1. Laparoscopic TME Richard L. Whelan, MD St. Luke’s Roosevelt Hospital Columbia University New York, N.Y. 2011 MISS Meeting, Salt Lake City

2. Disclosures Olympus Corporation Applied Medical Gore Corporation Atrium Corporation Ethicon Endosurgery

3. 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

4. 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

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

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

7. 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

8. 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)

9. 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

10. 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

11. 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

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

13. Laparoscopic Abdomino-Perineal Resection

14. Hand-assisted LAR

15. 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

16. Medial to Lateral Starting at Right Sacral Promontory

17. Initial Scoring in R Iliac Fossa

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

19. 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

20. 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

21. Retraction of Uterus to Abdominal Wall

22. 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

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

24. Deep pelvis Rectum Front view Side view

25. 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

26. Retract With Open Grasper Two point retraction Single point of retraction

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

28. Exposing Left Lateral Plane Bowel graspers Tissue Cutting Device

29. Exposing Right Lateral Pelvis Tissue cutting device

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

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

32. Scoring of Peritoneum Anteriorly

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

34. Rectum Pelvis Anterior peritoneal reflection Pubis Anus Leg Head Distal Rectal Retraction to Expose the Anterior Plane Tucus bladder 1 2 2 nd grasper

35. Early Anterior Dissection

36. 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

37. 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

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

39. Early Right Lateral Dissection Video clip  Cohen44PowerPoint_Hi.wmv

40. Posterior Scoring

41. Posterior Mobilization

42. Sparing the Right Hypogastric Nerve in Mid-pelvis

43. Initial Scoring Left Pelvis

44. Proximal Left Dissection

45. Initial Division of L lateral Attachments

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

47. 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.

48. Extraction wound Specimen Abdominal cavity Abdominal wall Specimen Extraction

49. Skin incision Fascial incision Peritoneal incision Skin incision Fascial incision Peritoneal incision Obesity

50. Hand-Assist Posterior Mobilization

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

52. Develop Plane Between Rectum & Mesorectum at Transection Level

53. Distal Transection of Rectum

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

55. Stapled EEA Anastomosis

56. 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

57. 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

58. 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

59. 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

60. 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

64. Need to add video clips

67. Laparoscopic TME: Summary

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

72. Exposing Left Lateral Plane Bowel graspers Tissue Cutting Device

73. Exposing Right Lateral Pelvis Tissue cutting device

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

79. 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)

80. Distal Rectal Transection

81. 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

82. 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

83. 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