Combined laparoscopic and TAMIS LAR in a morbidly obese patient after open right hepatectomy

Claudya Morin, MD1, Francois Letarte, MD, FRCSC2, Alexandre Bouchard, MD, FRCSC1, Sebastien Drolet, MD, FRCSC1. 1St-Francois-d’Assise Hospital, Laval University, Quebec City, QC, 2St. Paul’s Hospital, University of British Columbia, Vancouver, BC

Laparoscopic low anterior resection (LAR) for rectal cancer is a challenging surgery in morbidly obese male patients. Transanal minimally invasive surgery (TAMIS) is a flexible access platform developed in 2009 to gain mobility over the transanal endoscopic microsurgery (TEM) platform. A new hybrid approach combines laparoscopic and TAMIS views to accomplish a down-to-up mesorectum dissection with enhanced visibility. TAMIS allows for rectal transection having the tumour under direct vision and ensures a negative distal margin. This video demonstrates a case of combined laparoscopic and TAMIS LAR in a morbidly obese male patient after open hepatectomy. Combined laparoscopic and TAMIS LAR was carried out in a 69-year-old morbidly obese man with a clinical T3N1M1 rectal adenocarcinoma with 4 liver metastasis. The patient first underwent induction chemotherapy followed by right hepatectomy. Then he received neo-adjuvant long course chemoradiation. The surgery was initiated laparoscopically with mobilization of the splenic flexure, high ligation of the inferior mesenteric artery and TAMIS distal rectal transection and retrograde mesorectal dissection. The patient underwent a combined laparoscopic and TAMIS LAR with primary stapled anastomosis and diversion ileostomy. Tumour directed mesorectal excision was accomplished with 2 cm distal margin and an intact mesorectal fascia. Combined laparoscopic and TAMIS LAR is feasible and allows a good retrograde dissection for rectal cancer in morbidly obese male patients. This approach ensures distal transection under direct vision and offers the possibility for stapled anastomosis with a double purse-string suture technique.

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