LAP ANTERIOR RESECTION-STEP BY STEP Operative Surgery.pptx

In this presentation, I have shown various steps of doing Laparoscopic anterior resection with the help of many excellent pictures.

1. LAP ANTERIOR RESECTION DR.B.Selvaraj MS; Mch ; FICS; “ Surgical Educator” Malaysia OPERATIVE SURGERY

2. LAP ANTERIOR RESECTION INDICATIONS: Carcinoma of the rectum, where sphincter preservation is possible, high anterior resection is done for tumours of rectosigmoid junction and upper rectum which includes partial mesorectal excision . The anastomosis is made in the region of the junction of the mid and lower third of the rectum. Low anterior resection is done for mid-rectal tumors which includes a total mesorectal excision . The anastomosis is made at the level of the pelvic floor. For low anterior resections defunctioning stoma is made- loop ileostomy

3. LAP ANTERIOR RESECTION INDICATIONS: Carcinoma of rectum- High anterior resection for rectosigmoid and upper rectal tumors. Low anterior resection for mid rectal tumors. CONTRA INDICATIONS: Big tumors- T4 Narrow pelvis ANESTHESIA: GA/ETT POSITION: Lloyd– Davies- Lithotomy in padded Allen stirrups Diagnosis Confirmed by biopsy Staging by CECT Pre-op preparation Preoperative chemoradiation treatment is indicated for patients with T3, T4 lesions or tumors with enlarged pelvic lymph nodes found on pelvic computed tomography (CT) scan or endorectal ultrasound Adequate mechanical bowel preparation the day before surgery with orthograde enema Prophylactic IV broad spectrum antibiotics VTE prophylaxis with LMWH and pneumatic stockings Bladder catheterization The stoma nurse marks the ileostomy site for defunctioning . Intraoperative rigid proctoscopy is performed to determine the distal extent of the cancer.

4. SURGICAL ANATOMY

5. Port placement: Access 10 mm camera port just above umbilicus 12 mm ports at Rt subcostal area and suprapubic midline 5mm ports in both iliac fossae Position Lloyd-Davies- lithotomy with padded Allen stirrups Surgeon should stand on the right side LAP ANTERIOR RESECTION

6. Mobilisation Assess the position and resectability of the tumour. Assess liver and peritoneum for metastatic deposits and colon for synchronous tumours After retracting the sigmoid colon make an incision in peritoneum over sacral promontory and dissect retroperitoneal area Avoid injuring Lt ureter and Lt gonadal vessels Exposure Table may be tilted to right side with Trendelenburg position Surgeon stand on right side Small bowel swept out to RUQ, adhesions between small bowel and sigmoid colon are lysed if any LAP ANTERIOR RESECTION

7. Ligation of blood vessels Elevate the sigmoid colon and isolate the inferior mesenteric artery and left colic artery, which should be spared if appropriate. Ligate the superior hemorrhoidal artery at its take-off from the inferior mesenteric artery and sigmoidal arteries. Transection of blood vessels Transect sigmoidal arteries and superior hemorrhoidal artery Spare Lt colic artery Avoid injury to Lt ureter and Lt gonadal vessels during this manuver LAP ANTERIOR RESECTION

8. Mobilisation of Left Colon Incise the whiteline of Toldt upto splenic flexure Mobilise Lt Colon from retroperitoneal structures Avoid injury to Lt Ureter and Lt Gonadal vessels This mobilisation is Mattox Maneuver Mobilisation of splenic flexure Place the patient in reverse Trendelenburg position Divide the spleno -colic ligament and mobilise splenic flexure LAP ANTERIOR RESECTION

9. Testing possibility of tension free anastomosis Bring down the mobilized colon to determine possibility of tension free anastomosis Mobilisation of greater omentum from Transverse Colon Separate the greater omentum from the distal transverse colon and continue the dissection laterally towards the splenic flexure. LAP ANTERIOR RESECTION

10. Posterior Rectal dissection Carry on the dissection in the avascular plane between the meso-rectum and the pre-sacral fascia posteriorly. Carry the dissection through Waldeyer’s fascia to the level of the coccyx. The mesorectum is mobilized laterally toward both the right and left pelvic side wall, preserving the hypogastric nerves on the sacrum and ureters. Anterolateral ligament with middle rectal artery is divided Posterior Rectal dissection The mesorectum is divided laterally either with stapler or with a vessel sealer device, such as Harmonic scalpel/ LigaSure . Aim for a 2cm clearance below the distal margin of the tumour in rectum and a 5cm clearance of the mesorectum. High anterior resection Partial mesorectal excision Low anterior resection Total mesorectal excision LAP ANTERIOR RESECTION

11. Anterior Rectal dissection Trendelenburg position Extend the lateral fascial incision upto upper rectum The peritoneum is incised medial to the right ureter and extended around the rectum to join the pelvic peritoneal incision on the left meeting anterior to the rectum Anterior Rectal dissection In females dissect through recto-vaginal septum and in males through recto-vesical space. In males this dissection should be ventral to denonvillier’s fascia to spare seminal vesicles LAP ANTERIOR RESECTION

12. Transection of Rectum An endo GIA stapler is used to divide the rectum at the preselected area Need multiple firings to completely divide the rectum. Transection of Rectum Ensure that vagina in women is not incorporated in this staple lines LAP ANTERIOR RESECTION

13. Exteriorisation of the bowel & it’s resection Divided rectum and descending colon are brought out through a paraumbilical incision protected by a wound protector Proximal colon is transected at a point that allows tension free reach of the colon to the pubic bone. The anvil is detached and placed within the proximal colon, and the purse-string is tied around the anvil LAP ANTERIOR RESECTION

14. Stapler Colo-rectal anastomosis Prior to creation of the anastomosis, the proximal colon is tested to determine that adequate length is available In selected cases, division of the inferior mesenteric vein near its origin can facilitate the colonic mobilization Already the anvil is detached and placed within the proximal colon, and the purse-string is tied around the anvil LAP ANTERIOR RESECTION Stapler Colo-rectal anastomosis After careful deployment of the spike just posterior to the staple line in the rectum , the stapler is coupled and fired, completing the anastomosis- intra-corporeal colorectal anastomosis. Integrity of the anastomosis can be evaluated by gentle insufflation of the rectum with colonoscope to rule out any leak and by examining the tissue doughnuts

15. Alternate Colo-rectal anastomosis J pouch colorectal anastomosis also can be created LAP ANTERIOR RESECTION Defunctioning /Diverting Ileostomy Create a loop ileostomy to divert fecal stream to protect the anastomosis

16. Post-op Care No need to continue antibiotics postoperatively unless there is intraabdominal infection. Ambulation and incentive spirometry on postoperative day 1 is important for the prevention of postoperative atelectasis. Clear liquids are started on postoperative day 1, and diet is advanced as tolerated. The Foley catheter is left in place for a few days because of the high incidence of urinary retention in male patients. DVT prophylaxis should be continued until the time of discharge and can be considered as an outpatient in certain subsets of patients. LAP ANTERIOR RESECTION

17. Pearls & Pitfalls The mesorectal dissection should be performed sharply and meticulously. The colorectal anastomosis must be tension free, and this may require division of the sigmoid artery at its origin and mobilization of the splenic flexure of the colon. In T3 and T4 rectal cancers, preservation of the pelvic autonomic nerves may not be possible. In most patients, the 29-mm circular stapler works well. Using the maximum-size circular stapler may create radial tension, leading to anastomotic leak. If the anastomosis fails the “bubble test,” the anastomotic defect must be identified and repaired primarily. A protection loop ileostomy may be indicated for difficult or low anastomosis (<5 cm) and for patients who underwent preoperative chemoradiation treatment. LAP ANTERIOR RESECTION

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