views
99 likes
0 comments
10:54
Stomal prolapse and parastomal incisional hernia treatment using laparoscopic Sugarbaker modified technique with intraperitoneal onlay mesh repair
Introduction: Prolapse stands for one of the most common complications of colostomy (>10%). Parastomal incisional hernia also represents 10 to 50% of complications. When both are present, the Sugarbaker technique represents a good indication due to mesh repair and pseudo-subperitonization, which can manage both prolapse and hernia. The laparoscopic modified Sugarbaker technique can be performed laparoscopically even in case of multiple previous laparotomies.
Clinical case: We report the case of a 71-year-old male patient presenting with parastomal incisional hernia and stomal prolapse after multiple abdominal procedures for ulcerative colitis, including rectosigmoidectomy, Hartmann procedure for anastomotic leak, left extended colectomy and stomal transposition for ischemic necrosis. An intra-abdominal proctectomy was attempted to manage the recurrence of colitis on the rectal stump. However, this attempt proved unsuccessful, and a local abdominoperineal resection was performed. Due to symptomatic hernia and prolapse, the laparoscopic Sugarbaker modified surgical technique with intraperitoneal onlay mesh (IPOM) repair is performed to manage prolapse by pseudo-subperitonization and to manage hernia using an IPOM repair. As shown in this video, this technique is safe, reproducible, and effective.