Laparoscopic Low Anterior Rectal Resection with Diverting Loop Ileostomy

Abstract

This chapter describes the technical aspects of laparoscopic low anterior resection with diverting loop ileostomy, including patient positioning, instrumentation, type of incision and port placement, approach (lateral-to-medial and medial-to-lateral), steps of dissection and resection, and steps of reconstruction. In addition, the authors provide pearls and pitfalls.

Preference Card

• Laparoscopic camera, 10 mm, 30°

• Atraumatic 5 laparoscopic graspers, anvil grasper, and scissor

• Laparoscopic vessel sealer

• Laparoscopic hook electrocautery

• Laparoscopic 10 mm articulating linear stapler (60 mm)

• Circular stapler 28–33 mm

• Hasson blunt trocar

• Trocars to have available (1 × 10 mm, 2–3 × 5 mm)

• Purse string clamp

• Carter-Thomason suture passer

• Ileostomy rod and stoma appliance

• Flexible sigmoidoscope

• Laparoscopic suction/irrigation device

• Sutures

  • 2.0/3.0 polyglactin or catgut

  • 3.0 polydioxanone

  • 4.0 polyglecaprone

  • Skin stapler or 4.0 absorbable sutures for skin closure

  • 0 polypropylene with a straight needle

Patient Positioning/Operating Room Setup

• Modified lithotomy position with legs in stirrups to provide easy access to perineal region, thighs are flexed. Patient’s buttock slightly off the lower edge of the bed to allow access to the rectum (see Fig. 13.1).

• Both arms tucked, patient secured on a bean bag and taped to the operating room table.

• Prep and drape both legs, the underbuttock area, and the abdomen.

• Surgeon to patient’s right.

• Camera assistant initially to the patient’s left for port placement and then will go to the surgeon’s left.

• Assistant between the legs.

• Scrub nurse to surgeon’s right, at the patient’s feet (see Fig. 13.2).

• Monitor positioned on patient’s left side, feet level, and another one by patient’s left shoulder/head.

Nodal Points

Type of Incision/Port Locations

• Insert Veress needle in the left upper quadrant or an infraumbilical Hasson trocar.

• Create pneumoperitoneum to 15 mmHg.

• 5–10 mm trocar right upper quadrant, midclavicular line.

• 10 mm trocar right lower quadrant, midclavicular line (see Fig. 13.1).

• Additional 5–10 mm trocar left flank/left lower quadrant if needed.

Approach

• Place patient in the “left side up” and Trendelenburg position. This is key to dislodge the small intestine out of the pelvis and to expose the correct dissection planes.

• Lateral-to-medial approach: begins with lateral mobilization of the descending colon, dissecting along the left paracolic gutter on the white line of Toldt.

• Medial-to-lateral approach: begins with identification and ligation of vascular pedicle and ends with lateral dissection of the descending colon.

Dissection Step

Lateral-to-Medial Approach (See Fig. 13.4)

• Proximal mobilization is carried laterally along the white line of Toldt.

• Mobilize the splenic flexure by transecting the splenocolic ligaments using a vessel sealing device (Fig. 16.1).

• Care taken not to injure the spleen or the tail of the pancreas.

• Patient placed in the reverse Trendelenburg position.

• Camera assistant now to the surgeon’s right side.

• Enter the lesser sac by dividing the gastrocolic ligament until the area of the lateral mobilization is reached.

• Prepare for pelvic dissection once splenic flexure is mobilized.

• Place patient in “left side up” and Trendelenburg position.

• Identify the left ureter within the retroperitoneum.

• Score the medial side of the mesocolon starting at the level of the sacral promontory.

• Identify and isolate the inferior mesenteric artery (preaortic plane) and vein (lateral to ligament of Treitz) at their origin, and ligate them using a vessel sealer only after the left ureter has been identified and confirmed to be out of the ligation plane (Fig. 16.2).

• After vessel ligation, enter the avascular presacral plane (this areolar/avascular plane is entered by starting the dissection at the level of the sacral promontory, moving caudally behind the mesorectum).

• Dissect posterior to the mesorectum with an energy device along presacral fascia taking care not to injure the superior hypogastric nerves.

• Complete lateral and anterior dissection (Fig. 16.3), sparing the inferior hypogastric and pelvic splanchnic nerve bundles. These pelvic nerve plexi run laterally and anteriorly along the Denonvilliers fascia in males and along the rectovaginal fascia in females.

• Distal anatomical landmark for complete mesorectal excision are the levator ani muscles.

Fig. 16.1

Splenic flexure and transverse colon mobilization

Fig. 16.2

Inferior mesenteric vein ligation

Fig. 16.3

Peritoneal reflection incision

Medial-to-Lateral Approach (Fig. 16.4)

• Score the mesentery at the level of the sacral promontory, moving toward to the inferior mesenteric artery (IMA).

• Ligate the IMA after identification of the left ureter and gonadal vessels.

• Continue blunt dissection in the avascular plane, elevating the mesentery off of the retroperitoneum.

• Identify and ligate the Inferior mesenteric vein.

• Complete the mobilization with the lateral dissection.

• Splenic flexure mobilization as described above.

• Pelvic dissection as described above.

Fig. 16.4

Medial-to-lateral descending colon mobilization

Resection Step

• Distal margin/point of transection of the rectum is chosen (at least 1 cm distal margin for low to mid rectal tumors and 5 cm for high rectal tumors) using a laparoscopic linear stapler (Fig. 16.5).

• Divide the mesosigmoid colon using an energy device to the left of the inferior mesenteric artery stalk.

• Grasp the distal transected rectum with an atraumatic bowel grasper.

• Create a skin incision for specimen extraction either midline/periumbilical or Pfannenstiel (surgeon preference).

• Insert wound protector.

• Exteriorize the descending/sigmoid colon and rectum.

• Proximal point of transection chosen and clamped using a purse string clamp (>5 cm from lesion).

• Thread a 0 polypropylene on a straight cutting needle through the clamp to create purse string.

• Transect colon with scalpel along the purse string clamp.

• Send specimen to pathology.

Fig. 16.5

Transection of the rectum

Reconstruction Stage

• Insert the anvil of the circular stapler.

• Tie purse string snuggly around the shaft of the anvil.

• Return the bowel into the abdomen and insert wound protector and cover to prepare for insufflation and pneumoperitoneum.

• Perform a colorectal or coloanal end-to-end anastomosis using a circular stapler, after ensuring proper orientation of the mesocolon (Fig. 16.6).

• Perform an air leak test (Fig. 16.7) using a flexible or rigid sigmoidoscope after the proximal colon has been clamped with an atraumatic grasper.

• Visualize the anastomosis and check for hemostasis at the same time.

• Create a diverting loop ileostomy. See “ Ileostomy Creation and Closure” chapter (Chap. 21) for detailed steps.

Fig. 16.6

Air leak test of the anastomosis

Fig. 16.7

Transanal end-to-end anastomosis

Pearls and Pitfalls

• Key is to dissect the rectum along the “holy plane” to respect the surrounding important structures.

• Air leak test by submerging the anastomosis while insufflating air transanally is advised.

• Ureteric stents are advised for patients with predicted difficult anatomy or with significant intra-abdominal inflammation or locally advanced colonic malignancy.

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