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Endoscopic Submucosal Dissection (ESD) of the rectum for a large rectal polypoid lesion: a live educational procedure
Endoscopic Submucosal Dissection (ESD) is an endoscopic technique which allows ‘en bloc’ resection of early stage tumors and polyps in the gastrointestinal tract. In this case, Professor Yahagi presents the case of a 67-year-old male patient with an incidental finding of a large rectal polyp during an MRI study. Colonoscopy revealed a 5cm laterally spreading tumor granular type (LST-G) of the rectum, extending to one fourth of the rectal circumference. The ESD was performed with a dual channel gastroscope in retrovision due to the proximity of the LST-G to the anal verge. Glycerol and indigo carmine were injected into the submucosal plane to lift the target lesion. The mucosal incision followed by submucosal dissection was performed with a 1.5mm DualKnife™ (Olympus) using a swift coag electrosurgical setting. Hemostasis of large vessels was performed switching to the forced coag effect. The vascular submucosal network has been carefully assessed. All critical steps are evaluated during the procedure.
N Yahagi, R Rodriguez Luna, M Pizzicannella
Surgical intervention
4 months ago
857 views
12 likes
2 comments
43:23
Endoscopic Submucosal Dissection (ESD) of the rectum for a large rectal polypoid lesion: a live educational procedure
Endoscopic Submucosal Dissection (ESD) is an endoscopic technique which allows ‘en bloc’ resection of early stage tumors and polyps in the gastrointestinal tract. In this case, Professor Yahagi presents the case of a 67-year-old male patient with an incidental finding of a large rectal polyp during an MRI study. Colonoscopy revealed a 5cm laterally spreading tumor granular type (LST-G) of the rectum, extending to one fourth of the rectal circumference. The ESD was performed with a dual channel gastroscope in retrovision due to the proximity of the LST-G to the anal verge. Glycerol and indigo carmine were injected into the submucosal plane to lift the target lesion. The mucosal incision followed by submucosal dissection was performed with a 1.5mm DualKnife™ (Olympus) using a swift coag electrosurgical setting. Hemostasis of large vessels was performed switching to the forced coag effect. The vascular submucosal network has been carefully assessed. All critical steps are evaluated during the procedure.
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
1 year ago
3213 views
9 likes
2 comments
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.
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
1 year ago
2183 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.
Redo laparoscopic anterior resection
The reported incidence rates of regional recurrence for colorectal cancer after oncologic resection ranged between 5% and 19%. Locoregional recurrence occurs in the anastomotic site, the remnant colon, the peritoneal surface (nodal or soft tissue), or the retroperitoneum. As reported in the literature, in colorectal cancers, mucinous differentiation, lymphovascular invasion and anastomotic leakage are independent risk factors for anastomotic recurrence.
We present the case of an 86 year-old female patient. In 2014, the patient underwent a laparoscopic left colectomy for a Haggitt level 4 sigmoid polyp. The definitive histologic features showed a T2N0M0 mucinous adenocarcinoma. During the postoperative follow-up, 46 months after the left colectomy, an anastomotic recurrence was found. The patient underwent a laparoscopic colorectal resection for anastomotic recurrence. The operative time was 220 minutes. The patient was discharged on postoperative day 6. No complications occurred intraoperatively and postoperatively.
References:
1. Gopalan S, Bose JC, Periasamy S (2015) Anastomotic Recurrence of Colon Cancer-is it a Local Recurrence, a Second Primary, or a Metastatic Disease (Local Manifestation of Systemic Disease)? Indian J Surg 77:232-236.
2. Ramphal W, Boeding JRE, Gobardhan PD, Rutten HJT, de Winter L, Crolla R, Schreinemakers JMJ (2018) Oncologic outcome and recurrence rate following anastomotic leakage after curative resection for colorectal cancer. Surg Oncol 27:730-736.
3. Jung WB, Yu CS, Lim SB, Park IJ, Yoon YS, Kim JC (2017) Anastomotic Recurrence After Curative Resection for Colorectal Cancer. World J Surg 41:285-294.
F Corcione, M D'Ambra, U Bracale, S Dilillo, G Luglio
Surgical intervention
10 months ago
3331 views
5 likes
1 comment
23:20
Redo laparoscopic anterior resection
The reported incidence rates of regional recurrence for colorectal cancer after oncologic resection ranged between 5% and 19%. Locoregional recurrence occurs in the anastomotic site, the remnant colon, the peritoneal surface (nodal or soft tissue), or the retroperitoneum. As reported in the literature, in colorectal cancers, mucinous differentiation, lymphovascular invasion and anastomotic leakage are independent risk factors for anastomotic recurrence.
We present the case of an 86 year-old female patient. In 2014, the patient underwent a laparoscopic left colectomy for a Haggitt level 4 sigmoid polyp. The definitive histologic features showed a T2N0M0 mucinous adenocarcinoma. During the postoperative follow-up, 46 months after the left colectomy, an anastomotic recurrence was found. The patient underwent a laparoscopic colorectal resection for anastomotic recurrence. The operative time was 220 minutes. The patient was discharged on postoperative day 6. No complications occurred intraoperatively and postoperatively.
References:
1. Gopalan S, Bose JC, Periasamy S (2015) Anastomotic Recurrence of Colon Cancer-is it a Local Recurrence, a Second Primary, or a Metastatic Disease (Local Manifestation of Systemic Disease)? Indian J Surg 77:232-236.
2. Ramphal W, Boeding JRE, Gobardhan PD, Rutten HJT, de Winter L, Crolla R, Schreinemakers JMJ (2018) Oncologic outcome and recurrence rate following anastomotic leakage after curative resection for colorectal cancer. Surg Oncol 27:730-736.
3. Jung WB, Yu CS, Lim SB, Park IJ, Yoon YS, Kim JC (2017) Anastomotic Recurrence After Curative Resection for Colorectal Cancer. World J Surg 41:285-294.
Skeletons in the cupboard: MY mistakes
Professor Heald teaches us the importance of learning from our mistakes and from other people so as not to commit them again, he emphasizes lessons to learn where he tells us not only about the challenges of pelvic, oncological surgery, and possible mistakes to be made. We advise you to feel free to say what we think in the surgery room, you can help in difficult situations and proper planning prior to all surgeries.
Beautiful lesson of the day: to fail to prepare is to prepare to fail.
In this outstanding didactic lecture, Professor Heald explains part of his great experience and the experiences of a career of more than 50 years, truly amazing! and life lessons he now shares with us, where he shows a clear example that “we must be our own sternest critics” and have the “courage to fail”.
in conclusion: beware of Panic Factor, and you can always call a friend, talk to patients, forget your own pride, learn to apologize.
Remember: there are things under your control and others that are not!
Thank you Professor Heald for these great teachings.
RJ Heald
Lecture
6 months ago
609 views
7 likes
1 comment
31:37
Skeletons in the cupboard: MY mistakes
Professor Heald teaches us the importance of learning from our mistakes and from other people so as not to commit them again, he emphasizes lessons to learn where he tells us not only about the challenges of pelvic, oncological surgery, and possible mistakes to be made. We advise you to feel free to say what we think in the surgery room, you can help in difficult situations and proper planning prior to all surgeries.
Beautiful lesson of the day: to fail to prepare is to prepare to fail.
In this outstanding didactic lecture, Professor Heald explains part of his great experience and the experiences of a career of more than 50 years, truly amazing! and life lessons he now shares with us, where he shows a clear example that “we must be our own sternest critics” and have the “courage to fail”.
in conclusion: beware of Panic Factor, and you can always call a friend, talk to patients, forget your own pride, learn to apologize.
Remember: there are things under your control and others that are not!
Thank you Professor Heald for these great teachings.
Laparoscopic TME - The 6-step procedure
In this key lecture, Dr. Rullier describes a clear 6-step approach to perform a laparoscopic total mesorectal excision (TME).
The first step is posterior dissection of the TME plane in the presacral space. Hereafter, a right lateral dissection is performed with sparing of the hypogastric nerves followed by anterior dissection and identification of the seminal vesicles and pelvic plexus. A left lateral dissection is then performed whereafter the planes are connected.
In this procedure, the 6 essential landmarks are the following: ''the presacral space, hypogastric nerves, seminal vesicles, pelvic plexus, levator ani muscles, and Denonvilliers' fascia and the prostate.’
E Rullier
Lecture
6 months ago
1800 views
28 likes
0 comments
09:16
Laparoscopic TME - The 6-step procedure
In this key lecture, Dr. Rullier describes a clear 6-step approach to perform a laparoscopic total mesorectal excision (TME).
The first step is posterior dissection of the TME plane in the presacral space. Hereafter, a right lateral dissection is performed with sparing of the hypogastric nerves followed by anterior dissection and identification of the seminal vesicles and pelvic plexus. A left lateral dissection is then performed whereafter the planes are connected.
In this procedure, the 6 essential landmarks are the following: ''the presacral space, hypogastric nerves, seminal vesicles, pelvic plexus, levator ani muscles, and Denonvilliers' fascia and the prostate.’
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
1 year ago
4418 views
18 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.
Robotic triple docking ultralow anterior resection with intersphincteric resection and coloanal anastomosis
The da Vinci™ surgical robotic system with its increased instrument stability, magnified tridimensional view, and dexterity with 7 degrees of wristed motion of its instruments offers a distinct surgical advantage over traditional laparoscopic instruments. This is especially true in the deep pelvis, where the limited space and visibility make it extremely challenging to perform distal rectal dissection. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.
For very low rectal tumors close to the anorectal junction, if a sphincter-saving procedure is to be attempted, surgeons will frequently perform an intersphincteric resection (ISR) with a handsewn coloanal anastomosis. If successful, the patient will be able to avoid an abdominoperineal resection and its resulting permanent stoma.
ISR is a technically challenging procedure to perform, especially in male and obese patients. It is because the approach to the intersphincteric plane from the abdominal approach is deep within the pelvis and frequently curves anteriorly, which makes the intersphincteric plane challenging to approach laparoscopically. In addition, ISR from the perineum is also difficult as the anus has a small opening; as a result, when the surgeon sits directly in front of the perineum, assistants will be unable to adequately visualize the operating field, making it very challenging to properly assist for the dissection. It may potentially result in some blind dissection, which may lead to entry into the wrong plane and a poor oncological specimen.
With the da Vinci™ surgical robotic system, this problem can potentially be minimized. First, via the transabdominal approach, the robotic system is able to access deep into the pelvic cavity and dissect down to the intersphincteric plane beyond the puborectalis sling. Secondly, docking the robot and approaching the ISR perineally, the robotic system can also provide a magnified vision, a fine dissection and allow the assistant a good viewing position sitting in front of the perineum to assist in a more productive manner. These advantages of the robotic system will facilitate ISR dissection and retrieval of a superior oncological specimen.
This video features a totally robotic triple docking approach for an ultralow anterior resection with intersphincteric resection and handsewn coloanal anastomosis in a male patient with a low rectal cancer.
SAE Yeo
Surgical intervention
1 year ago
2397 views
5 likes
0 comments
15:36
Robotic triple docking ultralow anterior resection with intersphincteric resection and coloanal anastomosis
The da Vinci™ surgical robotic system with its increased instrument stability, magnified tridimensional view, and dexterity with 7 degrees of wristed motion of its instruments offers a distinct surgical advantage over traditional laparoscopic instruments. This is especially true in the deep pelvis, where the limited space and visibility make it extremely challenging to perform distal rectal dissection. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.
For very low rectal tumors close to the anorectal junction, if a sphincter-saving procedure is to be attempted, surgeons will frequently perform an intersphincteric resection (ISR) with a handsewn coloanal anastomosis. If successful, the patient will be able to avoid an abdominoperineal resection and its resulting permanent stoma.
ISR is a technically challenging procedure to perform, especially in male and obese patients. It is because the approach to the intersphincteric plane from the abdominal approach is deep within the pelvis and frequently curves anteriorly, which makes the intersphincteric plane challenging to approach laparoscopically. In addition, ISR from the perineum is also difficult as the anus has a small opening; as a result, when the surgeon sits directly in front of the perineum, assistants will be unable to adequately visualize the operating field, making it very challenging to properly assist for the dissection. It may potentially result in some blind dissection, which may lead to entry into the wrong plane and a poor oncological specimen.
With the da Vinci™ surgical robotic system, this problem can potentially be minimized. First, via the transabdominal approach, the robotic system is able to access deep into the pelvic cavity and dissect down to the intersphincteric plane beyond the puborectalis sling. Secondly, docking the robot and approaching the ISR perineally, the robotic system can also provide a magnified vision, a fine dissection and allow the assistant a good viewing position sitting in front of the perineum to assist in a more productive manner. These advantages of the robotic system will facilitate ISR dissection and retrieval of a superior oncological specimen.
This video features a totally robotic triple docking approach for an ultralow anterior resection with intersphincteric resection and handsewn coloanal anastomosis in a male patient with a low rectal cancer.
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
925 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.
Double transanal laparoscopic resection of large anal canal and low rectum polyps
Background: Rectal polyps, and especially small and medium-sized lesions are removed via conventional endoscopy. Large rectal polyps can be approached using endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). In more recent years, laparoscopic surgery underwent an evolution and a new application for endoluminal resection called transanal minimally invasive surgery (TAMIS) was introduced. The authors report the case of a 79-year-old man presenting with two large polyps of the anal canal (uTisN0) and low rectum (uTis vs T1N0), which were removed through TAMIS.
Video: The patient was placed in a prone, jackknife position with legs apart. The reusable transanal D-Port was introduced into the anus. Exploration of the cavity showed the presence of a large polyp involving the entire length of the anal canal and part of the lower third of the rectum and a second large polyp located 1cm above in the lower third of the rectum. The anal canal polyp was removed with the preservation of the muscular layer. The lower third rectal polyp was removed by resecting the full-thickness of the rectal wall. During the entire procedure, the surgeon worked under satisfactory ergonomics. The polyps were removed through the D-Port. The mucosal and submucosal flaps for anal canal resection, as well as the entire rectal wall opening for low rectal resection, were closed by means of two converging absorbable sutures.
Results: Operative time was 78 minutes for the anal canal polyp and 53 minutes for the low rectum polyp. Perioperative bleeding was 10cc. The postoperative course was uneventful, and the patient was discharged after 1 day. The pathological report for both polyps showed a tubulovillous adenoma with high-grade dysplasia and free margins (stage: pTis, 8 UICC edition).
Conclusions: TAMIS for double and large polyps located in the anal canal and low rectum offers advantages, such as excellent field exposure, safe en bloc polypectomy, and final endoluminal defect closure.
G Dapri
Surgical intervention
2 years ago
1423 views
233 likes
0 comments
07:49
Double transanal laparoscopic resection of large anal canal and low rectum polyps
Background: Rectal polyps, and especially small and medium-sized lesions are removed via conventional endoscopy. Large rectal polyps can be approached using endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). In more recent years, laparoscopic surgery underwent an evolution and a new application for endoluminal resection called transanal minimally invasive surgery (TAMIS) was introduced. The authors report the case of a 79-year-old man presenting with two large polyps of the anal canal (uTisN0) and low rectum (uTis vs T1N0), which were removed through TAMIS.
Video: The patient was placed in a prone, jackknife position with legs apart. The reusable transanal D-Port was introduced into the anus. Exploration of the cavity showed the presence of a large polyp involving the entire length of the anal canal and part of the lower third of the rectum and a second large polyp located 1cm above in the lower third of the rectum. The anal canal polyp was removed with the preservation of the muscular layer. The lower third rectal polyp was removed by resecting the full-thickness of the rectal wall. During the entire procedure, the surgeon worked under satisfactory ergonomics. The polyps were removed through the D-Port. The mucosal and submucosal flaps for anal canal resection, as well as the entire rectal wall opening for low rectal resection, were closed by means of two converging absorbable sutures.
Results: Operative time was 78 minutes for the anal canal polyp and 53 minutes for the low rectum polyp. Perioperative bleeding was 10cc. The postoperative course was uneventful, and the patient was discharged after 1 day. The pathological report for both polyps showed a tubulovillous adenoma with high-grade dysplasia and free margins (stage: pTis, 8 UICC edition).
Conclusions: TAMIS for double and large polyps located in the anal canal and low rectum offers advantages, such as excellent field exposure, safe en bloc polypectomy, and final endoluminal defect closure.
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
3323 views
10 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
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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.