Allison J Pang, MSc, MD, FRCSC, Sender Liberman, MD, FRCSC, Lawrence Lee, MD, PhD, FRCSC. McGill University
Obtaining a negative circumferential resection margin (CRM) in rectal cancer is crucial to the control of local recurrence. The adoption of a total mesocolic excision (TME) has greatly impacted oncologic outcomes by significantly decreasing local recurrence rates. Despite neoadjuvant therapies and laparoscopic techniques, obtaining a negative CRM with an intact TME can still remain a challenge during pelvic dissection. The transanal TME (TaTME) technique, combined with either an open or laparoscopic component, has become a new way of surgically resecting mid-to-low rectal cancers. Although long-term oncologic data is not yet available, TaTME has become a promising new technique that could help overcome some of the challenges and anatomic restrictions of deep pelvic dissections.
During a low anterior resection (LAR) for rectal cancer, there are several different reconstructive options. The preference in our institution is to perfrom a stapled side-to-end anastomosis. This type of reconstruction has better short-term functional outcomes as well as potentially lower anastomotic leak rates. However, a side-to-end anastomosis can be technically challenging in cases with a narrow pelvis, fatty mesentery, extensive diverticulosis, or insufficient colonic length.
We present a case of a 67-year-old obese gentlemen with a mid-rectal cancer, cT2N0. The tumor was located ~7cm from the anal verge. He was referred from an outside institution for consideration of TaTME given his large body habitus. A TaTME approach was performed with laparoscopic assistance. A side-to-end anastomosis was planned; however, the actual anastomosis was impossible to do due to an obstructed view. Once the anvil was passed down into the pelvis, we could not see the anvil engaging the pin of the circular stapler because the mesentery of the colonic conduit was so thick. Our video highlights the difficulties of making a side-to-end colorectal anastomosis when a patient has a narrow pelvis and bulky mesentery. It also demonstrates a creative technique that can be used to overcome these challenges.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94776
Program Number: V107
Presentation Session: Colorectal Videos II
Presentation Type: Video