The Advantages of Laparoscopic Approach for Intersphincteric Resection

Purpose The most difficult steps of Intersphincteric resection (ISR) are circular dissection and separation of the internal sphincter muscle from the external sphincter and puborectalis by the perineal approach. Further dissection of the intersphincteric space by the abdominal approach may reduce the problems associated with the perineal approach. We present our techniques of Laparoscopic ISR using three cases of ISR for rectal tumor (Male /Female 2:1) by the video presentation.
Presented Cases
Case 1 is a 68-year-old male with a large, laterally spreading rectal adenoma.
Case 2 is a 61-year-old male with rectal cancer whose tumor was located 4.0 centimeter from the anal verge. Laparoscopic surgery was performed after neoadjuvant chemo-radiotherapy.
Case 3 is a 71-year-old female with T1 rectal cancer whose tumor was located just above the dentate line. After dissecting the intersphincteric space, the prolapsing technique was useful in case it was a small-size tumor.
Technique
In case of male patient, First, we dissected the rectum with the mesorectum to the anal hiatus, initially on the posterior side along the avascular plane. Second, we dissected Denonvilliers’ fascia and exposed the seminal vesicle.The third step was dissection of the lateral tissues followed by incision of Denonvilliers’ fascia with rectal wall exposure taking care not to injure the neurovascular bundle. It was easier to perform this step on the left side than on the right side. Along this dissection plane, we could reach the puborectalis, which was separated from the rectal wall, and we entered the intersphincteric space from the lateral side of the rectal wall. Dissection of the intersphincteric space should be performed in the posterior to anterior direction and to the anal side as much as possible. The final step was dissection of the hiatus ligament at the posterior side of the rectum. Nearly circular dissection of the interspincteric space could be completed.
The difficulties associated with the perineal approach were reduced by this abdominal approach, and the tumor could be exteriorized easily.
Results
Laparoscopic ISR with total mesorectal excision was performed in a total of 15 patients (10 males, 5 females). The median age was 60.5 years. The T categories of the TNM classification of the rectal cancers were Tis 2, T1 1, T2 4, T3 8. The median distance from the anal verge to the tumor was 3.7 centimeter.The mean duration of surgery was 386 minutes. The mean blood loss was 108 miliiter, and mean postoperative hospital stay was 18 days. The diverting ileostomy was closed at a mean of 7.3 postoperative months. No remarkable perioperative complication was encountered.
Conclusion
laparoscopic ISR enabled us to reduce the difficulties associated with the perineal approach. An advantage of laparoscopic ISR was the ability to clearly visualize anatomical structures in the deep pelvic cavity.

Session: Podium Video Presentation

Program Number: V036