Low section of the rectum during laparoscopic total mesorectal excision using the ContourTM device

Laparoscopic Lower Anterior Rectal Resection Using a Curved Stapler: Original Technique and Preliminary Experience

Laparoscopic low anterior rectal resection (LLAR), allowing better visualization and rectal mobilization, can reduce postoperative pain and recovery. A Contour Curved Stapler (CCS) is a very helpful device because of its curved profile that consents better access into the pelvic cavity and allows to perform rectal closure and section in one shot, especially in the presence of a narrow pelvis, complex anatomy, or large tumors. We developed an original technique of laparoscopic rectal resection using CCS. Between 2005 and 2009, in 36 cases, we performed LLAR with a three-trocar technique, starting with mobilization of left colonic flexure followed by the section of inferior mesenteric vessels. The rectum was prepared up to the levator ani with total mesorectal excision. The Lapdisc® was inserted trough a suprapubic midline incision, allowing the CCS stapler placement into the pelvic cavity. After the rectal section, the anastomosis was then performed with a circular stapler. Ileostomy was performed if neoadjuvant radiotherapy and chemotherapy have been carried out or if the anastomosis was below 4 cm from the anal verge. Mean operative time was 135 minutes and no intra- or postoperative bleeding occurred. In 27 patients we performed temporary ileostomy. In two cases we observed anastomotic leakage; one of these patients already had ileostomy. No anastomotic stenosis occurred after one-year follow-up. This procedure simplifies the section of the lower rectum, reduces leaking rate resulting from technical difficulties, and does not nullify the benefits of laparoscopy.

Can a curved stapler made for open surgery be useful in laparoscopic lower rectal resections? Technique and experience of a single centre

BACKGROUND

The use of laparoscopy to perform lower anterior rectal resection is increasing worldwide because it allows better visualisation and rectal mobilisation and also reduces postoperative pain and recovery. The Contour Curved Stapler (CCS) is a very helpful device because of its curved profile that enables better access into the pelvic cavity and allows rectal closure and section to be performed in one shot. In this paper, we present an original technique to use this device, made for open surgery, in laparoscopy and the results of our experience.

METHODS

We retrospectively evaluated the data of all patients who underwent lower laparoscopic anterior rectal resection and in which the CCS was used to perform section of the rectum between September 2005 and September 2011. To perform section of the rectum a Lapdisc(®) was inserted through a 6-7 cm supra-pubic midline incision to allow placement of the CCS into the pelvic cavity. Patients' biographical and surgical data such as sex, age, indication for surgery, infection, anastomotic leakage or stenosis and staple-line bleeding were prospectively collected in a computerised database and evaluated.

RESULTS

Between September 2005 and September 2011, we performed 45 laparoscopic lower rectal resection using CCS, 27 male and 18 female with a mean age of 61 years (range 40-82 years) and a mean body mass index (BMI) of 26.5 kg/m(2) (range 16.5-35 kg/m(2)). In 29 cases a temporary ileostomy was performed. Mean operative time was 131 min (range 97-210 min). In all cases it was possible to perform a lower section of the rectum with CCS. No intraoperative or postoperative staple line bleeding occurred. In two patients we observed anastomotic leaks and in one of these a temporary ileostomy was performed. None of the patients showed an anastomotic stenosis at 1-year follow-up colonoscopy.

CONCLUSIONS

This study shows that CCS enables section of the lower rectum to be easily performed, especially in adverse anatomical condition, and the technique proposed by us allows the use of this stapler without giving up the benefits of laparoscopic access.

Laparoscopic rectal surgery: does immediate outcome differ in respect to sex?

PURPOSE

This study analyzed the immediate postoperative outcome of the laparoscopic approach to the rectum in relation to the sex of the patient.

METHODS

Two hundred thirty-nine patients were included in our study. The inclusion criterion was rectal cancer <15 cm from the anal margin. Exclusion criteria were the presence of anesthetic contraindications for pneumoperitoneum, T4, pancolonic polyposis, and ulcerative colitis. The parameters analyzed included demographics, comorbidities, previous abdominal surgery, preoperative chemoradiotherapy, body mass index, operative time, type of operation, difficulty score, conversion, hospital stay, postoperative morbidity according to the Dindo classification, and histopathologic analysis. Analysis was performed on an intention-to-treat basis. Results are given as number of cases and percentages for categorical data, and as median and 95% confidence interval for quantitative variables. Data were analyzed by use of bivariate analysis, contingency tables, and chi or Fisher exact tests for categorical variables, and ANOVA or t test for quantitative variables. The statistical significance level was set at 5% (alpha = 0.05), and two-tailed tests were used throughout.

RESULTS

We did not find any statistical differences related to sex in the global series, pure laparoscopy, or converted patients in relation to mortality, conversion, anastomotic leakage, morbidity, reintervention, and morbidity classification according to Dindo (P > .05). We only observed a trend in relation to a longer duration of surgery in men. This was statistically significant in the low anterior resection subgroup (P = .02) and in the overall series (P = .002). Statistical analysis also showed that postoperative stay was longer in men after an anterior resection (P = .015).

CONCLUSION

We believe that no important differences exist in perioperative outcomes between men and women after a laparoscopic approach to rectum cancer.

Endo-satinsky clamp for rectal transection during laparoscopic total mesorectal excision

BACKGROUND

We describe a technique of intracorporeal rectal transection using an endo-Satinsky clamp during laparoscopic total mesorectal excision.

METHODS

We use an abdominal approach through 5 trocars. The rectum and mesorectum are mobilized completely. A flexible trocar is placed at the site of a 12-mm right lower abdominal port after the trocar originally placed there is pulled out. The 12-mm trocar originally placed in the right lower abdomen is moved to the suprapubic site, in which a Pfannenstiel incision is anticipated. The endo-Satinsky clamp is inserted through the flexible trocar, and the rectum is grasped with the endo-Satinsky clamp just above the anticipated point of transection. The endostapler is introduced through the 12-mm suprapubic port and is positioned just distal to the clamp. The rectum is then transected. The transected bowel is resected extracorporeally. Anastomosis is completed intracorporeally by use of a double-stapling technique.

RESULTS

From February 2007 to March 2009, we performed low anterior resection with use of the endo-Satinsky clamp for 11 patients with rectal cancer (laparoscopic, 10 patients; robot-assisted, 1 patient). There were no operative complications or deaths. Mean operation time was 179.5 minutes (range, 120-265 min). The average number of cartridges used for rectal transection was 1.6 per patient.

CONCLUSION

The endo-Satinsky clamp is a useful device for rectal transection and irrigation. The use of this device makes it easier to place an endostapler just distal to the clamp and to transect the rectum in a more appropriate position.

Laparoscopic low rectal anastomosis using a new stapling device: early experience with the Contour stapler

Rectal cancer was initially considered a contraindication for the laparoscopic approach to low rectal resection due to the greater difficulty of deep pelvic dissection, but several studies have demonstrated its potential clinical advantages. The currently accepted technique for this intervention includes total mesorectal excision, which entails complete dissection of the mesorectum followed by low transection of the rectum. The laparoscopic approach provides good visualization and magnification of the operative field, but transection of the rectum may be more difficult. This is illustrated by the conversion rate of around 15% in most series, mainly due to technical difficulties. Contour placement may overcome these difficulties. Two key points support the interest in the use of devices with the features of the Contour. First, the current feeling and evidence indicate that with presently available laparoscopic devices, the section of the low rectum in selected patients (males and mid-third rectal tumors) is often difficult. Secondly, although the Contour device was designed for open surgery, surgeons have the intuitive perception that it perfectly accomplishes the functions an ideal laparoscopic stapler should include. There is clearly a need for more appropriate laparoscopic instruments for low rectal transection. The Contour device could be considered a prototype because it meets the surgeon's requirements when operating on the low rectum, providing one shot, simultaneous sewing and cutting function and a symmetric rectum section. However, a number of technical modifications would enhance the utility of the instrument in this setting.

The occlusive tourniquet: a simple method for rectal stump washout during open and laparoscopic surgery

Rectal stump washout with cytolytic agents is recommended and usually performed during anterior rectal or rectosigmoid resection. The use of a linear stapler instrument during ultralow anterior resection makes the placement of pelvic clamps difficult for rectal stump washout prior to resection. The objective of this work is to demonstrate the use of a simple procedure, the occlusive tourniquet for rectal stump washout. Occlusive tourniquet applied to open technique: after complete dissection of the rectum and sigmoid colon according to the usual technique, a simple piece of tubing from an intravenous line is passed behind and around the rectum/sigmoid colon at some point distal to the tumor to form an occlusive tourniquet. Occlusive tourniquet applied to laparoscopic technique: similar to the open technique, tubing is passed through the left iliac fossa trocar and passed behind the sigmoid mesocolon. This simple procedure allows easy exposure and dissection of the mesorectum, without traumatizing the rectum/sigmoid colon or the tumor and lavage can be performed without the need for clamps or other instruments which may traumatize the rectum and provoke anastomotic failure. In conclusion, the occlusive tourniquet is a simple method for rectal stump washout so this step can be done.

Can we predict immediate outcome after laparoscopic rectal surgery? Multivariate analysis of clinical, anatomic, and pathologic features after 3-dimensional reconstruction of the pelvic anatomy

OBJECTIVES

The laparoscopic approach for colon resection is widely accepted but its definitive role in rectal tumors is controversial due to the technical difficulties associated with this procedure. Tumor size and volume, and pelvic dimensions may influence intraoperative and/or immediate outcome. This study aimed to evaluate the predictive value of anatomic and pathologic features on immediate outcome after laparoscopic rectal resection.

MATERIAL AND METHODS

The study included a prospective series of 60 patients submitted to laparoscopic resection for rectal tumors. A preoperative computed tomography was performed in all patients. Three-dimension reconstruction of the pelvis, rectal tumor, and prostate was computed. Tumor and prostate volume and diameters were calculated, as were main pelvic diameters (subsacrum-retropubic, coccyx pubis, and promontorium coccyx), and lateral diameters, at the tumor level (3D Doctor Software package). Age, sex, body mass index (BMI), tumor height, previous radiotherapy treatment, and type of procedure (anterior resection, low anterior resection, and abdominoperineal resection) were recorded. Immediate outcome (morbidity, mortality, and stay) was also collected. Dependent variables were operative time, intraoperative difficulty, conversion, and postoperative morbidity. Univariate and multivariate analyses were performed (SPSS package).

RESULTS

The series included 36 men and 24 women, with a mean age of 72 years (range, 38-87). Surgical procedures were 10 anterior resections, 31 low anterior resections, and 19 abdominoperineal resections. Conversion rate was 9 of 60 (15%), operative time: 172 minutes (range, 90-360), morbidity: 31% and stay: 9 days (range, 6-43). Multivariate analysis showed tumor craniocaudal length was an independent predictive factor for conversion (P < 0.04, odds ratio [OR]: 1.5, confidence interval [CI]95%: 1-2.2). Pubic coccyx axis (P < 0.005) and sex (P < 0.009) showed independent values for operative time, and BMI (P < 0.02, OR: 1.2, CI 95%:1-1.5) was related to postoperative morbidity. When a subanalysis was performed in relation to sex, independent factors differed between males and females, with a predominance of anatomic and tumor measures in men.

CONCLUSION

Local anatomy and pathologic features directly affect surgical outcome in the laparoscopic approach to the rectum. Sex, BMI, lower pelvis diameter, and tumor size are independent predictors for conversion, operative time, and morbidity. These data should be taken into account when planning this kind of procedure.