September 05, 2010

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Laparoscopic Total Mesorectal Excision (TME)

A video of a laparoscopic total mesorectal excision for treating a rectal tumor by Professor Min-Hua Zheng (President of both the Chinese Society of Laparoscopic and Endoscopic Surgery and the Endoscopic and Laparoscopic Surgeons of Asia), Dr Bo Feng, and Dr You Li from Ruijin Hospital and Shanghai Jiaotong University School of Medicine, Shanghai, People’s Republic of China.

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The steps taken in the video are described as follows:

00:00:05	First, the key structures were identified: the aorta, the origin of the inferior mesenteric artery (IMA), and the sacral promontory. Next, the abdominal cavity was explored and the existence of carcinomatosis confirmed. The compliance of the descending and sigmoid colon was evaluated.
00:00:33	The peritoneum was first incised in the direction of the inferior mesenteric vein (IMV). The peritoneum was dissected at the site of the promontory and along the right border of the aorta until the third part of the duodenum. The IMA was dissected with an UltraCision® harmonic scalpel (UHS) at the site of its bifurcation with the aorta. Care was taken to protect the mesenteric plexus and to not particularly expose it.
00:01:44	The IMA was clamped with two Hemolock™ clips and then cut between the clips. Next, the inferior mesenteric vein (IMV) was dissected at the left side of the IMA with the UHS. The IMV was clamped with the clips and safely cut.
00:02:53	Further dissection along the Toldt’s line and the Toldt’s fascia, which covers the ureter and the iliac vessels, was undertaken.
00:03:05	The traction was changed, and an attempt to open the lateral peritoneum from the left side was made in order to free the descending colon.
00:05:16	The traction was changed and the original approach was resumed. The dissection was continued along the avascular plane towards the pelvic rim. The site between the fascia propria and the presacral fascia was located and dissected. The vertical segment of the rectum was dissected. The superior hypogastric nerve plexus was exposed and protected. Subsequently in the dissection, the superior hypogastric nerve, the branches, and the inferior hypogastric nerves were preserved. The dissection was continued on the lateral side, with attention paid to either side of the ureter so as not to expose them.
00:06:55	Traction was then placed on the rectum and the rectosigmoid. The pre-rectal space was opened, and the peritoneum was incised 1 cm above the pouch of Douglas. The dissection was continued laterally, posteriorly, and anteriorly.
00:07:34	The plane was opened towards Denonvillier’s fascia, and the right side of the vas deferens or seminal vesicle was protected (preserving the autonomic nerves that reach the pelvic floor). Posterior dissection of the lower rectum was performed. The fusion between the pre-sacral fascia and the fascia propria of the rectum was opened, and the fascia propria was dissected. The point where the rectum was cut was checked from the anus.
00:08:31	The bowel was divided using a stapler. On the other side, the dissection was continued in order to divide the mesocolon until the point that was chosen to divide the bowel was reached.

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Produced and published by Remedica Medical Education and Publishing Limited.