Laparoscopic TME Richard L. Whelan, MD St. Luke’s Roosevelt Hospital Columbia University New York, N.Y MISS Meeting, Salt Lake City

Disclosures Olympus Corporation Applied Medical Gore Corporation Atrium Corporation Ethicon Endosurgery

Total Mesorectal Excision (TME) for Rectal Cancer Articulated & popularized by William Heald TME results: significantly survival TME is the ‘gold standard’ world wide Been widely implemented and vetted (Sweden, Finland, Holland, etc) Concentration of rectal cases at “centers of excellence” in some countries

Pre-TME Situation Local recurrence rates varied widely (3-42%) Ratio of APR to LAR varied considerably Recognition that results varied from surgeon to surgeon (case volume and training) + lateral mesorectal margins  local recurrences 2 cm distal rectal margin policy  “coning in” & incomplete mesorectal excision There was no standard well articulated method

The mesorectal fascia is demonstrated as a low-signal intensity layer on MRI

Heald’s “Holy Plane” surrounds the mesorectum* - Easiest posteriorly - Anteriorly more difficult - Lateral dissection plane most difficult to find

Total Mesorectal Excision Method: Principal Elements -Complete rectal & circumferential mesorectal mobilization to pelvic floor -Resection of entire mesorectum -4-5 cm distal bowel margin -Distal rectum(2-3cm) preserved -Sharp dissection (scissor, cautery, etc) -Sparing of hypogastric and deep pelvic autonomic nerves

Surgical Approaches Standard open approach Laparoscopic (transanal removal specimen) Laparoscopic-assisted (extraction incision only) Hand-assisted laparoscopic Hybrid Laparoscopic / Open method TATA (Transanal – Transabdominal - Transanal)

Status of Laparoscopic TME & Rectal Resection for Cancer Laparoscopic methods have been proven to be safe and effective for colon cancer Far less data regarding rectal cancer resection Randomized multi-center laparoscopic rectal cancer trials – COLOR 2 in Europe (over 850 patients entered) – ACOSOG Study (over 120 patients enrolled) – MITT Group (lap vs Hand LAR, just starting) No long term prospective randomized results yet available Single center data suggests lap TME possible

Rectal Resection For Cancer Only After Gaining Experience Doing Laparoscopic Colectomy Should do rectal cases early only after: – Learning open TME methods – Learning 2 handed skills – Doing many lap colectomies Do not attempt LAR early in your laparoscopic experience

Advantages of Laparoscopic Methods for TME Superior visualization Improved ability to identify: – Planes – Nerves – Vessels Better able to do the distal portion of the mobilization sharply

Laparoscopic-Assisted LAR Resection: Port Placement Extraction site & possible stapling port

Laparoscopic Abdomino-Perineal Resection

Hand-assisted LAR

Straight Laparoscopic LAR: The Start Standard lateral to medial at left iliac fossa – Identify ureter & gonadal vessels – Mobilize main sigmoidal vessels – Enter posterior plane Medial to lateral – Right side – Base of rectosigmoid – Near sacral promontory – Score parallel to the main sigmoidal vessels

Medial to Lateral Starting at Right Sacral Promontory

Initial Scoring in R Iliac Fossa

Components of a TME (sphincter saving) Posterior mesorectal mobilization Lateral mesorectal mobilization Anterior mesorectal mobilization Distal mesorectal division Distal rectal division Anastomosis

Deep Pelvic Surgery The bony pelvis limits outward traction Important adjacent anterior structures – Bladder - Seminal vessicles – Prostate - Vagina Important posterior structures – Hypogastric nerves - Nervi erigente – Presacral veins Exposure is further limited in: – Males with narrow and long pelvis – Obese patients – Patients with large & bulky tumors

Retraction of the Giant Uterus #2 nylon suture on straightened retention needle passed through lower abdominal wall Once inside, needle passed through uterus near round ligament Passed back outside Tied over small gauze Identical suture on opposite side

Retraction of Uterus to Abdominal Wall

Other Methods of Uterine & Vaginal Retraction Uterine manipulator – Retractor placed transvaginally into cervix – Fixed in position either with cervical balloon or a clamp – Downard traction on external end of device retracts the uterus upwards Vaginal identification & retraction – Can use EEA sizers OR clean proctoscope

The Challenge of Transabdominal Closed Deep Pelvic Surgery Rectal transection level Pubis

Deep pelvis Rectum Front view Side view

Traction and Countertraction are Crucial ! The Assistant is the Key Need 4 hands to do deep mobilization Assistant provides much of the exposure Choose dissection target – Posterior, anterior or lateral Open atraumatic grasper is the tool Apply strong traction & countertraction Then retract cephalad !!! CRITICAL

Retract With Open Grasper Two point retraction Single point of retraction

Lateral Plane Exposure in Pelvis Bony confines of the pelvis Colon & Rectum Pubis

Exposing Left Lateral Plane Bowel graspers Tissue Cutting Device

Exposing Right Lateral Pelvis Tissue cutting device

Retraction to Expose R Side Video clip  0002PowerPoint_Hi.wmv

Importance of Cephalad Retraction Element Video Clip: Gordon22Powerpoint_Hi.wmv :

Scoring of Peritoneum Anteriorly

Rectum Pelvis Anterior peritoneal reflection Pubis Anus Leg Head Distal Rectal Retraction to Expose the Anterior Plane Tucus bladder 1 23 grasper

Rectum Pelvis Anterior peritoneal reflection Pubis Anus Leg Head Distal Rectal Retraction to Expose the Anterior Plane Tucus bladder nd grasper

Early Anterior Dissection

Anterior Deep Dissection In males: – Identify seminal vessicles – Leave Denonvillier’s fascia intact unless lesion is anterior – Avoid vas deferens (shouldn’t see it) In females: – Find plane between vagina and anterior rectal wall – More fat in this space than you think

Extraperitoneal Rectal Mobilization Alter traction until plane exposed Shift dissection target frequently – Left lateral to anterior – Anterior to right lateral – Lateral to posterior – Pull back camera to get broader view Find the clearest dissection field When confused, change exposure and/or shift dissection target

Pelvic Tissue Division & Dissection in Open & Closed LAR Monopolar cautery Bipolar device Ultrasonic shears Avoid blunt dissection

Early Right Lateral Dissection Video clip  Cohen44PowerPoint_Hi.wmv

Posterior Scoring

Posterior Mobilization

Sparing the Right Hypogastric Nerve in Mid-pelvis

Initial Scoring Left Pelvis

Proximal Left Dissection

Initial Division of L lateral Attachments

Minimally Invasive Strategies Laparoscopic-assisted Hand-assisted / Hybrid Full Open Incision Laparoscopic-assisted Full Open Incision Hand-assisted / Hybrid Full Open Incision

Hand and Hybrid Methods Offer patients much of the benefits of MIS Avoids full laparotomy Do not have to fully complete case laparoscopically Is a logical approach If can take flexure down closed then patient will benefit.

Extraction wound Specimen Abdominal cavity Abdominal wall Specimen Extraction

Skin incision Fascial incision Peritoneal incision Skin incision Fascial incision Peritoneal incision Obesity

Hand-Assist Posterior Mobilization

Hand-assisted Right Lateral Dissection Video clip: Gordon44Powerpoint_Hi.wmv

Develop Plane Between Rectum & Mesorectum at Transection Level

Distal Transection of Rectum

Transecting the Distal Rectum With Endo GIA Rectal transection level Via RLQ 12 mm Port OR Via Suprapubic 12 mm Port

Stapled EEA Anastomosis

How To Judge Completeness of TME Circumferential Resection Margin (CRM) Gross appearance of the specimen – Bilobed shape of the extraperitoneal posterior mesorectum – Extent of lateral resection – ? mesorectal defects Mesorectum should be “inked” prior to opening

Summary Learn open TME method first – Full mesorectal mobilization to levators – Wide lateral margins – Aim for 3-5 cm distal margin – Distal 1/3 rd lesions, divert Identify and preserve the hypogastric nerves Understand vascular anatomy of each patient Learn anterior deep pelvic anatomy Inspect your specimens carefully

Summary Routinely mobilize the splenic flexure Practice MIS methods on prolapse patients and sigmoid resections Once mastered open TME  MIS LAR/APR Find good 1 st assistant Initially, take splenic flexure down & devascularize proximally via closed methods Initiate pelvic dissection laparoscopically

Summary Can complete case using hybrid (open) or hand method if need be As experience is gained, increase percentage of pelvic dissection done laparoscopically Traction and counter traction critical plus element of cephalad retraction Stick to the “Holy Plane” As needed, shift operative field from posterior to lateral to anterior to find best exposure

Summary Transect distal rectum intracorporeally provided can do it with 2 60 mm cartridges Alternative is to use open TA stapler via Pfannenstiel suprapubic incision Hand approach is logical if having difficulty OR if lesion is bulky or patient quite obese

Need to add video clips

Laparoscopic TME: Summary

Lateral Plane Exposure in Pelvis Bony confines of the pelvis Colon & Rectum

Exposing Left Lateral Plane Bowel graspers Tissue Cutting Device

Exposing Right Lateral Pelvis Tissue cutting device

Rectum Pelvis Abdomen Distal resection point Pubis Anus Leg Head Distal Rectal Transection Stapler Tucus

Distal Rectal Transection Angled staple line often obtained (spear shaped) Multiple staple cartridges often necessary True transverse division with one cartridge rarely obtained. Use of suprapubic port to staple helps greatly (alternate RLQ 12 mm port)

Distal Rectal Transection

Pelvic Exposure In Open LAR Traction, countertraction critical St. Marks, Dever, Sawyer retractors are critical – Head light vs Lighted retractors (fiberoptic light cables) – Bookwalter & similar self retaining retractors Single person provides exposure for deep lateral, anterolateral areas (2 St. Marks) – Sidewall and mesorectum retracted – Retraction is outward & cephalad Must work within the confines of the bony pelvis

Laparoscopic TME Exposure is of paramount importance Closed methods pose different challenges – Small bowel retraction – Uterine retraction Some challenges are the same for open & closed methods – Exposure obtained via traction & counter traction – Working in the deep pelvis – Confines of the bony pelvis are the same

Retraction & Counter traction Mandatory * Cannot do deep pelvic dissection alone Need skilled 1 st assistant Decide area to be exposed (lateral rectum on the right) – Retractor (via R sided port) retracts sidewall tissue laterally and towards the head – 2 nd grasper (open) retracts right side of rectum medially and cephalad * Especially in the obese patient