Akinari Nomura, Yasuo Koga, Shuusuke Miyake, Hironori Iwasaki, Hirokazu Noshiro. Saga University
Background In laparoscopic surgery for lower rectal cancer, not only surgical smoke flowing from the operative field but also the sway of the operative field caused by evacuation and insufflation at a high flow rate often interfere with the surgeons’ ability to maintain a clear and steady visual field.
Aim The aims of this study are: (1) to construct a novel smoke evacuation system which overcomes the drawbacks of the conventional evacuation system; and (2) to visually describe a refinement of surgical smoke evacuation in order to perform laparoscopic total mesorectal excision (TME) in a stable operative field with increased visibility.
Methods The suction button of the electric scalpel (Opti4TM) is covered with the attached plastic cover in order to allow continuous pushing, and the suction tube is connected to the RapidVacTM smoke evacuator. A high-frequency sensor probe of the RapidVac is connected to the electric wire of the Opti4.
Patient and surgical procedures A 63-year-old male patient with cT2N0M0 lower rectal cancer located 20 mm from the anal verge underwent laparoscopic total intersphincteric resection (ISR), as follows. Pelvic dissection is commenced with posterior mobilization. Wide dissection to expose the levator ani muscle fascia below the pelvic splanchnic nerves expedites the subsequent dissection along the interior surface of the autonomic nerves up to the distal end of the rectum. After cutting all the nerve branches extending from the neurovascular bundle toward the rectum, the intersphincteric space is reached from a direction anterolateral to the rectum. Sufficient transabdominal intersphincteric dissection facilitates the ensuing transanal dissection. A diverting stoma is not created.
Results Surgical smoke was effectively eliminated from the immediate vicinity of the source through the tip of the electric scalpel synchronized with an electric current, and the required flow rate for insufflation and evacuation was slow, allowing the visual field to be kept clear and steady. Therefore, the surgeons were able to perform laparoscopic autonomic nerve-preserving TME with sufficient transabdominal ISR while accurately identifying the dissectable layer. The patient was discharged from hospital without any complications, including anastomotic leakage. At the 1-month follow up, the Wexner, IPSS, and IIEF-5 score were recorded as 0, 0, and 20 points, respectively.
Conclusions The novel evacuation system outlined here enables surgeons to perform laparoscopic anatomical dissection using an electric scalpel alone in a stable operative field with increased visibility, and will contribute significantly to successful function-preserving radical surgery for lower rectal cancer.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79488
Program Number: V037
Presentation Session: Thursday Exhibit Hall Video Presentations Session 2 (Non CME)
Presentation Type: EHVideo