Laparoscopic intersphincteric resection using needlescopic instruments

Kazuhiro Sakamoto, MD, Hiroshi Okazawa, MD, Masaya Kawai, MD, Kazuhiro Takehara, MD, Yoshihiko Tashiro, MD, Koichiro Niwa, MD, Kiichi Nagayasu, MD, Shun Ishiyama, MD, Kiichi Sugimoto, MD, Makoto Takahashi, MD, Yutaka Kojima, MD, Michitoshi Goto, MD, Yuichi Tomiki, MD

Department of Coloproctological Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan

(Introduction)
Intersphincteric resection (ISR) is the final procedure used to preserve the anal function in very low rectal cancer patients. Recently, this procedure was performed using laparoscopy (Lap). We report our clinical experience of the Lap-ISR procedure carried out using needlescopic instruments.

(Operative procedure)
Under general anesthesia, the patient was placed in the lithotomy position. The port for the camera was created first at the umbilicus using the open method. Two 5-mm ports were inserted through the right upper and lower quadrants, and the upper port was placed where a diverting stoma would be created. Two needlescopic forceps (Endo-Relief™, Hope Denshi Co.,Chiba, Japan), with or without a trocar, were inserted into the left upper and lower quadrants. Thereafter, we performed the following procedures: ligation of the inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV), dissection of the mesentery, total mesorectal excision with the preservation of the autonomic nerves, and dissection of the intersphincteric space. After transanal intersphincteric dissection, extraction of the specimens, and coloanal anastomosis, the ileostomy covering was created at the right upper port, and the abdominal drain was inserted into the right lower port.

(Results)
Two patients with very low rectal cancer underwent the Lap-ISR procedure with needlescopic forceps. One patient was a 60-year-old woman with no laparotomy history and a body mass index (BMI) of 22.4. Colonoscopy revealed a c-T2 tumor, and the distal border was located 1.5 cm distal from the dentate line. Computed tomography (CT) scans showed no distant metastasis. The other patient was a 61-year-old man with a BMI of 20.0. Colonoscopy revealed a c-T2 tumor, and the distal border was located 2.5 cm distal from the dentate line. The CT scan showed no distant metastasis and regional lymph nodes. In both cases, this procedure could be performed without the insertion of an additional port or by replacing the needlescopic forceps with the conventional 5-mm forceps.

(Conclusions)
Lap-ISR is suitable for reduced port surgery, particularly needlescopic surgery, single port surgery, or mixed surgery, because the surgical specimen is extracted through the anus without creating an extraction site. However, the shaft of the needlescopic forceps is less rigid and shorter than that of the conventional 5-mm forceps. Our Lap-ISR procedure using needlescopic instruments is a minimally invasive surgical method that can be used for non-obese patients or patients with small stature.

Session: Poster Presentation

Program Number: P034