rof. Melino Laparoscopic anterior rectal resection

hello hello uh how are you can you hear me so uh the case that uh we are gonna share and perform

is a tumor located at the upper rack what what uh we are doing now uh we are uh

starting our procedure by the inferior mesenteric artery so we are going to open the mesenterium

close to the artery where we can identify the root of inferior mesenteric artery

The idea here is to desiccate around the artery and also to prepare the artery to be ligated.

One of the most important points is to avoid damage to the hypogastric plexus.

So this is why we have to understand well where is the origin of the artery.

And this is why it's very important to open the planes in the embryological origin.

So the patient is positioned in Trendelenburg and also in a right-side chute.

And the idea, once we identify the artery, is to skeletonize the artery and then ligate it.

it. So how we do that, we usually, we like to use the monopolar dissection. And once

we have the dissection that we do around the artery, and the idea is to skeletonize that,

so we are going to be able to grab the artery and go around and go behind to separate the

artery from the branch of the nerves. As I told you, the patient is positioned in this

uh uh uh friendlenburg and right tilt uh so uh once uh we uh are prepared uh for this and uh

the trokers uh we place uh uh 10 millimeters at the umbilical uh area uh 112 at the right

uh iliac fossa and two fives in the opposite side from left and right at the level of the

belly button. So, with that, I am able to expose the sigmoid, as you can see, and also I am able

to get the area if I need to take down the splenic flexure. As you see, this tumor is located at the

upper rectum, but we need to dissect the rectum below because we have to do at least five centimeters

meters uh distal margin for this tumor if you have any question of course you can stop me and

we can discuss and this is the case uh 41 years old male patient with rectal bleeding and so no

mass or hemorrhoids as a rectal examination and no distant metastasis and

And presacral, not positive or suspicious nodes, and they decide for surgery in this case.

And the idea is to do a laparoscopy, upper rectal dissection.

So again, now we are going to lift the meso.

once we have the origin of the artery is done,

detaching a little bit the adhesions,

and we will dissect around the artery.

Usually, we just open the first spit of the visceral peritoneum,

and we wait for the pneumo to help us for this dissection

because when we do the pneumo,

the pneumo will allow and help us to complete the dissection.

When we lift the tissue and we bump, we are able to recognize the different planes.

It's very important to be in the proper plane to avoid damage to important structures as the nerves.

And so you're doing this again, trying to detach the tissue that are around the artery.

Can you hear me well?

we will grab the artery now and lift in a gently way in a kind way and then we are going to dissect

below the artery now we switch the instruments for this bipolar and we are going to continue our

dissection laterally and this is what we are recommending now and why we are recommending

that because when we start laterally in the early moments of the surgery it

allowed us to follow the fold or the toe fascia and so with the fold of the

toe fascia oh can you hear me now we are dissecting laterally because it allowed

allowed us to detach the toe fascia, and so we are using the lateral approach because

it facilitates to recognize the embryological planes.

Once you do medial to lateral, we have to go across the meso, but when we dissecting

this way, we use the embryological plane and the position of the colon to favor us, and

And this is almost the same principle of the CME or the bottom-up technique

because it allows this dissection to follow the fold of the toe fascia.

Can you hear me now?

And also allows us to recognize very early the position of the ureter and the gonadal vessel.

So when you come medial to lateral, you have to go across.

cross and there is a big risk in this is very slim patient to get behind the nerves and damage

the nerves and with this type of dissection we are able to recognize those planes it facilitates

the dissection and nowadays with the instruments that we have uh even balaparoscopy uh it is

it's possible to turn a little bit, and as I told you, we use a lot of monopolar dissection

to keeping this proper plane. So you have no bleeding when you are in the proper plane.

You can use blood dissection exactly as we do in open surgery. This strategy helps us

to follow the proper plane, the embryological plane, and to avoid damage at the marginal

arcades. Now we are detaching the gonadal vessels in the patient very lean, have to be gently and

careful to avoid damage to this area. The moves usually have to be perpendicular

for the blunt dissection and the traction and the pneumoperitoneum

help us to identify the embryological planes. What we are doing, we are just following the

planes and so it's very easy to recognize the planes when you do when we use this type of

strategy of course the way that we do the traction and the way that we grab the meso

and the way that we lift the meso it's also important because uh if you don't lift a little

bit the meso it is it's going to be dangerous and so uh the traction has to be a little bit

upper and laterally as you can see and one of the important thing is that when

we do this type of the dissection we also are going to recognize the nerves

early and so one of the secrets to be in in this plane is to be very close to the

to the mesenterium because in the retroperitoneum we have some fat that

that does not belong to the meso.

And so it's very important to recognize

the difference of those planes.

And here, you can see that with traction,

we are able to recognize that not all the fat

belongs to the meso.

And we are able to be in the proper plane.

No advanced energy, just pure monopolar,

exactly as we teach or we are done in the past

in open surgery.

surgery. Now we are going to open a little bit wide in direction to the pelvis. This

idea is to separate this very slim fit from the meso. Monopolar impure cuts help us to

be in the proper plane. We are dissecting down, releasing the adhesions. And as Bill

Hill always teach us where is the plane for the mesoretum is the innermost

dissectable plane it means that more central as you can do and now once the

artery is ligated so we are able also to dissect to lift the meso and there is a

low risk to damage the nerve when we do this because we already detached the

meso from the other side. You see that it's very simple now to connect both sides. And with patients

that are a little bit more fat and the patient that has a very low rectal cancer, when they

receive a primo-stimulant radiation therapy, this strategy always allows us to be in the proper

plane. We communicate both sides and we are safe that we are not damaging the nerves. The idea of

of this strategy is to preserve better the nerves

at the right and the left sides.

Now we are gonna continue our dissection

being more central as we can.

And so as you can see, we get it at the other side

and we are able to detach only this area

where we have some lymphatic branches

branches. And now we are going to go down and dissect the rectum and the area that's around

the rectum. Do you have any doubt? Can you hear me? I cannot hear you. I don't know if it's a

connection problem, but I cannot hear you. Now we are dissecting down. As you can see,

this is an easy plane to acquit, being posteriorly. You can see that the nerves

is strapped to the left side so it have to go gently to not to damage the nerve and we go

in the innermost dissectable plane so it means that the more central plane that we can do

we detach this is a very good vision that we have with a 30 degree scope

now we go to the left side we are going to complete this uh opening of the peritoneum

At the anterior sides, as we plan for a good dissection with a good distance margin, we are going to start our anterior dissection now.

So, a system is going to grab the junction.

function, we like to open a little bit in the upper side of the Douglas pouch because

it gives for us a flap, and this flap will help us to do a traction without touching

the tumor.

So usually this type of traction that we perform, we try to avoid to grab the rectum or the

the meso we try to be in the peritoneum to avoid disruption of the tissue and we are going to

continue our anterior dissection combining both areas at the left and the right side as you can

see can you i have no sound from you so if you if you want to do any question please i believe

that's important to send by chat because i cannot hear you now we communicate the peritoneum and now

Now, as we communicate, our strategy is going to dissect down.

We are using the advantage of the flap to help us to get in the proper plane.

This is really a very good technique for the dissection.

And as an intra-zonal approach, we do 12 o'clock first, and then we come laterally,

and we are going to join both dissections.

The lateral dissection with the anterior dissection.

It is very important to keeping the proper plane for doing this.

And as you can see, when we are working at the left side,

our traction is from the left to the right.

But we never push.

We have to, in fact, we have to push towards to the sacrum

and never pull the rectum outside of the pelvis.

otherwise you are gonna be in a wrong plane and usually at 11 to 12 o'clock

we have to build the area where we are gonna dissect and why this is important

because we want to keep the innervation in place so as I told you not every fat

belongs to the mesorectum and some of them carry some branch of the nerve and

to be in the proper plane is very important to understand that this is the

lateral dissection that we perform inner most dissectable plane means more central more central

is the best place to be assistant is going to lift again anterior part of the bladder

and we are going to push against the sacrum this allowed us to have this beautiful image

anteriorly. As you saw, I didn't detach posteriorly too much. And I use this as an advantage to help

me to do a good exposure of the anterior part of the rectum. Because this does not allow me to pull

the rectum outside of the pelvis. And then the anterior dissection is preserved. And I have a

a better view. This is the main idea of doing this type of approach, lateral and anteriorly.

As you saw, the nerve is completely preserved. This is a very good strategy to improve the

functional results of the bladder and urinary and structural function. And then we go to the

other side once we do the left side we are going to go the left right side and the right side

or forceps are going to work a little bit more parallel with the the uh pelvic wall side uh

side wall and so we are going to communicate both both dissection lateral posteriorly

to be in the proper plane and this is a very important point of entrance of the rectum

it's not too lateral if you go lateral you increase the chance to damage the nerves

so now our system is going to grab and lift the uh at two o'clock and we are going to detach some

branches of the arrogant pillar located this area and we are going to go down to the pelvis

at the right side exactly as we did at the left side we are going to do at the right side

very easy to recognize the plane that's where we have to go, and there is a low risk to

damage the nerves.

But the left hand that's doing the exposure is very important.

This spatula with monopolar is just cutting what our left hand is exposing.

So, the secret of the surgery is to know how to read the planes and how to expose the plane.

As we need five centimeters distal margin for the meso, and now this is one of the points

of the, some branches of the erogenous pillar getting into the mesorectum where we have

to cross and cut.

cuts. Now we are going to dissect posteriorly and detach the rectum completely. So you can see the

hypogastric nerves at the right side. Now we are going to lift posteriorly and we are going to

complete the posterior dissection. We believe that when we switch for the anterior first,

instead of going posteriorly first, it helps us and allows us to see better what we are doing

anteriorly and you see all the branches of the nerves and the neurovascular bundle that we have

to preserve and now uh we are going to continue our dissection posteriorly we do at the right

we do at the left now we are able to communicate both sides very good uh traction allowed us to

the mesorectum. It's not a complete TME, it's a partial TME, as the lesion is located in the

upper rectum. So once we get these five centimeters distal margin, so we are able to prepare now,

we are going to be able to prepare the rectum for the transsection.

Mobilization of the rectum is important because we want also attention-free anastomosis.

So, this mobilization also help us posteriorly, help us to do a very good transsection.

And now, we are going to prepare the rectum for the transsection.

As I told you, five centimeters distal margin is very important in an oncological way, so

we are going to choose where we are going to do our rectal transsection.

important to go very gently not to perforate the the rectum and to be as perpendicular as we can

because if we go perpendicular it facilitates to put our uh staper and his taper has to be

perpendicular this is a case that we did live in a in court one course in irkut in france

The idea to demonstrate how we achieve the proper margin, at least a 5-centimeter margin, is a partial TME dissection because it's an upper rectum tumor.

And one of the difficult things is to complete this posterior dissection of the mesorectum for a good transection.

As you saw, we didn't detach the mesorectin to the elevators because there is no need

to do it laterally.

And we have branches of the nerves that runs and gives a function for the patient.

So we usually, we don't dissect the mesorectin too much.

And so for this type of case, usually this is enough.

And now the goal is to try to transect the retina with just one stapler.

But usually, in a small pelvis, it's not possible.

We have to use at least one or two cartridges.

And we are going to use that tristaple signia device for this transection.

And we are going to angulate the stapler.

Two things you can do.

you can try to do this laterally or you can do a suprapubic transaction but the

goal is always to do a 45 90 degrees transaction I believe that this is a

place for in the CNN if you have it for the green because it's a point where you

can change your transaction area but unfortunately during this procedure we

We didn't have the green to check the position of the transaction.

We have to trust in our feelings.

Now we articulate, we place this taper.

We're going to fire.

In this case, probably, we are going to fire two times,

checking the position, checking if the device is working.

We have some sign on the back of the device that tells us if the system is okay

and ready to go.

We push the green button, and then we do the transsection.

The system by itself calculates the thickness of the tissue.

So the speed goes and varies depending

on the thickness of the tissue, because sometimes you

need more compression.

We are going to use the second cartridge.

And once the green is OK, we are able to use it.

We use the technique that is a Chinese hat, trying to be as perpendicular as we can to

follow the same line, trying to avoid one more cartridge, so reposition this taper to

have a good, a very good transaction.

Three cartridges is bad, we know that increase the risk of leaks, two is usually is good.

area that were not cut so we're gonna use the scissor to cut that distal part

and then we have our specimen but it's not ready yet for this type of

anastomosis as I told you we need attention free anastomosis so we did

the artery but we didn't need the vein so what we are going to do now is to

lift the transverse mesocollum we are going to identify the origin of the

infirmus and third vein as you can see we have some additions at the right

angle we are going to detach these additions and now we are able to

recognize and see the vein now we see the origin of the vein we can patients

is already in lateral position so lateral tilt so we have to fight with some bowel we use this

sponge to try to spare in the bowel as a barrier and help us to dissect we use Blount dissection

but remember that we did a lot of this dissection at the lateral side once we recognize they are the

the origin of the vein, that is the rule that I described.

It's one inch up and one inch left.

So we are going to open a window at the top of the pancreas.

So we see the origin of the vein.

We go two centimeters or three up and two centimeters to the left of the vein.

And we are going to open a window that will allow us to get into the lesser sac.

and this is going to facilitate we do that before we ligate the vein this is going to facilitate us

to lift the meso at the pancreas and usually with one bite we are able to to connect and

we are going to enter into the lesser sac you can see now the stomach and so we see this window

that we're done and now we are going to dissect and transect the vein usually for the vessel

ligation we are very confident to use the vessel sealer at the vein but for the arteries sometimes

depending on the patient depending on the age we can use some clips but also in the vein you can

use some clips if you want so we are gonna ligate the vein it's very important to relax for this

this ligation and transsection, you relax the traction from your assistant, and now

once you ligate the vein, you are able to follow the planes on the top of the pancreas

and communicate the hold that we did before with this area where we ligate the veins.

So we are going to communicate both things. This is the maneuver that we call delta wing.

We were in the lesser sac before, remember, and now we are just connecting both dissections.

Now, we can change also the position for the traction from our assistant.

He's going to grab a little bit closer at the origin of the vein where we already did the transsection,

and we are going to communicate this posterior dissection that can be done in blounts.

And I like to use this sponge to help us to lift the meso, because we're doing that, we decrease the pressure of the instrument at the marginal arcades, and we decrease the chance to damage the meso.

One of the things that you can have as a complication is to damage the vein, lifting the meso with the tip of your instrument, so it's very important to be gentle in this dissection.

As you can see, we are still in the proper plane that we did some dissection from below.

In fact, from laterally, we are lifting the meson in a proper way.

We are detaching this area on the gerontous fascia area.

We will communicate our previous dissection.

Remember that we did laterally with this one.

this will help us and facilitate to do the mesonal we are lifting detaching the mesonal

now we are going to follow the pancreas and we are going to follow the what we call the window

that allowed us to get in the proper area detaching from the pancreas without damaging it

This is a medial to lateral approach for splenic flexure, and we go above the pancreas as far as we can.

Remember, when you lift, you can lift the pancreas together with you, so it's very important always to be in the proper area.

And when we arrive at the tail of the pancreas, we put some sponge, and we are going to go now for the supracolic dissection.

Those are the steps for splenic flexure that we described.

And now it's very easy because once you recognize and you detach the peplum, the supracolic

dissection is very easy because all the additions from the peplum or from the stomach, you're

going to see in front of you.

So because the pancreas is already out there and done, and so it's very easy to recognize

those additions.

and we see this sponge below and it's very fast also we don't care about the

spleen because we are far away from the spleen if it's possible we try not to

see the spleen just cutting instead of clogging before now we are gonna change

the position of our system he's gonna grab inside of the mesocolon at the

upper part because these are going to give us a better view and we are going to change this

position as you can see we use the our instruments to expose explains far away we just want to

release this addition we had some bleeding it's very important to have this area done

on without too much bleeding.

And now we are gonna do this traction from the inside.

This allowed us to see better the plane that we should go.

Too fast is not good.

Too fast bleeds.

It's very important to keep calm,

calm down, relaxing.

No rush is important in surgery.

We have these additions.

We are far away from the spleen.

I am already with the same sponge that I have at the beginning.

Now I'm going to have the traction from the inside from my assistant.

And as you can see, only a small sheet that holds this area of the column.

And now we are going to detach it under the vision.

We are going to lift the column, we are going to detach the splenic flexure.

Pancreas is below.

We are secure about the pancreas.

Brown's dissection helps also to find the proper plane.

And now we return back to the plane.

And now we are going to lift, as you can see, in a very easy way and under vision.

We are able to, we will be able to detach everything.

We had some traction with some disruption of the fat.

and now it bleeds a little bit, but now it's under control. We are going to

change our sponge for another one, a clean one. This is the second one that we

are using, so it means that the surgery is still dry, only two sponges from now. We

are going to lift the column and detach. This is, as we are using a 30 degree

scope, this is a very important maneuver. We have to turn the camera to see

see from the upper part in direction to the down part and now as we complete

here the splenic flexure we have to communicate our lateral dissection with

the upper part dissection so we clean there is no bleeding so we are

gonna clean again the scope and now we are gonna dissect as the meso is done we

are going to communicate this digestion laterally we are going to finish the dissection laterally

we have a redundant column but uh once we are in the proper plane as you can see

so uh it's very easy to uh to preserve the arcade with a good traction very uh only one attachment

attachment to finish this pleniflexor and it's done. So we did this pleniflexor, we did the

transsection of the rectum. What we have to do now when we are going to extract this specimen out,

so I like to prepare the meso inside. So this allowed me to have the meso outside without

traction and without a chance for rupture of the marginal arcades. So we are going to put this in

the position again by the trendelenburg the meso goes up and the rectum also goes up so i'm going

to recognize where i like the vein and and i'm gonna choose where i'm gonna do the the

transsection of the meso so i can follow the root of the vein in direction to the artery or i can

keep a small branch of the vein to secure a good drainage in this case we prefer to go

close to the vein and

we have a lot of

meso to remove

as it is in the

upper part of the rectum we need

approximately at least

10 to 15 centimeters

proximal margin

because we are going to take it from the origin

of the artery so we

already have the area where we are going to

transect, the rectum is down

everything is going to arrive

what we are going to do now is we are going to do

suprapubic incision with a wound protector and we are going to remove from our outside

now we have the meso the mesorectum looks perfect and then and then uh what we are going to do we

are going to prepare uh for the circular taper because we are going to do end-to-end anastomosis

so we use this device to help us to create the push string once we do the push string we are

going to transact the bowel removing the specimen and we are going to grab down the bowel we are

going to open the bowel and put the uh anvil and we are going to close uh the first spring suture

sometimes this suture is enough sometimes we need to reinforce the suture and then uh once we uh

close our

device again. We are going to do the

pneumoperitoneum, and we are going to put the

anvil through the suture that we did,

the first one. This is a double staple technique.

We try to remove the area of the

transection of the bowel. Once the staple is inside,

inside we choose where we are going to put our anvil inside and so the shaft is going to come

out at the crossing line we usually go close to the staple line and now looks like in a good

position what we aim is to attach the anvil and now we are going to check for the position of

the mezzo it is very important to check the mezzo not to be rotated before we go looks great and now

we have a non-tensioned osmosis so we are going to close the stapler non-tensioned osmosis we are

going to close the stapler we are going to remove the stapler and of course we need to check the

doughnuts to see if doughnuts are okay.

Masculine is not rotated.

Colon seems good.

Good vascularization.

There is a discussion if we are going to close or not the mesenteric gap.

I believe that when you can, it's important to close to avoid internal hernia.

What is one of the complications?

So we always check the position of the bowel.

And you see here, this small bowel wants to go inside.

And so we check this position.

And what we also do, we do the pneumatic tests.

Some people use glue to have the meso in the position,

which is Professor Francesco Corcioni like to use the glue to put the meso in the place.

And one of the good things if we can do the pneumatic tests under endoscopy,

so if you have the colonoscope inside of the room it's important to check it so we are checking the

donuts and as we can see there's no tension anastomosis we are gonna use some saline solution

to clean everything up now patient can be uh we can change a little bit and increase the

Trendelenburg to facilitate this area and this moment of the surgery. We are going to insufflate

and we are going to clean this up and we are going to put some water and I like usually to suture

this junction and I like also to check the anastomosis at both sides as you can see.

We are going to clean and use some saline solution now to clean this up

and check for bubbles in the pneumatic test.

In my idea, the best way for doing the pneumatic test is using the flexible endoscope.

It's the colonoscope.

Because also, we do not check only the bubbles, but also we can check for the mucosa integrity.

integrity. We can check for the mucosal coloration. So if you have a ischemic or

a hematoma at the mucosal level, so we use the flexible endoscope to check inside.

We also don't do too much bowel preparation. We just ask for the diet before. So some patients

are not clean enough, as you can see in this case. But we can see the anastomosis is well done.

on. We can check the anastomosis. We can insufflate, not bubble. The pneumatic test is negative.

The amount and the distance from the dentate line looks okay. And now we're going to remove

the scope and clean everything. Usually we don't put drains for this type of surgery.

we just close the holes and we don't use drain we do not use drains this is what

I want to share with you I appreciate your time and thank you very much for

being with me it was a pleasure and thank you very much for the meeting for

having me this afternoon and I hope that I could help if you with some ideas and

and tips and tricks for the anterior resection.

Thank you very much.