Techniques for Complete Total Mesorectal Excision in Laparoscopic Low Anterior Resection: the Importance of Identifying Visceral Pelvic Fascia and Neurovascular Bundle

Ziqiang wang, Ziqiang wang, YuanChuan Zhang, YuanChuan Zhang, Zhongguang Zhou, Zhongguang Zhou. department of gastrointestinal and colorectal surgery, West China hospital,

Due to better local control and survival provided by total mesorectal excision (TME) for treatment of rectal cancer, TME has wildly been accepted as the gold standard for surgery of middle or low rectal cancer. Laparoscopic surgery for low anterior resection has been reported to be feasible and provide better pelvic exposure, and even offer a macroscopically more complete specimen after TME for rectal cancer. Because of the confinement of pelvis, poor retraction and limitation of straight instruments, however, complete TME can not always be performed in all patients, especially for beginners in laparoscopic colorectal surgery. Incomplete mesorectal excision is more likely to occur on the right side of the mesorectum, due to the blocking effect of the neurovascular bundle. Since Nov, 2007, a total of 306 procedures of laparoscopic low anterior resection were performed at our hospital. We retrospectively assessed our own previous 20 videos, our latest 20 videos and 5 videos we acquired from the internet, using a presupposed criteria. The quality of TME for each video was classified into one of four levels: “Good”, “acceptable”, “poor”, “very bad”. There were 13 good, 6 acceptable and 1 poor procedures in the previous 20 videos and 18 good and 2 acceptable procedures in the latest 20 videos. And techniques for complete total mesorectal excision in laparoscopic low anterior resection were drawn from our experience. The most important points include: identifying the visceral pelvic fascia in front of the sacral promontory; keeping the dissecting plane very close to the visceral pelvic fascia, cut the peritoneum 1-3 centimeters in front of the peritoneal reflex line, identifying the neurovascular bundle (especially on the right side), suspending the uterus or bladder, using 10mm instruments for better exposure.

Session: VidTV3
Program Number: V095

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