Takeshi Yanagita, Makio Mike, Hirotaka Honjo, Nobuyasu Kano, Hiroshi Kusanagi. Kameda Medical Center
Endoscopic surgery has been widely accepted in various surgical fields, and an increasing number of colorectal surgeries are being performed mainly by the laparoscopic technique. It is true that, in some situations, surgical procedures can be performed by laparoscopic techniques more easily and efficiently than by those of open surgery because of excellent visualization and identification of anatomic structure. But it is very confusing for the surgical residents, because they must learn laparoscopic procedures, as well as open procedures. It is very important for the educators to make these procedures easy to understand by stylizing. In our hospital, laparoscopic surgery including laparoscopic low anterior resection (LAR) has been stylized so that unexperienced surgical residents can understand anatomical membrane structures from the viewpoint of education.
Five ports of the same size are created at the same site, regardless of the location of tumors. The infraumbilical site (12-mm) is used as a camera port. A 12-mm trocar is placed at the right lower quadrant, and another 12-mm trocar is placed at the right abdomen, superior to the level of the umbilicus. Two 12-mm ports are created at the left side and at the left lower quadrant, which are symmetrical with the right ones. When an operator does not have much experience, initially, he/she carries out lateral-to-medial mobilization to get used to manipulating a grasper and a dissector. Once familiarized, the operator begins with medial-to-lateral mobilization. In almost all cases, the inferior mesenteric artery was transected after the left colic artery branched. A first assistant retracts the rectum upward, keeping traction, and the dissection of rectum is continued into the pelvis along with the fascia propria of the rectum, preserving the hypogastric nerves and pelvic plexus as far as possible. Posterior dissection of the rectum always precedes anterior dissection. Then, on the anterior portion, dissection is carried out behind the Denonvilliers’ fascia. While the first assistant retracts the rectum cranially, the operator identifies and dissects the limit of lateral ligament and mesorectum. The operator identifies and enters the loose layer between the longitudinal muscle of the rectum and mesorectum, and cut the mesorectum. The rectum is then transected with a linear stapler. The specimen is pulled out through the extended left lower quadrant port site. End-to-end double-stapling technique anastomosis is carried.
The Mann-Whitney U test was used to compare perioperative factors (age, sex, BMI, ASA-PS, TNM stage, tumor size, location, operative duration, blood loss, open conversion, complication, and hospital stay) between surgical residents and senior surgeons.
Sixty-six patients underwent laparoscopic LAR by twelve surgical residents under the supervision of the experienced surgeon. Operative durations were significantly different (P=0.04), comparing surgical residents with senior surgeons, but other perioperative factors were not significantly different.
Usage of peculiar techniques of laparoscopic procedure can make LAR easier and more efficient. However, the stylized setting of the ports and the similar operative field and procedure to open surgery can help surgical residents understand clearly and perform safely both laparoscopic and open procedures.