Ligating the rectum with cable tie facilitates rectum transection in laparoscopic anterior resection of rectal cancer

Modified serial techniques "ASTRO" facilitated laparoscopic total mesorectal excision for ultralow-lying rectal cancer in obese male patients: how we do it (with video)

BACKGROUND

Laparoscopic total mesorectal excision (LaTME) is a technically challenging for ultralow-lying rectal cancer in obese male patients. Herein, we introduced modified serial techniques "ASTRO" to facilitate LaTME, and the short-term outcomes were presented.

METHODS

A prospective study (NCT05067413) was conducted between December 2020 and January 2022. The modified serial surgical techniques "ASTRO" included 5 key steps: (1) Anterior peritoneal reflection (APR) dissection at the highest line along with a "n"-shaped membrane bridge; (2) suspending the APR with a purse-string suture through the bladder peritoneum to enlarge the operating space of the anterior rectal wall; (3) traction and counter-traction continuously of the rectum applied with a cotton tape around the rectum; (4) resection of the pelvic rectum on tripartition, followed by the sequence of "posterior > anterior > lateral" principle; and (5) the trans-anterior Obturator nerve gateway was adapted to transect the distal rectum. The operative data and postoperative short-term outcomes were collected.

RESULTS

Twenty-four consecutive patients underwent this procedure successfully. The average body mass index (BMI) was 29.9±1.3. The average of tumor height from anal verge was 4.0 cm (range, 3.0-4.5 cm). The median operating time and blood loss was 217 min (range, 165-420 min) and 50 ml (range, 20-100 ml) respectively. The anterior operation space at the midsagittal plane of the pelvis inlet was increased by 2.0 ± 0.3 cm. The calculated dominant angle was 20 ± 3°. The length of stapling line was 6.8 ± 1.0 cm with 11 cases by one cartridge and 13 cases by 2 cartridges. Eight patients developed postoperative complications including 4 with anastomosis leakage (16.7%), 2 with urinary retention (8.3%), one with anastomotic stenosis (4.2%) and one with ileus (4.2%). All the complications were relatively mild and the patients recovered well.

CONCLUSION

Modified serial techniques "ASTRO" could expand the operating space and facilitate LaTME in obese male patients, thereby reducing the risk of conversion to open and transanal dissection.

Advantages of ligating the rectum with gauze pad band in laparoscopic anterior resection of rectal cancer: a propensity score matched analysis

Purpose

It is difficult to maintain sufficient tension throughout laparoscopic anterior resection with total mesorectal excision, which causes a decline in surgical quality. We used a soft, inexpensive gauze pad band pulling the rectal tube to analyze the effect of surgery.

Methods

A gauze pad band was positioned at the proximal of the tumor, followed by fastening the rectal tube and ligating the rectum. 233 patients undergoing laparoscopic anterior resection for mid to low rectal cancer were enrolled between January 2018 and December 2020. After propensity score matching, 63 cases were selected in gauze pad band group and 126 cases were selected in traditional group. The two groups were compared in preoperative, intraoperative, and pathological characteristics.

Results

Compared to traditional group, the median operation duration (203 min vs. 233 min, p < 0.001) and the median intraoperative bleeding (48 ml vs. 67 ml, p < 0.001) were lesser in gauze pad band group. A higher percentage of one cartridge transection of rectum (36/63 vs. 51/126, p = 0.030), shorter length of cartridges used (6.88 ± 1.27 cm vs. 7.28 ± 1.25 cm, p = 0.040), and longer distal resection margin (2.74 ± 0.76 cm vs. 2.16 + 0.68 cm, p < 0.001) were found in the gauze pad band group. The completeness of total mesorectal excision (61/63 vs. 109/126, p = 0.022), harvested lymph nodes (19 vs. 17, p < 0.001) and positive lymph nodes (1 vs. 0, p = 0.046) were higher in gauze pad band group.

Conclusion

Ligation of the rectum with a gauze pad band allows for a reduction in operative time and intraoperative bleeding while increasing the rate of one cartridge transection. It also protected the quality of total mesorectal excision and membrane anatomy.

Trial registration: Not applicable.

Transanterior obturator nerve gateway: a novel approach to achieving intracorporeal distal rectal transection for ultralow rectal cancer

BACKGROUND

Intracorporeal rectal transection at the anorectal junction for ultralow rectal cancer is technically difficult due to pelvic width and limited roticulation, which might require a transanal transection or an oblique transection with multiple firings. These procedures were reported to be associated with the increased risk of morbidity. To address these problems, we presented a novel technique Transanterior Obturator Nerve Gateway (TANG) to transect rectum for ultralow rectal cancer and evaluated its safety and feasibility in this study.

METHODS

A total of 210 consecutive patients who underwent laparoscopic coloanal anastomosis with or without partial intersphincteric resection (CAA/pISR) for rectal cancers between January 2017 and January 2020 were included. Eighty of these patients were analyzed using propensity score matching (PSM). The perioperative characteristics, TANG-related variables, and genitourinary and anal function outcomes were analyzed.

RESULTS

Among these enrolled patients, 170 patients underwent traditional transection, and 40 underwent TANG transection; the patients were matched to include 40 patients in each group by PSM. After PSM, there were no significant differences in the operating time (p = 0.351) or bleeding volume (p = 0.474) between the two groups. However, the TANG group had fewer cases of conversion to transanal transection (0 vs. 13, p < 0.001). Moreover, the patients in TANG group had a more desirable transection with longer distal resection margin (1.7 vs. 1.1 cm, p < 0.001), shorter stapling line (6.6 vs. 10.3 cm, p < 0.001) and fewer stapler firings (p < 0.001). The overall postoperative complication rates and genitourinary and anal function outcomes were not significantly different between the two groups.

CONCLUSIONS

The TANG approach appears to be a safe, feasible and effective approach for intracorporeal ultralow rectal transection with more distal resection, more vertical transection and fewer stapler firings.