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General and digestive surgery

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.
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 month ago
418 views
3 likes
1 comment
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.
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
6 months ago
1443 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.
Live interactive transanal TME (TaTME) with the TEO™ platform
Randomized clinical trials such as COLOR II, COREAN and CLASICC, have shown better results for laparoscopic total mesorectal excision (TME), in terms of short-term and long-term outcomes, when compared with open TME.
Laparoscopic TME presents some limitations such as low rectal cancer which has a high risk of leaving a positive circumferential resection margin (CRM) and a narrow pelvis. Conversion to open procedures remains unsatisfactory.
Transanal TME (taTME) has been proposed to give a new option in cases where laparoscopic TME is difficult.
In this video, we present the case of a transanal approach with the TEO™ platform for low rectal cancer.
A Melani, A D'Urso, D Mutter, J Marescaux
Surgical intervention
1 year ago
3405 views
324 likes
0 comments
45:51
Live interactive transanal TME (TaTME) with the TEO™ platform
Randomized clinical trials such as COLOR II, COREAN and CLASICC, have shown better results for laparoscopic total mesorectal excision (TME), in terms of short-term and long-term outcomes, when compared with open TME.
Laparoscopic TME presents some limitations such as low rectal cancer which has a high risk of leaving a positive circumferential resection margin (CRM) and a narrow pelvis. Conversion to open procedures remains unsatisfactory.
Transanal TME (taTME) has been proposed to give a new option in cases where laparoscopic TME is difficult.
In this video, we present the case of a transanal approach with the TEO™ platform for low rectal cancer.
Laparoscopic total mesorectal excision (TME) through single right iliac fossa (RIF) incision
Background: Single incision laparoscopy is worth of interest during up-to-down rectal resection because it allows to use the single site as the site of temporary ileostomy placement at the end of the procedure.
Video: This video shows an up-to-down single incision laparoscopic rectal resection in a 49-year-old woman presenting with a rectal adenocarcinoma located 12cm away from the anal margin. Preoperative work-up showed a T2N0M0 tumor. The procedure was entirely performed with curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany), inserted in the right flank. The uterus and the peritoneal sheet covering the vagina were retrieved using percutaneous sutures. A circular mechanical colorectal anastomosis was performed and a final temporary ileostomy was placed at the site of the single access.
Results: The procedure duration was 297 minutes, and peroperative bleeding was unsignificant. The final scar length was 2.5cm, and the patient was discharged on postoperative day 5. The pathological report confirmed a pT2N0M0 tumor (20 negative nodes).
Conclusions: Up-to-down single incision laparoscopic rectal resection allows to place the temporary ileostomy at the single incision site, offering oncological results comparable to conventional laparoscopy.
G Dapri, N Bachir, L Antolino, K Grozdev, D Guta, K Jottard, GB Cadière
Surgical intervention
3 years ago
2204 views
107 likes
0 comments
09:22
Laparoscopic total mesorectal excision (TME) through single right iliac fossa (RIF) incision
Background: Single incision laparoscopy is worth of interest during up-to-down rectal resection because it allows to use the single site as the site of temporary ileostomy placement at the end of the procedure.
Video: This video shows an up-to-down single incision laparoscopic rectal resection in a 49-year-old woman presenting with a rectal adenocarcinoma located 12cm away from the anal margin. Preoperative work-up showed a T2N0M0 tumor. The procedure was entirely performed with curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany), inserted in the right flank. The uterus and the peritoneal sheet covering the vagina were retrieved using percutaneous sutures. A circular mechanical colorectal anastomosis was performed and a final temporary ileostomy was placed at the site of the single access.
Results: The procedure duration was 297 minutes, and peroperative bleeding was unsignificant. The final scar length was 2.5cm, and the patient was discharged on postoperative day 5. The pathological report confirmed a pT2N0M0 tumor (20 negative nodes).
Conclusions: Up-to-down single incision laparoscopic rectal resection allows to place the temporary ileostomy at the single incision site, offering oncological results comparable to conventional laparoscopy.
Transanal laparoscopic TME with a new port assisted by single incision
Background: Rectal resection with total mesorectal excision (TME) can be performed through the anus going up into the abdominal cavity. This approach has to be performed using a transanal device in order to create a retroperitoneum, allowing the surgeon to perform a TME similar to the one performed from the abdomen going down to the anus. A new reusable port named DAPRI Port or D-Port (Karl Storz Endoskope, Tuttlingen, Germany) has been developed, and a new platform together with curved reusable instruments according to DAPRI (Karl Storz Endoskope) has been created. The D-Port allows to maintain one of the rules of laparoscopy, which is the optical system in the middle of the two ancillary operative tools. In addition, the cost of the procedure is not increased, due to the reusable material.
Video: This video shows a down-to-up rectal resection assisted by single incision laparoscopy, in a 65-year old man presenting with a rectal adenocarcinoma 4cm away from the anal margin. Preoperative work-up showed a T2N0M0 tumor, after radiochemotherapy. The procedure was performed transabdominally for the vascular dissection and transanally for the TME. The abdominal single site was then used for the placement of the temporary ileostomy.
Results: Total operative time was 301 minutes, and partial transanal laparoscopy was 145 minutes. Perioperative bleeding was 50cc. The final scar length was 2.5cm, and the patient was discharged after 5 days. The pathological report confirmed a pT2N0M0 tumor (15 negative nodes).
Conclusions: Down-to-up rectal resection is an interesting procedure, and when associated with single incision laparoscopy, it offers the possibility to use the single site as the site for temporary ileostomy.
G Dapri, L Antolino, N Bachir, D Guta, K Grozdev, B Nebbot, K Jottard, GB Cadière
Surgical intervention
3 years ago
2749 views
40 likes
0 comments
12:53
Transanal laparoscopic TME with a new port assisted by single incision
Background: Rectal resection with total mesorectal excision (TME) can be performed through the anus going up into the abdominal cavity. This approach has to be performed using a transanal device in order to create a retroperitoneum, allowing the surgeon to perform a TME similar to the one performed from the abdomen going down to the anus. A new reusable port named DAPRI Port or D-Port (Karl Storz Endoskope, Tuttlingen, Germany) has been developed, and a new platform together with curved reusable instruments according to DAPRI (Karl Storz Endoskope) has been created. The D-Port allows to maintain one of the rules of laparoscopy, which is the optical system in the middle of the two ancillary operative tools. In addition, the cost of the procedure is not increased, due to the reusable material.
Video: This video shows a down-to-up rectal resection assisted by single incision laparoscopy, in a 65-year old man presenting with a rectal adenocarcinoma 4cm away from the anal margin. Preoperative work-up showed a T2N0M0 tumor, after radiochemotherapy. The procedure was performed transabdominally for the vascular dissection and transanally for the TME. The abdominal single site was then used for the placement of the temporary ileostomy.
Results: Total operative time was 301 minutes, and partial transanal laparoscopy was 145 minutes. Perioperative bleeding was 50cc. The final scar length was 2.5cm, and the patient was discharged after 5 days. The pathological report confirmed a pT2N0M0 tumor (15 negative nodes).
Conclusions: Down-to-up rectal resection is an interesting procedure, and when associated with single incision laparoscopy, it offers the possibility to use the single site as the site for temporary ileostomy.
PROGRESS - Transanal TME with colo-anal anastomosis without trans-abdominal assistance for rectal cancer in a male patient
The authors put forward an original oncologic Total Mesorectal Excision (TME) technique combined with distal sigmoidectomy followed by a mechanical colo-anal side-to-end anastomosis using a purely transanal route.
The originality of this technique lies in the strictly transanal approach without any laparoscopic assistance as well as in the oncologic dissection of the rectum around its fascia propria. In addition, the technique is outstanding in the mobilization of the sigmoid mesocolon’s root as well as in the retroperitoneal mobilization of the vascular inferior mesenteric axis, hence avoiding contact with intra-abdominal organs.
This technique is called PROGRESS (Peri Rectal Oncologic Gateway for Retroperitoneal EndoScopic Surgery) due to the retroperitoneal endoscopic dissection using a perirectal access.
The video shows images of remarkable quality, especially of anatomical nerve structures, due to the use of a 4mm, 30-degree scope and a Karl Storz High-Definition camera introduced through the TEO™ device.
J Leroy, D Ntourakis, J Marescaux
Surgical intervention
6 years ago
5906 views
34 likes
1 comment
18:55
PROGRESS - Transanal TME with colo-anal anastomosis without trans-abdominal assistance for rectal cancer in a male patient
The authors put forward an original oncologic Total Mesorectal Excision (TME) technique combined with distal sigmoidectomy followed by a mechanical colo-anal side-to-end anastomosis using a purely transanal route.
The originality of this technique lies in the strictly transanal approach without any laparoscopic assistance as well as in the oncologic dissection of the rectum around its fascia propria. In addition, the technique is outstanding in the mobilization of the sigmoid mesocolon’s root as well as in the retroperitoneal mobilization of the vascular inferior mesenteric axis, hence avoiding contact with intra-abdominal organs.
This technique is called PROGRESS (Peri Rectal Oncologic Gateway for Retroperitoneal EndoScopic Surgery) due to the retroperitoneal endoscopic dissection using a perirectal access.
The video shows images of remarkable quality, especially of anatomical nerve structures, due to the use of a 4mm, 30-degree scope and a Karl Storz High-Definition camera introduced through the TEO™ device.
The glove TEM port: the poor man's TEM
Objective: Single port laparoscopic tools and principles are transferable to transanal work. Initial experiences and small series have recently been reported with the use of commercially available singe port systems. In an effort to improve the ergonomic constraints as well as to reduce the costs associated with these commercially available ports, we have further evolved our personal experience with the glove port towards an access modality equivalent to Transanal Endoscopic Microsurgery (TEM) for the intraluminal management of rectal disease. Here we describe this new and cost-effective technique for transanal work in a short video.
Materials and Methods: The glove TEM port is constructed on table by using a circular anal dilator (CAD), a wound retractor-protector (ALEXIS®, Applied Medical) and a standard sterile surgical glove. The wound retractor-protector is inserted through the CAD and anchors itself at the anorectal junction. Sealing the outer ring of the wound retractor with the cuff of the surgical glove creates a workspace and airtight seal. Through the fingers of the glove, standard laparoscopic trocar sleeves are inserted (along with a gas insufflation channel) through which a conventional 30-degree videoscope along with straight rigid laparoscopic instruments are inserted. Excellent views can be obtained with the regular laparoscopic optics after the creation of a stable pneumorectum of 10-15mmHg. The same principles apply for the dissection and resection as with a conventional TEM. The flexibility of the glove provides enhanced instrument maneuverability in each of the horizontal, vertical and rotational planes as well as improved tip abduction and adduction especially useful for suturing.
Results: Initial preliminary work standardised both set-up and application of the apparatus and confirmed it outperformed commercially available counterparts in this application with regard to stability, instrument maneuverability and range of movement. Thereafter, all patients eligible for TEM have been offered the option to participate in our pilot study. With this new access modality, ten consecutive patients between October 2010 and January 2011 underwent resection of benign (n=6) or malignant (n=4) rectal tumors. Only one case had to be converted to a conventional TEM procedure because anatomical features prohibited inserting the CAD high enough into the anal canal. The case we present here is a full-thickness excision of an early rectal cancer in an 87-year-old female patient who was unfit for the conventional radical rectal resection.
Conclusions: The glove TEM port is a safe, cheap and readily available tool that can be used in combination with regular laparoscopic tools for transanal resection of rectal lesions. It is surgeon-friendly, economically attractive, and universally applicable.
R Hompes, F Ris, C Cunningham, N Mortensen, R Cahill
Surgical intervention
7 years ago
2571 views
30 likes
1 comment
08:10
The glove TEM port: the poor man's TEM
Objective: Single port laparoscopic tools and principles are transferable to transanal work. Initial experiences and small series have recently been reported with the use of commercially available singe port systems. In an effort to improve the ergonomic constraints as well as to reduce the costs associated with these commercially available ports, we have further evolved our personal experience with the glove port towards an access modality equivalent to Transanal Endoscopic Microsurgery (TEM) for the intraluminal management of rectal disease. Here we describe this new and cost-effective technique for transanal work in a short video.
Materials and Methods: The glove TEM port is constructed on table by using a circular anal dilator (CAD), a wound retractor-protector (ALEXIS®, Applied Medical) and a standard sterile surgical glove. The wound retractor-protector is inserted through the CAD and anchors itself at the anorectal junction. Sealing the outer ring of the wound retractor with the cuff of the surgical glove creates a workspace and airtight seal. Through the fingers of the glove, standard laparoscopic trocar sleeves are inserted (along with a gas insufflation channel) through which a conventional 30-degree videoscope along with straight rigid laparoscopic instruments are inserted. Excellent views can be obtained with the regular laparoscopic optics after the creation of a stable pneumorectum of 10-15mmHg. The same principles apply for the dissection and resection as with a conventional TEM. The flexibility of the glove provides enhanced instrument maneuverability in each of the horizontal, vertical and rotational planes as well as improved tip abduction and adduction especially useful for suturing.
Results: Initial preliminary work standardised both set-up and application of the apparatus and confirmed it outperformed commercially available counterparts in this application with regard to stability, instrument maneuverability and range of movement. Thereafter, all patients eligible for TEM have been offered the option to participate in our pilot study. With this new access modality, ten consecutive patients between October 2010 and January 2011 underwent resection of benign (n=6) or malignant (n=4) rectal tumors. Only one case had to be converted to a conventional TEM procedure because anatomical features prohibited inserting the CAD high enough into the anal canal. The case we present here is a full-thickness excision of an early rectal cancer in an 87-year-old female patient who was unfit for the conventional radical rectal resection.
Conclusions: The glove TEM port is a safe, cheap and readily available tool that can be used in combination with regular laparoscopic tools for transanal resection of rectal lesions. It is surgeon-friendly, economically attractive, and universally applicable.
Robotic total mesorectal excision, a practical solution in an obese female patient
This video describes a practical solution to total mesorectal excision using robotics. The patient is a 55-year-old female with a BMI of 32 and low rectal cancer localized 3cm above the anorectal ring. She also has large uterine fibroids.
The patient received preoperative chemoradiation and subsequently underwent a surgical procedure in form of ultra low anterior resection with colonic J pouch creation and protective ileostomy.
The concept of the procedure utilizes several surgical techniques which seem to be best suited for an obese patient with locally advanced low rectal cancer. The main emphasis during this presentation is placed on robotic total mesorectal excision. On the other hand, we would like to present a fairly universal approach to any low rectal cancer.
Several important issues in regards to the current robotic technology are discussed. These include the obvious advantage in the deep pelvis, hybrid concept, and the answer to the question “Why isn’t the entire procedure performed robotically?”
S Marecik, M Zawadzki, C Corning, J Park, L Prasad
Surgical intervention
7 years ago
3611 views
26 likes
0 comments
15:28
Robotic total mesorectal excision, a practical solution in an obese female patient
This video describes a practical solution to total mesorectal excision using robotics. The patient is a 55-year-old female with a BMI of 32 and low rectal cancer localized 3cm above the anorectal ring. She also has large uterine fibroids.
The patient received preoperative chemoradiation and subsequently underwent a surgical procedure in form of ultra low anterior resection with colonic J pouch creation and protective ileostomy.
The concept of the procedure utilizes several surgical techniques which seem to be best suited for an obese patient with locally advanced low rectal cancer. The main emphasis during this presentation is placed on robotic total mesorectal excision. On the other hand, we would like to present a fairly universal approach to any low rectal cancer.
Several important issues in regards to the current robotic technology are discussed. These include the obvious advantage in the deep pelvis, hybrid concept, and the answer to the question “Why isn’t the entire procedure performed robotically?”
Autonomic nerve-preserving laparoscopic total mesorectal excision in a male patient based on a new anatomical concept
Dr. Kinugasa proposed the new concept of surgical anatomy in the pelvis. In his concept, the pre-hypogastric nerve fascia is defined as a fibrous membrane, which covers the superior hypogastric nerve plexus, the hypogastric nerves and the pelvic nerve plexus. In this video, we present our procedure of laparoscopic Total Mesorectal Excision (TME) in a male patient, focusing on the relationship of the hypogastric nerve fascia, the Denonvilliers’ fascia and the nervous system in the pelvis. The technical characteristics of this procedure are as follows: sharp dissection with electrocautery through the entire procedure, posterior and lateral dissection along the pre-hypogastric nerve fascia, anterior dissection behind the Denonvilliers’ fascia (DVF), and unroofing of neurovascular bundles by the assistant in order to recognize and dissect the lowest part of the mesorectum in the antero-lateral corner of the pelvis.
Y Sakai, K Hida, K Kawada, JI Kawamura, A Nomura, S Nagayama, S Hasegawa
Surgical intervention
8 years ago
9015 views
49 likes
1 comment
14:29
Autonomic nerve-preserving laparoscopic total mesorectal excision in a male patient based on a new anatomical concept
Dr. Kinugasa proposed the new concept of surgical anatomy in the pelvis. In his concept, the pre-hypogastric nerve fascia is defined as a fibrous membrane, which covers the superior hypogastric nerve plexus, the hypogastric nerves and the pelvic nerve plexus. In this video, we present our procedure of laparoscopic Total Mesorectal Excision (TME) in a male patient, focusing on the relationship of the hypogastric nerve fascia, the Denonvilliers’ fascia and the nervous system in the pelvis. The technical characteristics of this procedure are as follows: sharp dissection with electrocautery through the entire procedure, posterior and lateral dissection along the pre-hypogastric nerve fascia, anterior dissection behind the Denonvilliers’ fascia (DVF), and unroofing of neurovascular bundles by the assistant in order to recognize and dissect the lowest part of the mesorectum in the antero-lateral corner of the pelvis.
TME for rectal cancer in a female patient: low rectal dissection
Total mesorectal excision (TME) has been established as a standardized radical surgical procedure in malignant tumors of the middle and lower rectal third. The objectives of TME are low rates of locoregional recurrences and good functional results. Total mesorectal excision in the radical surgical treatment of lower and middle third rectal carcinomas is the essential part of lymphatic dissection in these tumors. This film shows the low rectal dissection performed by a very experienced surgeon in a female patient presenting with cancer of the middle third of the rectum. Thanks to an adequate traction and counter-traction and thanks to the use of scissors (roticulator endo minishears), the rectum surrounded by its fascia propria is progressively divided.
J Leroy, J Marescaux
Surgical intervention
9 years ago
336 views
17 likes
0 comments
04:17
TME for rectal cancer in a female patient: low rectal dissection
Total mesorectal excision (TME) has been established as a standardized radical surgical procedure in malignant tumors of the middle and lower rectal third. The objectives of TME are low rates of locoregional recurrences and good functional results. Total mesorectal excision in the radical surgical treatment of lower and middle third rectal carcinomas is the essential part of lymphatic dissection in these tumors. This film shows the low rectal dissection performed by a very experienced surgeon in a female patient presenting with cancer of the middle third of the rectum. Thanks to an adequate traction and counter-traction and thanks to the use of scissors (roticulator endo minishears), the rectum surrounded by its fascia propria is progressively divided.