Laparoscopic Total Mesorectal Excision (Operation Primers, 6) 3642047300, 9783642047305

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This book has been sponsored by Ethicon Endo-Surgery (Europe) GmbH and Johnson & Johnson MEDICAL GmbH, Norderstedt, Germany. The authors are responsible for the content of the publication. Information provided in this book is offered in good faith as an educational tool for health care professionals. The information has been thoroughly reviewed and is believed to be useful and accurate at the time of its publication, but is offered without warranty of any kind. The authors and the sponsors shall not be responsible for any loss or damage arising from its use.

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Operation Primer

LAPAROSCOPIC TOTAL MESORECTAL EXCISION (TME) FOR CANCER Editors Marc Immenroth Thorsten Berg Jürgen Brenner Authors Matthias Anthuber Johann Spatz Assisted by Ann-Katrin Güler Birgit Wahl Clemens Bilharz

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Authors Matthias Anthuber, M.D. Head of the Department of General, Visceral and Transplantation Surgery, Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany Johann Spatz, M.D. Department of General, Visceral and Transplantation Surgery, Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany

Editors Marc Immenroth, PhD Marketing Manager and Sales Support, Ethicon Products, Johnson & Johnson MEDICAL GmbH, Hummelsbütteler Steindamm 71, 22851 Norderstedt, Germany Thorsten Berg, M.D. Director Outcomes Research, Johnson & Johnson Medical Pty Ltd, 1–5 Khartoum Road, North Ryde, NSW 2113, Australia Jürgen Brenner, M.D. Director European Surgical Institute, a division of Johnson & Johnson MEDICAL GmbH, Hummelsbütteler Steindamm 71, 22851 Norderstedt, Germany

ISBN 978-3-642-04730-5 Laparoscopic Total Mesorectal Excision for Cancer Bibliografische Information der Deutschen Bibliothek The Deutsche Bibliothek lists this publication in Deutsche Nationalbibliographie; detailed bibliographic data are available in the internet at http://dnb.ddb.de. This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Ethicon Endo-Surgery (Europe) GmbH. Violations are liable to prosecution under the German Copyright Law. First published in Germany in 2010 by Springer Medizin Verlag springer.com © Ethicon Endo-Surgery (Europe) GmbH The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers, authors and sponsors cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. SPIN 12668120 Layout and typesetting: Dr. Carl GmbH, Stuttgart, Germany Printing: Stürtz GmbH, Würzburg, Germany 18/5135/DK – 5 4 3 2 1 0

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Editors' preface The idea for the Operation Primer series originated in a scientific study entitled “Mental Training in Surgical Education” that formed part of a collaborative project between the surgical department of the University of Cologne, the Institute of Sports and Sports Sciences of the University of Heidelberg and the European Surgical Institute (ESI) in Norderstedt. The aim of the study was to evaluate the effect of mental training, which has been used successfully in top-class sports for decades, on surgical training. However, in order for mental training to be applied to surgery, it first had to undergo modification. In the course of this modification, the first Operation Primer was produced, the layout of which was largely adopted for the final version presented here. In the last two years five Operation Primers have been published in this series: Laparoscopic Sigmoidectomy for Cancer, Laparoscopic Sigmoidectomy for Diverticulitis, Thyroidectomy with Harmonic FOCUS®, Laparoscopic Cholecystectomy and Stapled Transanal Rectal Resection with Contour® TranstarTM Curved Cutter Stapler Procedure Set. Now you hold the sixth Operation Primer in your hand: Laparoscopic Total Mesorectal Excision for Cancer. The feedback has been overwhelming so far. We have received encouraging and motivating messages from all over the world. Operation Primers have been translated into other languages and we have had requests for specialities other than general and visceral surgery as well. This success wouldn’t have been possible without the excellent support and the great effort of the respective authors of each Operation Primer. Therefore, we would like to express our very special thanks to all of them. We are very proud that we could win respected international experts from all over Europe, i.e. Belgium, Germany, Italy, France, Spain, Switzerland and United Kingdom. For this Operation Primer our special thanks go to the authors Matthias Anthuber and Johann Spatz who made a very great contribution to constitute the present Operation Primer Laparoscopic Total Mesorectal Excision for Cancer and to accomplish our superior objective of the series: describing the operation in the simplest possible manner, but without over-simplifying. We have also received great support of Dr. Carl GmbH which has accompanied us at each stage of the working process and has made a great contribution in making these innovative surgical textbooks what they are. Detlev Ruge was responsible for making most of the pictures featured in the whole series. The diagrams, line drawings, etc. were mainly produced by Thomas Heller. The existing concept of practical surgical primers has become reality through the publishing company Springer Medizin Verlag Heidelberg. Sincere thanks to all of them! The previous success of the published Operation Primers has raised the bar for this volume. Whilst we have spent a lot of time on establishing of the scientific basis, the main focus has always been on the practical relevance. We hope we have met the readers’ highest expectations.

The Editors

March 2010

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Authors' preface Total mesorectal excision (TME) is the “gold standard” in the surgical treatment of rectal cancer located in the middle and the lower third of the rectum. This technique is beyond doubt indispensable to achieve an acceptable low rate of local recurrence (< 10 %). The feasibility of laparoscopic assisted TME has been shown in a variety of studies, still only 3–4 % of rectal resections for cancer disease are performed laparoscopically in Germany and other countries throughout Europe and the United States. Apart from positive effects in the immediate perioperative course in terms of enhancing accelerated recovery, laparoscopy in the scenario of rectal resection offers excellent visualization of the autonomic nerves and mesorectal fascia through magnification, proper illumination and high resolution imaging techniques (HDTV). This facilitates nerve sparing surgery particularly in the narrow male pelvis and is crucial to preserve the sexual and bladder function. In addition, saving the mesorectal fascia as the anatomical border of the circumferential margin is of utmost importance to achieve proper oncological radicality. More important than the mere feasibility of rectum resection in the laparoscopic technique is the question whether this approach is equivalent with the “gold standard” of open resection in terms of morbidity, mortality, rate of anastomotic leakage, lymph node harvest, rate of local recurrence, disease-free and overall survival. In a Cochrane review including 42 studies and 4224 patients no significant difference could be found between the open and laparoscopical technique with regard to the above mentioned criteria (Breukink et al., 2006). However, a clear adverse effect on morbidity, anastomotic leakage and local recurrence along with a trend towards decreased disease-free and overall survival was observed in the group of patients where laparoscopy had to be converted to open resection. In addition, data from a German quality control study demonstrate that experienced centers achieve better results with lower conversion rates and perioperative morbidity and mortality than those hospitals being at the beginning of their individual learning curves (Ptok et al., 2006). Understanding this, it becomes clear that all means to improve ones own manual and mental skills have to be exploited to move a steep course up the learning curve and to be able to perform laparoscopical TME as an oncological safe alternative to open resection. We believe this Operation Primer to be an excellent teaching tool advocating a standardized technique not only for those who begin but also for the advanced surgeons. A giant with two hands inside may be a dwarf with two sticks.

Matthias Anthuber Johann Spatz

March 2010

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Authors Matthias Anthuber, M.D. – Studied Medicine in Munich, Germany – 1985–1995 Medical Doctor at the Department of Surgery at the University of Munich, Großhadern, Germany – 1986 Doctorate in Medicine at the University of Munich, Germany – 1993 Qualified as General Surgeon – 1995–2003 Surgeon Consultant at the Department of Surgery at the University of Regensburg, Germany – 1996 Qualified as Visceral Surgeon – 1997 State Doctorate at the University of Regensburg, Germany – 1999 Associate Professor at the University of Regensburg, Germany – 2003 Head of the Department of General and Visceral Surgery of the General Hospital Altötting, Germany – Since 2004 Head of the Department of General, Visceral and Transplantation Surgery of the Hospital of Augsburg, Germany – 2005 Associate Professor at the University of Munich, Germany – Since 2005 Teaching surgeon for the Ethicon hospitation programm for laparoscopic rectal cancer surgery Focus of Research and Work – Surgical oncology of the gastrointestinal tract – Hepato-biliary surgery – Minimal invasive Surgery First author and Co-author of many scientific articles in surgical journals and of specialists books

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Johann Spatz, M.D. – Studied Medicine in Munich, Germany – 1997 Intern and surgical training at the University Hospital of Regensburg, Germany – 1999 Medical Doctor at the University of Regensburg, Germany – 2003 Qualified as General Surgeon – Since 2005 Senior Surgeon in the Department of General, Visceral and Transplantation Surgery of the Hospital of Augsburg, Germany – Since 2006 Teaching surgeon for the Ethicon hospitation programm for laparoscopic rectal cancer surgery – 2007 Qualified as Visceral Surgeon – Since 2008 Vice Chair of the Department of General, Visceral and Transplantation Surgery of the Hospital of Augsburg, Germany Focus of Research and Work – Surgical oncology of the gastrointestinal tract – Minimal invasive Surgery – Multimodal Fast Track Rehabilitation – Improvement of lymph node staging in gastrointestinal cancers First author and Co-author of many scientific articles in surgical journals and of specialists books

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Editors Marc Immenroth, PhD – Studied Psychology (Diploma) and Sports Science (Master) in Heidelberg, Germany – 1999–2006 Sports Psychologist (including consultant to many German top athletes during their preparation for the World Championships and Olympics) and Industrial Psychologist (including consultant to Lufthansa Inc.) – 2000 Research Scientist at the University of Greifswald, Germany (Policlinic for Restorative Dentistry and Periodontology) – 2001–2004 Research Scientist at the University of Heidelberg, Germany (Institute of Sports and Sports Science) – 2002 Doctorate in Psychology at the University of Heidelberg, Germany – 2005–2006 Assistant Lecturer at the University of Giessen, Germany (Institute of Sports) – 2006 –2008 Assistant Professor at the University of Greifswald, Germany (Institute of Sports) – 2006–2009 European Clinical Studies Manager at Ethicon Endo-Surgery (Europe) GmbH in Norderstedt, Germany – Since 2009 Marketing Manager and Sales Support at Ethicon Products, Johnson & Johnson MEDICAL GmbH in Norderstedt, Germany Focus of Research and Work – Mental Training in Sport, Surgery and Aviation – Virtual Reality in Surgical Education – Coping with Emotion and Stress Author of many scientific articles and textbooks in psychology, sports science and medicine

Thorsten Berg, M.D. – Studied Medicine in Heidelberg, Germany – 1996 Intern at the University Hospital, Durban, South Africa – 1997 Intern at the Surgical Department of the General Hospital, Ludwigshafen, Germany – 2003 Qualified as General Surgeon – 2003 Director of Education of European Surgical Institute in Norderstedt, Germany – 2005 Director of Clinical Development at Ethicon Endo-Surgery (Europe) GmbH in Norderstedt, Germany – 2006 Senior Manager Health Outcome at Ethicon Endo-Surgery (Europe) GmbH in Norderstedt, Germany – 2007 Doctorate in Medicine at the University of Heidelberg, Germany – Since 2008 Director Outcomes Research at Johnson & Johnson Medical in Sydney, Australia

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Jürgen Brenner, M.D. – Studied Medicine in Hamburg, Germany – 1972 Doctorate in Medicine at the University of Hamburg, Germany – 1972 Institute for Neuroanatomy, University of Hamburg, Germany – 1974 Senior Resident at the Department of Surgery of the General Hospital Hamburg-Wandsbek, Germany – 1981 Medical Director of the Department for Colorectal and Trauma Surgery at St. Adolf Stift Hospital in Reinbek, Germany – 1987 Director for Surgical Research of Ethicon Inc. in Norderstedt, Germany – 1989 Director of the European Surgical Institute and Vice President Professional Education Europe at Ethicon Endo-Surgery (Europe) GmbH in Norderstedt, Germany – 2004 Managing Director at Ethicon Endo-Surgery Germany in Norderstedt, Germany – Since 2008 Director of European Surgical Institute in Norderstedt, Germany

Assistants Ann-Katrin Güler, M.D. – Studied Medicine in Hamburg, Germany – Since 2007 member of the Market Access Department at Ethicon Endo-Surgery (Europe) GmbH in Norderstedt, Germany – 2009 Doctorate in Medicine at the University of Hamburg, Germany

Birgit Wahl, M.D. – Studied Medicine in Freiburg, Germany – 2000–2003 Intern at different Surgical Departments, Germany – 2003 Doctorate in Medicine at the University of Freiburg, Germany – 2003–2006 Product Manager at Spitta Publishing House in Balingen, Germany – Since 2006 Free Medical Writer at Dr. Carl GmbH in Stuttgart, Germany – Since 2008 certified Medical Journalist, Deutsche Fachjournalisten-Schule in Berlin, Germany

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Clemens Bilharz – Studied Medicine in Freiburg, Germany – 1988–1998 Intern at the Department of Anaesthetics and Intensive Care at the University of Tübingen and Marienhospital in Stuttgart, Germany – 1999–2000 Certified Lector of Scientific Journals, WBS Training AG in Stuttgart, Germany – 2000–2003 Lector and Project Manager at Georg Thieme Verlag in Stuttgart, Germany – 2004–2006 Medical Advisor at Schmittgall Werbeagentur in Stuttgart, Germany – Since 2006 Project Manager and Medical Writer at Dr. Carl GmbH in Stuttgart, Germany

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Contents Introduction Structure and handling of the Operation Primer

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I Preparations for the operation Basic instruments Additional instruments for laparoscopic total mesorectal excision (TME) Emptying the bladder Positioning of the patient Shaving Neutral electrode Setting up the equipment Skin disinfection Sterile draping Positioning of the operating team

21 22 24 24 25 25 25 25 25 26

II Creating the pneumoperitoneum – placing the trocar for the scope a) Hasson method (open technique) b) Trocar with optical obturator c) Veress needle (closed technique)

28 29 30

III Placing the working trocars Placing the working trocars

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IV Nodal points 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum Dissecting the anterior mesorectum Dividing the rectum Performing a mini-incision and extracting the rectosigmoid Dividing the proximal colon Preparing the anastomosis extra-abdominally Preparing the anastomosis intra-abdominally Anastomosing colon and rectum Verifying the anastomosis Placing a protective stoma Finishing the operation

36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68

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V Management of difficult situations and complications 1. Adhesions 2. Blood vessel injuries a) Diffuse bleeding / bleeding from minor vessels b) Bleeding from major vessels 3. Organ injuries a) Greater omentum b) Bowel c) Spleen d) Stomach e) Liver f) Pancreas g) Prostate, seminal vesicles, vagina 4. Preperitoneal air emphysema a) Veress needle b) Trocar 5. Losing a swab in the abdominal cavity 6. Difficulties when identifying the inferior mesenteric artery 7. Extensive adhesions of the sigmoid to the abdominal wall 8. Injury of the left sympathetic trunk 9. Injury of the autonomic nerve plexus 10. Injury of the left ureter 11. Injury of the iliac vessels 12. Difficulties when clipping a) Incorrectly positioned clips b) Insecurely positioned clips c) Lost and slipped clips 13. Positive anastomotic leak test 14. Rotation of the left colon 15. Spastic colon 16. Spread of tumor cells

71 71 71 71 71 71 72 72 72 72 72 72 73 73 73 73 73 73 74 74 74 74 74 74 75 75 75 75 75 76

VI Anatomical variations Vascular variations Sigmoid position variations

77 81

Appendices Sample operation note Bibliography List of key words

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84 86 94

Introduction From an educational point of view, the Operation Primer is somewhat plagiaristic. The layout – and this can be admitted freely – is largely adapted over from commonly available cook books. In such books, the ingredients and cooking utensils required to prepare the recipe in question are normally listed first. The most important cooking procedures are then described briefly in the text. Photographs support the written explanations and show what the dish should look like when prepared. Sometimes diagrams and illustrations make individual cooking steps clearer. Despite these obvious parallels, there is a crucial difference between cook books and the Operation Primer: in the Operation Primer, complicated and complex surgical techniques are described that are intended to help the surgeon and his team perform an operation safely and economically. Ultimately, it always comes down to the patient's welfare. The following must therefore be said early in this introduction: • The use of the Operation Primer as an aid to operating requires that surgical techniques have first been completely mastered. • Being alert to possible mistakes is categorically the most important principle when operating; avoiding mistakes is crucial. As already mentioned in the Editors' preface, the concept of the Operation Primer originated in a scientific study with the title “Mental Training in Surgical Education” that formed part of a collaborative project between the surgical department of the University of Cologne (under Prof. Hans Troidl), the Institute of Sports and Sports Science of the University of Heidelberg, and the European Surgical Institute (ESI) in Norderstedt. Laparoscopic cholecystectomy was the initial focus. Mental training is derived from top-class sports. This is understood as methodically repeating and consciously imagining actions and movements without actually carrying them out at the same time (cf. Driskell, Copper & Moran, 1994; Feltz & Landers, 1983; Immenroth, 2003; Immenroth, Eberspächer & Hermann, 2008). Scientific involvement with imagining movement has a long tradition in medical and psychological research. As early as 1852, Lotze described how imagining and perceiving movements can lead to a concurrent performance “with quiet movements …” (Lotze, 1852). This phenomenon later became known by the names “Ideomotion” and “Carpenter effect” (Carpenter, 1874). In the collaborative project, mental training was modified in such a way that it could be employed in the training and further education of young surgeons. In mental training in surgery, surgeons visualize the operation from the inner perspective without performing any actual movements, i.e., they go through the operation step by step in their mind's eye. In the study that was conducted at the ESI, the first Operation Primer was used as the basis for this visualization. In this primer, laparoscopic cholecystectomy was subdivided into individual, clearly depicted steps, the so-called nodal points. The study evaluated the effect of the mental training on learning laparoscopic cholecystectomy compared with practical training and with a control group. The planning, conduct, and evaluation of the study took seven years (2000–2007), with over 100 surgeons participating.

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The results corresponded exactly with the expectations: the mentally trained surgeons improved in a similar degree to those surgeons who received additional practical training on a pelvi trainer simulator (in some subscales even more). Moreover, there was greater improvement in these two groups compared with the control group, which did not receive any additional mental or practical training (cf. in detail, Immenroth, Bürger, Brenner, Nagelschmidt, Eberspächer & Troidl, 2007; Immenroth, Bürger, Brenner, Kemmler, Nagelschmidt, Eberspächer & Troidl, 2005; Immenroth, Eberspächer, Nagelschmidt, Troidl, Bürger, Brenner, Berg, Müller & Kemmler, 2005). Furthermore, the study included a questionnaire to determine the extent to which the mentally trained surgeons accepted mental training as a teaching method in surgery. Mental training was assessed as very positive by all 34 mentally trained surgeons. The Operation Primer received particular acclaim in the evaluation (cf. in detail, Immenroth et al., 2007): • 28 surgeons wished to use similar self-made Operation Primers in their daily work. • 29 surgeons attributed the success of the mental training at least in part to the Operation Primer. • 30 surgeons wanted to have these Operation Primers as a fixed component of the course at the ESI. This positive response to the study was the starting point for the production of the present series of Operation Primers. Prior to publication, the Operation Primer was developed by methodical and didactical means and then adapted to the readers' needs and wishes. This was carried out following a survey of 93 surgeons (interns, resident doctors, assistant medical directors and medical directors) who participated in surgical courses at the ESI. They evaluated in detail the structure and components by means of a questionnaire. The results of this survey gave important findings on how to optimize the Operation Primer. The sense and representation of the nodal points, the comprehensibility and detail of the text, and the photographs of the operation were highly valued especially by young surgeons (Güler, Immenroth, Berg, Bürger & Gawad, 2006). The comprehensive research undertaken with this Operation Primer series will ensure its overall value to the reader.

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Structure and handling of the Operation Primer

Structure and handling of the Operation Primer In the present series of Operation Primers, an attempt has been made to standardize the described laparoscopic operations as much as possible. This is achieved first by applying the same format to all operating techniques described. Second, operative sequences that are performed identically in all operations are always explained using the same blocks of text. By following a general structure for the description of all operations and by using identical text blocks, it was intended to aid recognition of recurring patterns and their translation into action even for different operations. The Operation Primer is divided into six chapters, each identified by Roman numerals and different register colors on the margin. The contents of the individual chapters will now be explained. In Preparations for the operation, the basic instruments for all laparoscopic operations and then the additional laparoscopic instruments for the specific operation are listed. This is followed by a detailed description of the positioning and shaving of the patient, attaching the neutral electrode, setting up the equipment, skin disinfection and sterile draping of the patient. The operative preparation is concluded with a detailed description and picture of how the operating team is to be positioned for the operation in question.

I

Preparations for the operation

II Creating the pneumoperitoneum – placing the trocar for the scope III Placing the working trocars IV Nodal points V Management of difficult situations and complications VI Anatomical variations Appendices

In the chapter Creating the pneumoperitoneum – placing the trocar for the scope, three alternatives are shown in detail: the Hasson method, trocar with optical obturator, and Veress needle. The choice of method is up to the individual surgeon. All three alternatives are employed in surgical practice. However, it should be pointed out that the greatest danger in minimally invasive surgery is the insertion of the Veress needle, as it is done “blind”.

3 possibilities for creating the pneumoperitoneum: the choice is up to the surgeon

Placing the working trocars is explained in detail in the next chapter. The written explanations are supplemented by diagrams. In order to keep a constant overview of the placement of the trocars, even during the following description of the operation sequence, these illustrations are shown in diminished size in every single operative step.

Continuous illustration of the trocar positions

The core of the Operation Primer is the chapter Nodal points. This is where the actual sequence of the operation is described in detail. However, prior to this detailed explanation, the term nodal point will be explained briefly. In the Editors' preface and introduction, mental training was mentioned as a form of training used successfully in top-class sports for decades, and this is where the term originates. In sports as in surgery, a nodal point is understood as one of those structural components of movement that are absolutely essential for performing the movement optimally. Nodal points have to be passed through in succession and are characterized by a reduction in the degrees of freedom of action. In mental training they act as orientation points for methodical repetition and conscious imagining of the athletic or operative movement (cf. in detail Immenroth et al., 2008). For every operation in the Operation Primer series, these nodal points were extracted in a prolonged process by the authors in collaboration with the editors.

Veress needle = greatest danger!

T4

T1 T2

T3

Nodal point = term from top-class sports Nodal points: 1) absolutely essential 2) successive order 3) no degrees of freedom

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Structure and handling of the Operation Primer

Flow chart of the sequence of nodal points on each double page

The nodal points represent the basic structural framework of an operation. Because of their particular relevance and for better orientation, all of the nodal points in the Operation Primer are shown on the left on each double page as a flow chart. The current nodal point is highlighted graphically. The instruments required for this nodal point and the specific trocars for it are listed in a box on the right, beside the flow chart.

Maximum of 7±2 instructions per nodal point

Below the instrument box, instructions regarding the nodal point are given as briefly as possible. According to Miller (1956), people can best store 7±2 units of information (“Magical number 7”). Therefore, no more than seven single instructions are listed per nodal point, if possible.With regard to the instructions, it should be noted that the change of instruments between the individual nodal points is not described explicitly as a rule; rather, this is apparent through different instruments in the instrument box.

Danger warnings are pointed out in red! Alternatives: In small blue print at the end of the nodal point.

Where necessary, particular moments of danger are pointed out in red. The described operation sequence is only one way of performing the operation safely and economically, namely the way preferred by the authors. Undoubtedly, a number of other equally valid operation sequences exist. As far as possible, notes on alternative methods are given in small blue print at the end of each nodal point. In the fifth chapter, the Management of difficult situations and complications is described in detail. In general, details on adhesions, bleeding, injuries to organs, etc. are given first.

Illustration of the most important anatomical variations

The following chapter goes into relevant Anatomical variations, which can occur in the described operation sequence and may require a different approach. In order to provide a clear description, only the most important anatomical variations are mentioned.

Example of an operation note in the appendices

In order to give the Operation Primer even more practical relevance, an example of an operation note is reproduced in the Appendices. Besides the operation note, the appendices also contain the bibliographical references and list of key words.

(→ p. 73, V-4) = reference to the 4th section of chapter V

In order to avoid repetition, reference is made throughout the text to relevant chapters of the Operation Primer, if necessary. To do this, the Roman numeral of the chapter and the number of the corresponding section are shown in parentheses. Referral is made most often to the fifth chapter where the management of difficult situations and complications is described. These references are set off in red letters.

All sources in the literature are listed in the bibliography

Finally, it must be pointed out that for better readability of the Operation Primer no bibliographical references at all are given in the text. However, in order to give an overview of the basic and more extensive sources, the entire literature is listed in the bibliography.

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Preparations for the operation

Preparations for the operation Make sure that the following preoperative requirements for laparoscopic total mesorectal excision (TME) have been met: • • • • • •

The indication for the operation is correct. The patient has given detailed informed written consent. A standard rigid sigmoidoscopy has been performed. The bowel is prepared appropriately prior to laparoscopic colorectal surgery. The optimal location for the protective stoma has been marked. Thromboprophylaxis (low-molecular-weight heparin) has been given as per local practice. • Single-dose perioperative antibiotic prophylaxis has been given.

Basic instruments • • • • • • • • • • • • • •

Size 11 scalpel 10-ml syringe with 0.9 % NaCl solution Dissecting scissors 2 Langenbeck hooks 2 Overholt clamps 2 Roux hooks Suction device Needle holder Suture scissors 2 surgical forceps 2 Backhaus clamps Compresses Swabs with an integral X-ray contrast strip Sutures: – Peritoneum/Fascia: 2 absorbable, polyfilament – Subcutaneous: 3–0 absorbable, polyfilament – Skin: 4–0 or 5–0 absorbable, monofilament – Colon: 4–0 absorbable, mono- or polyfilament – For ligatures: 2–0 absorbable, polyfilament • Skin adhesive, if necessary • Dressings Instruments for the first access, depending on the type of access: a) Hasson method – Hasson trocar (10/12 mm) – 2 retaining sutures (2–0) – Purse-string suture (2–0) b) Trocar with optical obturator (e.g. Endopath XCEL® bladeless trocar, Ethicon Endo-Surgery) c) Veress needle (e.g. Endopath® Ultra Veress Insufflation Needle, Ethicon Endo-Surgery) There should always be a basic laparotomy set in the operating room so that in an emergency a laparotomy can be performed without delay!

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I

I

Preparations for the operation

Additional instruments for laparoscopic total mesorectal excision (TME) Trocars: T1: Trocar for the scope T2: Working trocar T3: Working trocar T4: Working trocar

(e.g. Endopath XCEL® trocar, Ethicon Endo-Surgery) (10/12 mm) (5 mm or 10/12 mm) (10/12 mm) (5 mm or 10/12 mm)

• Additional trocars, if necessary • Reducer caps, if necessary • Angled scope (0° scope, if necessary, for trocar with optical obturator) Dissecting instruments: • 2 atraumatic grasping forceps (5 mm and/or 10 mm) • Curved dissector • Ultrasonic dissector (e.g. Harmonic ACE® shears, Ethicon Endo-Surgery) • HF (high frequency) electrode handle and forceps (e.g. for hemostasis in the subcutaneous fatty tissue) • Curved scissors • Dissecting swab • Suction-irrigation instrument • Endoscopic linear cutter (e.g. Echelon™ 60 Endopath® Stapler or Echelon™ 60 Flex Endopath® Stapler endoscopic linear cutter, Ethicon Endo-Surgery) • Additional cartridges • Linear cutter (e.g. Proximate® TLC 75 linear cutter, Ethicon Endo-Surgery) • Transluminal circular stapler (e.g. Proximate® ILS circular stapler, Ethicon EndoSurgery) • Anvil forceps • Purse-string suture (2–0 non-absorbable, monofilament) • Sutures for protective stoma (3–0 absorbable, polyfilament) • Silicone drain for protective stoma • Clip applier (e.g. Absolok® clip applier, Ethicon Endo-Surgery) • 6 titanium or absorbable clips • Plastic-coated drape • 2 Allis clamps • 100-ml syringe • Antiseptic solution (e.g. Lavasept®) • Silicone drain, if indicated • Stoma bag Before using any instruments read the instructions for use and become familiar with the instrument!

Alternative: Instead of Harmonic® shears, bipolar scissors can be used for dissecting.

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Basic instruments

Additional instruments for laparoscopic total mesorectal excision (TME)

23

I

Preparations for the operation

Emptying the bladder • In order to avoid injuries to the bladder, make sure that the patient's bladder is emptied preoperatively by placing a temporary transurethral catheter.

Positioning of the patient • Position the patient in lithotomy position. • Place the buttocks at the distal edge of the table and stretch thighs and legs apart with a slight flexure. • Place the right arm alongside the body and the left arm at an angle no greater than 70° to the long axis of the body in order to avoid injuries to the axillary nerve. • Use shoulder supports on both sides and right lateral support or a vacuum mattress to prevent the patient from sliding when put in extreme positions. • After identifying the anatomical landmarks (nodal point 2) put the patient in a Trendelenburg (10 – 30°) and right-lateral position (10 – 25°).

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Shaving • Shave the patient from the mamillae to above the pubic symphysis and from left to the right anterior superior iliac spine in order to be able to convert to a conventional operation if complications occur. • If monopolar current is used, shave the adhesion side for the neutral electrode (as close as possible to the operating field, e.g. on the upper thigh).

Neutral electrode • Before placing the neutral electrode, ensure that the skin at this site and all skin areas in contact with the table are absolutely dry. • Then stick the entire surface of the electrode carefully above the greatest possible muscle mass (e.g. on the upper thigh). The conducting cable must be at the greatest possible distance from the operating field. When using monopolar current, always guard against burns on moist areas of the skin due to current!

Setting up the equipment • Set the generator of the ultrasonic dissector and the HF electrode to an appropriate power level for the intended use. • Position the foot pedal. • Attach the suction-irrigation instrument. • Select a maximum pressure of 12 mmHg on the CO2 insufflator (with a flow of 6 – 8 l/min).

Skin disinfection • Disinfect the skin from the mamillae to the pubic symphysis. Pay particular attention to careful disinfection of all skin folds.

Sterile draping • Drape the operating field with sterile drapes so that it is limited cranially at the level of the xiphoid, just above the symphysis caudally, and by the anterior axillary lines laterally.

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I

Preparations for the operation

Positioning of the operating team Lithotomy position • The surgeon stands to the right at the level of the patient's abdomen. • The camera assistant stands to the right at the level of the patient's head. • The scrub nurse stands to the right at the level of the patient's leg. • One monitor is located in the line of vision of the surgeon and the camera assistant at the level of the patient's abdomen. • An additional monitor can be installed on the left at the level of the patient's head.

Camera assistant

Surgeon

Scrub nurse

Alternative: There is the possibility to operate with a second assistant. In that case the second assistant stands to the left of the patient at the level of the patient's abdomen. A second monitor is located in the line of vision of the second assistant on the right at the level of the patient's head. A second assistant may be helpful for transanal stapling of the anastomosis particularly in cases with a very short rectal stump.

26

Creating the pneumoperitoneum – placing the trocar for the scope II

Creating the pneumoperitoneum – placing the trocar for the scope There are three ways of creating a pneumoperitoneum, which will be described in detail below: a) Hasson method (open technique) b) Trocar with optical obturator c) Veress needle (closed technique) Because of the large variety of trocars available and the resulting variety of methods of introducing the trocars, follow their individual instruction manuals!

27

II

Creating the pneumoperitoneum – placing the trocar for the scope

a) Hasson method (open technique) Size 11 scalpel Scissors 2 surgical forceps 2 Langenbeck hooks 2 retaining sutures (2–0) Purse-string suture (2–0) Hasson trocar (10/12 mm) Incise the skin 2–3 cm above and left lateral of the umbilicus (transmuscular route), making a 1.5- to 2-cm skin incision. This removes the need to close the fascia after removal of the trocar for the scope. Ensure that the skin incision is the correct length: • An incision that is too small can make insertion of the trocars much more difficult. If the skin around the trocars then suffers increased tension, this may lead to skin necrosis! • An incision that is too large can result in gas loss and trocar dislocation (→ p. 73, V-4b; p. 76, V-16)!

Spread the subcutaneous fat with the scissors as far as the linea alba. Try to stay midway between the two bellies of the rectus abdominis muscle. Use two Langenbeck hooks to expose the fascia of the anterior rectus sheath. Then insert two 2–0 retaining sutures at the junction between the linea alba and the rectus muscle and draw the fascia upwards by pulling the sutures. Use a scalpel to open the fascia between the two retaining sutures over a distance of 1.5 cm. To expose the peritoneum, retract the fascia by repositioning the Langenbeck hooks. Now lift the peritoneum with the surgical forceps and incise it with the scissors over a length of about 1–1.5 cm. Check for the presence of close adhesions by inserting a finger into the incision site and palpating over the entire 360° circumference of the site. Place a purse-string suture around the peritoneal incision and introduce the blunt Hasson trocar through the incision into the free abdominal cavity. Secure the trocar with the two previously placed retaining sutures by tying them around the wings of the trocar cone. Tighten the purse-string suture around the Hasson trocar. Secure the CO2 supply tube to the trocar, remove the obturator, and insufflate the gas until the preselected maximum pressure of 12 mmHg is reached. Alternative: Incise the skin 2–3 cm above the umbilicus.

Alternative: It is possible to perform an open technique without using a Hasson trocar. After incising the peritoneum place a blunt probe through the incision in the free abdominal cavity, using it as a support for the placement of the trocar for the scope under vision control.

28

b) Trocar with optical obturator Size 11 scalpel Trocar with optical obturator Scope (0°)

Incise the skin 2–3 cm above and left lateral of the umbilicus (transmuscular route), making a 1.5-cm skin incision. This removes the need to close the fascia after removal of the trocar for the scope. Ensure that the skin incision is the correct length: • An incision that is too small can make insertion of the trocars much more difficult. If the skin around the trocars then suffers increased tension, this may lead to skin necrosis! • An incision that is too large can result in gas loss and trocar dislocation (→ p. 73, V-4b; p. 76, V-16)!

Insert the scope into the optical obturator located in the trocar and lock it. Place the transparent conical tip into the incision. Now carefully push the different layers of the abdominal wall tangentially apart by applying light pressure and using to-and-fro rotating movements of the blunt obturator tip. The special construction of the obturator allows the layers to be identified before they are pushed apart. Perform this tissue separation and the final perforation of the peritoneum under constant vision. When inserting the trocar, take care • to go in perpendicular to the abdominal wall, • to support the trocar with the hand, and • not to use excessive force in order to avoid blood vessel and organ injuries in the event of loss of resistance (→ p. 71, V-2; V-3)!

Finally, remove the scope together with the obturator from the trocar. Secure the CO2 supply tube to the trocar and insufflate the gas until the preselected maximum pressure of 12 mmHg is reached. Alternative: Incise the skin 2–3 cm above the umbilicus.

29

II

Creating the pneumoperitoneum – placing the trocar for the scope

c) Veress needle (closed technique)

Insertion of the Veress needle and the first trocar are the most dangerous moments in minimally invasive surgery, as the insertion is done “blind“. There are many reported cases of major injuries to the aorta and the iliac artery caused by the use of the Veress needle!

Size 11 scalpel 2 Backhaus clamps Veress needle 10-ml syringe with NaCl solution Trocar for the scope T1 (10/12 mm) Patients who have undergone previous surgery carry a higher risk of having adhesions! In these patients or in case of hepatomegaly, the Veress needle should be avoided!

To minimize the risk of injury that may be caused by the Veress needle, select access in the left upper abdomen above and lateral to the umbilicus. Incise the skin 2–3 cm above and left lateral of the umbilicus (transmuscular route), making a 1.5- to 2-cm skin incision (→ p. 76, V-16). This removes the need to close the fascia after removal of the trocar for the scope. With the help of the assistant, elevate the abdominal wall with two Backhaus clamps, and carefully insert the Veress needle vertically with your hand supported above the skin incision. The penetration of the abdominal wall layers by the Veress needle can be felt or even heard. When inserting the Veress needle, take care • to go in perpendicular to the abdominal wall (→ p. 73, V-4a), • to support the hand holding the needle, and • not to use excessive force in order to avoid blood vessel and organ injuries in the event of loss of resistance (→ p. 71, V-2; V-3)!

Check the correct position of the Veress needle by applying the following obligatory safety tests: Aspiration test Attach a 10-ml syringe filled with NaCl solution to the Veress needle. It should be possible to aspirate air as a sign that the intra-abdominal position is correct. Injection test Inject NaCl solution through the Veress needle into the abdominal cavity. This can be done easily if it is in the correct position. Increased resistance of the syringe plunger indicates a possible incorrect position of the Veress needle.

30

Alternative: When using the Endopath® Ultra Veress Insufflation Needle (Ethicon Endo-Surgery), the valve is opened to perform the injection test, whereupon the NaCl solution is released into the abdominal cavity if the Veress needle is in the correct position. In addition, the red marker ball drops down, indicating that NaCl solution is released into the abdominal cavity.

Rotation test Carefully rotate the slightly tilted needle inside the abdominal cavity. If the needle can be rotated freely, adhesions in close proximity are unlikely. Slurp test Apply one drop of NaCl solution onto the cone of the Veress needle, placing it convex on the opening. Now pull up the abdominal wall, making sure not to fix the Veress needle with your hand. Elevating the abdominal wall will create a partial vacuum, which in turn will cause the drop of NaCl to be sucked into the abdominal cavity, provided the Veress needle is correctly placed. A substantial vacuum will cause an additional “slurping“ sound to be heard at the cone of the Veress needle. If the safety tests indicate that the Veress needle has been placed correctly, attach the gas supply tube. Excessively high intra-abdominal resting pressure and no flow indicate that the tip of the Veress needle is obstructed, e.g. by the greater omentum (→ p. 71, V-3a). In this case, perform the following test: Manometer test In order to release the Veress needle, manually lift up the abdominal wall. This should result in an obvious pressure drop. If this is not the case, remove the Veress needle and then place it again. Insufflate the CO2 until the preselected maximum pressure of 12 mmHg is reached (recommended maximum flow through the Veress needle: ~1.8 l/min). After that, remove the Veress needle from the skin incision. To be sure that the Veress needle has been placed correctly, check for an adequate flow during the CO2 insufflation and an appropriate increase in pressure on the insufflator!

Now place the trocar for the scope in the skin incision above the umbilicus. To do so use either • a trocar with a sharp tip (10/12 mm) or • a trocar with optical obturator. When inserting the trocar, take care • to go in perpendicular to the abdominal wall, • to support the trocar with the hand, and • not to use excessive force in order to avoid blood vessel and organ injuries in the event of loss of resistance (→ p. 71, V-2; V-3)! Alternative: Incise the skin 2–3 cm above the umbilicus.

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III Placing the working trocars

Placing the working trocars Trocar for the scope T1 (10/12 mm) Working trocar

T2 (5 mm or 10/12 mm)

Working trocar

T3 (10/12 mm)

Working trocar

T4 (5 mm or 10/12 mm)

Size 11 scalpel Reducer caps, if necessary Insert the scope into the trocar (T1). Perform a diagnostic laparoscopy to make sure that there are no pathological changes and/or injuries which might change the operative strategy or even prevent continuation of the operation (→ p. 71, V-2; V-3). Choose the working trocar sites T2, T3 and T4 by palpating the abdominal wall under vision and use diaphanoscopy to ensure that no major cutaneous vessels will be injured when the trocars are inserted (→ p. 71, V-1; V-2). T2: In the left fossa iliaca T3: In the right fossa iliaca T4: In the right upper abdomen quadrant (if possible, place T4 at the planned position for the protective stoma) Incise the skin with a scalpel according to the trocar diameter: about 1 cm when using a 5-mm trocar and 1.5-cm with a 10/12-mm trocar. Now insert the working trocars under vision. Ensure that the skin incisions are the right size!

When placing the trocars – particularly T3 and T4 – make sure that they point exactly towards the operating field, as later corrections will not be possible. When placing the trocars, take care • to insert the trocar under vision to avoid injuries (→ p. 71; V-2; V-3), • to point the trocars exactly towards the operating field, as later corrections will be difficult, if not impossible, • to place additional trocars at any time to gain optimal working conditions, • to place the trocars with a minimum distance of 10 cm between them in order to avoid interference of camera and instruments, and • to pay attention to the distance between the trocars and the iliac spine (at least 1 cm distance)!

Remove the obturators from the trocars and attach the reducer caps to T2, T3 and T4, if necessary. There are many ways to position the trocars. We prefer the following placement, but it should be the surgeon's choice!

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Placing the working trocars III

T4

T1 T2

T3 T1 T2 T3 T4

Trocar for the scope Working trocar Working trocar Working trocar

33

IV Nodal points

Nodal points 1 Exploring the abdominal cavity 2 Identifying the anatomical landmarks 3 Dissecting the lymph nodes and the sigmoid mesentery 4 Dividing the inferior mesenteric vessels 5 Mobilizing the sigmoid and the descending colon 6 Mobilizing the splenic flexure 7 Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum 8 Dissecting the anterior mesorectum 9 Dividing the rectum 10 Performing a mini-incision and extracting the rectosigmoid 11 Dividing the proximal colon 12 Preparing the anastomosis extra-abdominally 13 Preparing the anastomosis intra-abdominally 14 Anastomosing colon and rectum 15 Verifying the anastomosis 16 Placing a protective stoma 17 Finishing the operation 34

Nodal points

IV

Overview nodal points

35

IV Nodal points Nodal point 1

Exploring the abdominal cavity

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery T4

Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum

T1 T2

T1 T2 T3 T4

Scope – Harmonic® shears, if necessary Atraumatic grasping forceps, if necessary

T3

Examine the abdominal cavity carefully by inspecting it in a clockwise direction:

Preparing the anastomosis extra-abdominally

• Pelvis: dome of the bladder, Pouch of Douglas, the internal hernial orifices, and the uterus and adnexa in women • Cecum with appendix • Ascending colon • Right upper abdomen: liver and gallbladder, right colonic flexure • Greater omentum • Transverse colon • Left upper abdomen: stomach and spleen, splenic flexure • Descending colon • Sigmoid colon • Jejunum and ileum

Preparing the anastomosis intra-abdominally

Look particularly for adhesions, erythema, vascular injection, serous fluid, pus, tumors and peritoneal carcinosis.

Dissecting the anterior mesorectum Dividing the rectum Performing a mini-incision and extracting the rectosigmoid Dividing the proximal colon

Anastomosing colon and rectum

Try to identify the tumor before continuing with the procedure. Note that only tumors lying inside the peritoneal cavity are visible laparoscopically!

Verifying the anastomosis Placing a protective stoma

Don't handle the tumor directly with the instruments to avoid spread of tumor cells (→ p. 76, V-16)!

Finishing the operation

Particularly check the trocar incision sites for adhesions and possible bleeding. Change the scope position, if necessary (→ p. 71, V-1; V-2). Divide any adhesions in the operating field using sharp dissection (→ p. 71, V-1). Divide any adhesions with organs promptly in order to avoid injuries (→ p. 71, V-3)!

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Diagnostic laparoscopy

Liver and gallbladder

Stomach and spleen

Cecum with appendix

Sigmoid colon

Urinary bladder and uterus with adnexa

37

IV Nodal points Nodal point 2

Identifying the anatomical landmarks

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery T4

Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum Dissecting the anterior mesorectum Dividing the rectum Performing a mini-incision and extracting the rectosigmoid Dividing the proximal colon Preparing the anastomosis extra-abdominally Preparing the anastomosis intra-abdominally Anastomosing colon and rectum Verifying the anastomosis Placing a protective stoma Finishing the operation

38

T1 T2

T1 T2 T3 T4

Scope Atraumatic grasping forceps Harmonic® shears, if necessary Atraumatic grasping forceps, if necessary

T3

Identify the following anatomical landmarks: Lower abdomen: • Sigmoid colon • Rectum and rectosigmoid junction • Inferior mesenteric artery • Genital organs in women (uterus, adnexa) Upper abdomen: • Spleen • Splenic flexure • Transverse colon Position the patient in a Trendelenburg and right-lateral position in order to make the small intestine slide into the right abdomen by gravity (→ p. 24, I). Retract the jejunum to the right hypochondrium below the right transverse colon with an atraumatic grasping forceps (T2). Then place the distal portion of the small intestine in the right iliac fossa along with the cecum.

View of lower abdomen with small bowel and uterus

Uterus Small bowel

Anatomical overview

Spleen Splenic flexure Pancreas Transverse colon Sigmoid colon Rectum

39

IV Nodal points Nodal point 3

Dissecting the lymph nodes and the sigmoid mesentery

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery T4

Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure

T1 T2

T1 T2 T3 T4

Scope – Harmonic® shears Atraumatic grasping forceps

T3

Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum

Elevate the sigmoid to the abdominal wall with an atraumatic grasping forceps (T4) to achieve an excellent exposure of the sigmoid mesentery.

Dissecting the anterior mesorectum

Incise the peritoneum along the right anterior border of the aorta starting from the sacral promontory to the inferior border of the pancreas with Harmonic® shears (T3).

Dividing the rectum

Identify the inferior mesenteric artery and vein (→ p. 73, V-6).

Performing a mini-incision and extracting the rectosigmoid

Then dissect the sigmoid mesentery and the lymph nodes from the retroperitoneal structures close to the aorta with Harmonic® shears (T3). It is important to identify the left ureter, the autonomic preaortic nerve plexus and the iliac vessels running into the pelvis.

Dividing the proximal colon Preparing the anastomosis extra-abdominally Preparing the anastomosis intra-abdominally Anastomosing colon and rectum Verifying the anastomosis Placing a protective stoma Finishing the operation

40

To avoid injuries of the left ureter, the autonomic preaortic nerve plexus and the iliac vessels identify them clearly while separating the sigmoid mesentery (→ p. 71, V-2; p. 74, V-9; V-10; V-11)!

Dissection line in malignant disease Spleen

Sigmoid arteries Sigmoid colon Inferior mesenteric vein Inferior mesenteric artery Dissection line Aorta Pancreas

Incising the peritoneum

Peritoneum

Harmonic® shears

Identifying the inferior mesenteric artery

Inferior mesenteric artery

41

IV Nodal points Nodal point 4

Dividing the inferior mesenteric vessels

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery T4

Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum Dissecting the anterior mesorectum Dividing the rectum Performing a mini-incision and extracting the rectosigmoid Dividing the proximal colon Preparing the anastomosis extra-abdominally Preparing the anastomosis intra-abdominally Anastomosing colon and rectum Verifying the anastomosis Placing a protective stoma

T1 T2

T1 Scope T2 – T3 Harmonic® shears, later clip applier and 6 clips T4 Atraumatic grasping forceps

T3

Isolate the inferior mesenteric artery by removing the surrounding lymph node tissue in a circular fashion with Harmonic® shears (T3) (→ p. 73, V-6). Perform a careful dissection, as the left ureter and the left sympathetic trunk adhere to the posterior aspect of the inferior mesenteric pedicle. Visualize the left ureter and the left sympathetic trunk before isolating and dividing the inferior mesenteric artery to avoid injuring them (→ p. 74, V-8; V-10)!

Place one peripheral clip and two central clips with the clip applier (T3) to facilitate a division of the inferior mesenteric artery 1 cm away from the aorta. Ensure that there is enough space between the central clips and the peripheral clip. Ensure that there is enough space between the central clips and the peripheral clip to avoid slipping of the clips following division of the vessel (→ p. 71, V-2; p. 74, V-12)!

As the left ureter runs adjacent to the origin of the inferior mesenteric artery in the retroperitoneum it is important to visualize the ureter prior to any division. Identify the left ureter prior to any ligature, cauterization or division (→ p. 74, V-10)!

Finishing the operation

Divide the inferior mesenteric artery with Harmonic® shears (T3) under vision between the central clips and the peripheral clip. Ensure that the Harmonic® blade does not come into contact with the clips. Ensure that the Harmonic® blade does not come into contact with the clips to avoid any damage to the blade or to the clips!

Isolate, clip and divide the inferior mesenteric vein below the left colic vein or below the inferior border of the pancreas. Alternative: Seal the inferior mesenteric artery and/or inferior mesenteric vein with an endoscopic linear cutter (vascular cartridge).

42

Clipping the inferior mesenteric artery

Peripheral clip

Inferior mesenteric artery Central Clips

Dividing the inferior mesenteric artery

Peripheral clip Inferior mesenteric artery Central clips

Dividing the inferior mesenteric vein

Inferior mesenteric vein Peripheral clip Central clips

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IV Nodal points Nodal point 5

Mobilizing the sigmoid and the descending colon

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery T4

Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum Dissecting the anterior mesorectum Dividing the rectum Performing a mini-incision and extracting the rectosigmoid

T1 T2

T1 T2 T3 T4

Scope – Harmonic® shears Atraumatic grasping forceps

T3

Use an atraumatic grasping forceps through T4 to move the sigmoid loop medially. Dissect left lateral embryonic adhesions between peritoneum of the abdominal wall and the sigmoid and the descending colon with Harmonic® shears (T3) (→ p. 71, V-1; p. 73, V-7). Dissect in the direction of the splenic flexure in the plane of Gerota's fascia from lateral to medial to connect the two dissection planes. It is important to identify the ureter, the hypogastric nerve structure and the gonadal blood vessels that cross the iliac vessels running into the pelvis.

Dividing the proximal colon Preparing the anastomosis extra-abdominally Preparing the anastomosis intra-abdominally Anastomosing colon and rectum Verifying the anastomosis Placing a protective stoma Finishing the operation

44

Make sure that the left ureter is clearly identified before connecting the two dissection planes and pay attention to the hypogastric nerve structure, the gonadal blood vessels and the iliac vessels in order to avoid injuries (→ p. 71, V-2; p. 73, V-7; p. 74, V-9; V-10; V-11)!

In case of extensive lateral adhesions due to inflammation, perform the dissection from medial to lateral to avoid ureter damage (→ p. 73, V-7).

Dissecting the left lateral embryonic adhesions

Lateral adhesions

Colon

Dissecting in the plane of Gerota's fascia

Gerota's fascia

Identifying the ureter

Ureter

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IV Nodal points Nodal point 6

Mobilizing the splenic flexure

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery

T1 T4 T5 T2

Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum Dissecting the anterior mesorectum Dividing the rectum Performing a mini-incision and extracting the rectosigmoid Dividing the proximal colon Preparing the anastomosis extra-abdominally Preparing the anastomosis intra-abdominally Anastomosing colon and rectum Verifying the anastomosis Placing a protective stoma

T1 T2 T3 T4

Scope Harmonic® shears Atraumatic grasping forceps Atraumatic grasping forceps

T3

To assure a tension-free anastomosis, dissect the splenic flexure and the left third of the transverse colon. Put the patient in the reverse Trendelenburg position to reach the dissection area of the splenic flexure. In an anti-clockwise direction, use Harmonic® shears (T2) to dissect the adhesions of the greater omentum and the splenocolic ligament close to the colonic wall. To avoid injuries to the spleen, make sure to dissect the adhesions of the greater omentum and the splenocolic ligament close to the colonic wall before retracting the splenic flexure medially (→ p. 71, V-1; p. 72, V-3c)!

Use an atraumatic grasping forceps (T4) to smoothly tear the splenic flexure in a mediocaudal direction. Mobilize the transverse colon up to the inferior border of the pancreas with Harmonic® shears (T2) while preserving the vascular supply of the transverse and proximal left colon. Dissect the area of the transverse mesocolon carefully, as it could have adhesions to the pancreas which can result in injuries of the pancreatic tail. It is sometimes difficult to distinguish the pancreatic tail from fat of the transverse colon mesentery.

Finishing the operation Identify the pancreatic tail carefully in order to avoid injuries of the pancreas (→ p. 72, V-3f)!

Alternative: If the patient has a high splenic flexure introduce an additional trocar (T5) above T2 in the left upper abdomen quadrant. Introduce an atraumatic grasping forceps in T4 and keep the greater omentum away. Change Harmonic® shears to T5 and dissect the splenic flexure from this position.

46

Mobilizing the splenic flexure

Spleen

Omental fat

Splenic flexure

Loosening of omental adhesions Omental adhesion

Descending colon

Identifying the pancreatic tail

Spleen

Pancreatic tail

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IV Nodal points Nodal point 7

Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery T4

Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum Dissecting the anterior mesorectum

T1 T2

T1 T2 T3 T4

Scope – Harmonic® shears Atraumatic grasping forceps

T3

Put the patient back into Trendelenburg position (→ p. 24, I). Extend the peritoneal incision caudally and anteriorly from the promontory to the rectovesical or rectouterine pouch with Harmonic® shears (T3). Identify the hypogastric nerves carefully which can be difficult in obese patients.

Dividing the rectum Performing a mini-incision and extracting the rectosigmoid Dividing the proximal colon Preparing the anastomosis extra-abdominally Preparing the anastomosis intra-abdominally Anastomosing colon and rectum Verifying the anastomosis Placing a protective stoma

To avoid injuries of the hypogastric nerves identify them with care (→ p. 74, V-9)!

Separate the lateral and posterior mesorectum cautiously from both sides from the parietal fascia of the pelvis down to the pelvic floor in the avascular tissue layer on Waldeyers' fascia with Harmonic® shears (T3). It is mandatory to resect the complete mesorectum without damaging the mesorectal fascia or the rectal wall. Take care not to injure the rectal wall and the mesorectum. Extract the mesorectum in total to make sure to remove possible existing lymph node metastases (→ p. 72, V-3b; p. 76, V-16)!

Identify again the hypogastric nerves and the left ureter that pass laterally to the dissection plane. Be aware of the presacral venous plexus running on the anterior surface of the sacrum.

Finishing the operation Pay attention to the hypogastric nerves, the left ureter and the presacral venous plexus in order to avoid any injuries (→ p. 71, V-2; p. 74, V-9; V-10)!

Look for a possibly existing medial rectal artery which crosses the dissection plane. Identify a possibly existing medial rectal artery in order to avoid injuries (→ p. 71, V-2)!

If there is a medial rectal artery, coagulate or clip it and divide the artery with Harmonic® shears (T3). Read the instruction manual for the Harmonic® instrument in use carefully and become familiar with the maximum vessel size, which is allowed to coagulate with the Harmonic® instrument in use!

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Anatomical overview of the rectum Sacrum Mesorectum Peritoneum Rectovescial pouch Presacral fascia/Fascia pelvis parietale (Waldeyer) Presacral space Posterior mesorectal fascia Anterior mesorectal fascia (posterior layer of Denonvilliers' fascia) Prerectal space Rectovesical or rectoprostatic fascia (anterior layer of Denonvilliers' fascia) Dissection line

Border lamellae of the small pelvis Presacral fascia/Fascia pelvis parietale (Waldeyer) Presacral space Posterior mesorectal fascia Anterior mesorectal fascia Prerectal space Rectovesical or rectoprostatic fascia Anterior lamella of genitourinary system Fascia diaphragmatis pelvis superior

Dissecting the mesorectum

Mesorectum

Waldeyers' fascia

Left hypogastric nerve

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IV Nodal points Nodal point 8

Dissecting the anterior mesorectum

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery T4

Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum Dissecting the anterior mesorectum Dividing the rectum Performing a mini-incision and extracting the rectosigmoid Dividing the proximal colon Preparing the anastomosis extra-abdominally Preparing the anastomosis intra-abdominally Anastomosing colon and rectum Verifying the anastomosis Placing a protective stoma Finishing the operation

50

T1 T2

T1: T2: T3: T4:

Scope – Harmonic® shears Atraumatic grasping forceps

T3

Incise the rectovesical or rectouterine pouch and dissect the rectum anteriorly and caudally on the posterior surface of Denonvilliers' fascia with Harmonic® shears (T3). It is important not to injure the anterior rectum and mesorectum and to excise the mesorectum en bloc. Take care not to damage the rectal wall and to avoid a coning of the mesorectum in order to perform a radical lymph node dissection (→ p. 72, V-3b; p. 76, V-16)!

As the hypogastric nerves, the seminal vesicles, the prostate and the vagina are running laterally and anteriorly to Denonvilliers' fascia, be careful not to injure Denonvilliers' fascia. Take care not to injure Denonvilliers' fascia, the hypogastric nerves, the seminal vesicles, the prostate and the vagina (→ p. 72, V-3g; p. 74, V-9)!

Incising the rectouterine pouch

Rectouterine pouch

Rectum

Dissecting the anterior mesorectum

Mesorectum

Rectum

Identifying Denonvilliers' fascia

Denonvilliers' fascia

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IV Nodal points Nodal point 9

Dividing the rectum

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery T4

Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum Dissecting the anterior mesorectum Dividing the rectum Performing a mini-incision and extracting the rectosigmoid Dividing the proximal colon

T1 T2

T1 Scope T2 – T3 Endoscopic linear cutter, additional cartridges, if necessary T4 Atraumatic grasping forceps

T3

Place the endoscopic linear cutter (T3) around the rectum at the level of the determined division line perpendicular to the digestive tract. It is important to divide the rectum at least 2 cm below the tumor. Close the endoscopic linear cutter (T3). In case of difficulties closing the cutter, reposition the jaws and grasp less tissue. An accumulation of tissue at the proximal end of the jaws may result in an incomplete staple line. Make sure that there is no accumulated tissue at the proximal end of the jaws of the endoscopic linear cutter to avoid an insufficient staple line leading to anastomotic leakage (→ p. 75, V-13)!

Preparing the anastomosis extra-abdominally

Fire the endoscopic linear cutter (T3).

Preparing the anastomosis intra-abdominally

Open the jaws of the endoscopic linear cutter (T3) and make sure tissue is cleared from the jaws. Then remove the endoscopic linear cutter.

Anastomosing colon and rectum

For a large diameter rectum, place and fire the endoscopic linear cutter again with additional cartridges until the rectum is totally divided.

Verifying the anastomosis Placing a protective stoma Finishing the operation

52

Grasp the cut end of the resected rectosigmoid with an atraumatic grasping forceps (T4) in order to avoid slippage of the rectosigmoid in the abdominal cavity and to facilitate the extraction. Examine the staple line and check for proper blood supply.

Placing the jaws of the endoscopic linear cutter

Rectum Jaws of the endoscopic linear cutter

Opening the endoscopic linear cutter after firing

Rectum Jaws of the endoscopic linear cutter

Examining the staple line

Staple line

Rectum

53

IV Nodal points Nodal point 10

Performing a mini-incision and extracting the rectosigmoid

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery Dividing the inferior mesenteric vessels

T1 T2 T3 T4

Scope – Atraumatic grasping forceps Atraumatic grasping forceps

T4

T1

T2

Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum Dissecting the anterior mesorectum Dividing the rectum Performing a mini-incision and extracting the rectosigmoid Dividing the proximal colon Preparing the anastomosis extra-abdominally Preparing the anastomosis intra-abdominally Anastomosing colon and rectum Verifying the anastomosis Placing a protective stoma Finishing the operation

54

– Scalpel – 2 Roux hooks – Plastic-coated drape – 2 Allis clamps

T3

Use an atraumatic grasping forceps (T3) to grasp the cut end of the resected rectosigmoid that is held by the atraumatic grasping forceps in T4. Remove the T4 atraumatic grasping forceps. Use a scalpel to widen the left lower incision of T2 to an appropriate length for easy extraction of the resected rectosigmoid and remove T2. The incision size depends on the volume of specimen, and patient habitus. Position two Roux hooks in order to leave the incision open. Place a waterproof plastic-coated drape around the incision (7–11 cm of diameter) in order to protect the abdominal wall from bacterial and cellular contamination. Place a plastic-coated drape before extracting the rectosigmoid that contains the tumor in order to avoid spread of tumor cells (→ p. 76, V-16)!

Then pass the resected rectosigmoid through the protected incision with the atraumatic grasping forceps (T3). Grasp the rectosigmoid with two Allis clamps. Alternative: Perform an incision in the suprapubic region (Pfannenstiel incision) for extraction of the resected rectosigmoid.

Skin incision locations for rectosigmoid extraction

Incision at position of T2 Alternative: Pfannenstiel incision

Widening the lower left incision – mini-incision

Mini incision Trocar T2

Extracting the rectosigmoid through a plastic-coated drape

Cut end of rectosigmoid

Plastic-coated drape

55

IV Nodal points Nodal point 11

Dividing the proximal colon

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum Dissecting the anterior mesorectum Dividing the rectum Performing a mini-incision and extracting the rectosigmoid Dividing the proximal colon Preparing the anastomosis extra-abdominally Preparing the anastomosis intra-abdominally Anastomosing colon and rectum

T1 – T3 – T4 – – 2 Overholt clamps – Curved scissors – Sutures for ligatures 2–0 absorbable, polyfilament – Linear cutter

T4

T1

T2 T3

Determine the proximal resection margin, which should be located at least 10 cm above the tumor. Then dissect the sigmoid mesentery in steps by using Overholt clamps and ligatures. Check for proper blood supply and rosy serosa of the sigmoid colon before continuing. If the blood supply is insufficient, divide the colon more proximally. If the anastomosis will be located more than 6 cm from the anocutaneous line, a straight end-to-end-anastomosis or a side-to-end-anastomosis can be performed. If the anastomosis will be located less than 6 cm from the anocutaneous line, creation of a colonic pouch (transverse coloplasty or J-shaped) at the level of the antimesenteric taenia is recommended. To perform a side-to-end-anastomosis transect the sigmoid colon with a linear cutter. Therefore place the linear cutter around the sigmoid colon at the level of the determined division line.

Verifying the anastomosis

Close and fire the linear cutter to dissect the specimen. Then open the jaws of the linear cutter and remove it.

Placing a protective stoma

Examine the staple line and check for proper blood supply.

Finishing the operation

Inspect the resected specimen and check for complete resection.

56

Dividing the sigmoid mesentery

Curved scissors Overholt clamp

Vessel arcade

Checking for proper blood supply

Sigmoid colon

Dissecting the specimen

Linear cutter

Sigmoid colon

57

IV Nodal points Nodal point 12

Preparing the anastomosis extra-abdominally

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum Dissecting the anterior mesorectum Dividing the rectum Performing a mini-incision and extracting the rectosigmoid

T1 – T3 – T4 – – HF electrode or scissors – 2 surgical forceps – Needle holder – Purse-string suture – 2 Allis clamps – Antiseptic solution – Anvil of circular stapler – Absorbable polyfilament suture 2

T4

T1

T2 T3

Incise the distal end of the sigmoid colon between the taenia with a HF electrode or scissors and insert a hand-sewn purse-string suture. After that place two Allis clamps and wash out the lumen of the colon with an antiseptic solution. Introduce the anvil (at least 29 mm in diameter) in the colonic lumen and close the purse-string suture. Replace the prepared colon into the lower abdominal cavity.

Dividing the proximal colon

Close the peritoneum and the abdominal layers by primary closure with an absorbable polyfilament suture.

Preparing the anastomosis extra-abdominally

Close the peritoneum carefully after the procedure, as the peritoneal fluid has been shown to contain viable tumor cells (→ p. 76, V-16)!

Preparing the anastomosis intra-abdominally Anastomosing colon and rectum Verifying the anastomosis Placing a protective stoma Finishing the operation

58

Inserting the purse-string suture

Purse-string suture Sigmoid colon

Introducing the anvil

Anvil

Sigmoid colon

Closing the peritoneum

Peritoneum

59

IV Nodal points Nodal point 13

Preparing the anastomosis intra-abdominally

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery T4

T1

Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum Dissecting the anterior mesorectum Dividing the rectum Performing a mini-incision and extracting the rectosigmoid

T1 Scope T3 Anvil forceps T4 Atraumatic grasping forceps

T2 T3

– Circular stapler

Re-establish the pneumoperitoneum. Then introduce the scope in T1. Before performing the anastomosis be aware that this is the most important step of the procedure and should be performed precisely. Be aware that any mistake could subsequently lead to serious complications (→ p. 75, V-13; V-14; V-15)!

Dividing the proximal colon

With the scope (T1) inspect the descending colon and make sure the proximal colon is not twisted or in spasm and has enough length.

Preparing the anastomosis extra-abdominally

Pay attention that the proximal colon is not twisted or in spasm and has enough length to enable a tension-free anastomosis (→ p. 75, V-14; V-15)!

Preparing the anastomosis intra-abdominally

Put the patient into a steep lithotomy position and perform an atraumatic dilatation of the anus with three lubricated fingers. Then cautiously introduce the circular stapler with smooth rotation through the anus into the rectum. It is important to introduce the circular stapler with caution and not against any resistance.

Anastomosing colon and rectum Verifying the anastomosis Placing a protective stoma Finishing the operation

Introduce the circular stapler cautiously in order to avoid any injury or a perforation of the rectum (→ p. 72, V-3b)!

Determine the perforation location for the trocar shaft, which is optimally placed directly above or under the staple line. Afterwards perforate the rectal stump with the trocar shaft of the circular stapler. Turn the instrument gently while holding the knob. Use the anvil forceps (T3) to facilitate the perforation of the rectal stump.

60

Inspecting the descending colon

Non-twisted descending colon

Perforating the rectal stump

Trocar shaft of circular stapler Staple line

61

IV Nodal points Nodal point 14

Anastomosing colon and rectum

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery T4

T1

Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure

T1 Scope T3 Anvil forceps T4 Atraumatic grasping forceps

T2 T3

– Circular stapler

Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum

Use the anvil forceps (T3) to connect the anvil shaft to the trocar shaft of the circular stapler.

Dissecting the anterior mesorectum

With the scope (T1) re-check the descending colon up to the splenic flexure and make sure that the proximal colon is not twisted or in spasm and has enough length.

Dividing the rectum Performing a mini-incision and extracting the rectosigmoid Dividing the proximal colon Preparing the anastomosis extra-abdominally Preparing the anastomosis intra-abdominally Anastomosing colon and rectum Verifying the anastomosis Placing a protective stoma Finishing the operation

Before approximating colon and rectum make sure that the proximal colon is not twisted or in spasm and has enough length to enable a tension-free anastomosis (→ p. 75, V-14; V-15)!

Pull back the circular stapler gently to increase the amount of tissue that will fall within the circular staple line to prevent anastomotic stenosis. Close the circular stapler by turning the knob in a clockwise direction so that the colon and rectum will be approximated. Wait at least 15 seconds for optimal tissue compression. Before firing make sure that no neighboring organs are incarcerated (e.g. vagina, adnexa). In women retract the posterior vaginal wall and perform a digital vaginal examination in case of doubt. Be aware that there is a high risk of incarcerating neighboring organs (e.g. vagina, adnexa) while performing the anastomosis!

Fire the device by squeezing the firing handle in one motion. Make sure that the firing handle makes contact to the shaft (plastic-to-plastic). A crunch should be heard and felt, indicating a proper staple formation, cutting of tissue and that the firing cycle has been fully completed. Then open the circular stapler by rotating the knob anti-clockwise by ½ to ¾. Note that these instructions apply for the Proximate® ILS circular stapler (Ethicon Endo-Surgery). Before using another type of circular stapler read the instruction manual carefully!

Turn the instrument 90° to each side to make sure that the anvil is loosened completely from the surrounding tissue. Withdraw it through the anus, while pressing the pelvic floor cranially to prevent tension to the anastomosis when removing the stapler head. Smoothly rotate the circular stapler while it is being extracted.

62

Connecting the anvil shaft with the trocar shaft

Trocar shaft

Anvil shaft

Anastomosing colon and rectum Anastomosis

Sigmoid colon

63

IV Nodal points Nodal point 15

Verifying the anastomosis

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery T4

Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum Dissecting the anterior mesorectum Dividing the rectum Performing a mini-incision and extracting the rectosigmoid

T1 Scope T3 Suction-irrigation instrument, later atraumatic grasping forceps T4 Atraumatic grasping forceps, if necessary

T1

T2 T3

– 100-ml syringe – Silicone drain, if indicated

First check for circular appearance of the amputated rectal and colonic rings (“doughnuts”). Two complete “doughnuts” should be seen. Then verify the anastomosis with an insufflation test. Fill the pelvis with water using the suction-irrigation instrument (T3) and carefully insufflate about 100 ml air via the rectum using a syringe, while the proximal colon is closed with an atraumatic grasping forceps (T3). Look for bubbles, indicating an incomplete anastomosis (→ p. 75, V-13). If in doubt, redo the insufflation test.

Dividing the proximal colon Preparing the anastomosis extra-abdominally

It is mandatory to verify the completeness of the anastomosis before terminating the surgery to be sure that there is no anastomotic leakage (→ p. 75, V-13)!

Preparing the anastomosis intra-abdominally

Depending on the intraoperative site, insert a silicone drain in the pelvis with an atraumatic grasping forceps (T3).

Anastomosing colon and rectum Verifying the anastomosis Placing a protective stoma Finishing the operation

64

Alternative: Instead of an insufflation test an endoscopic transanal evaluation of the anastomosis can be performed.

Checking of rectal and colonic rings

Colonic ring

Rectal ring

Looking for bubbles Uterus

Pelvis with water

Sigmoid colon

65

IV Nodal points Nodal point 16

Placing a protective stoma

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum Dissecting the anterior mesorectum Dividing the rectum Performing a mini-incision and extracting the rectosigmoid Dividing the proximal colon Preparing the anastomosis extra-abdominally Preparing the anastomosis intra-abdominally Anastomosing colon and rectum Verifying the anastomosis

T1 Scope T3 Atraumatic grasping forceps T4 Atraumatic grasping forceps – Scalpel – Silicone drain – HF electrode – Mounted swab – Antiseptic solution – Surgical forceps – Needle holder – Curved scissors – Sutures for ileostomy 3–0 absorbable, polyfilament

Place a protective stoma, if the anastomosis is located less than 5 cm from the anocutaneous line or if a neoadjuvant radio- or chemotherapy has been performed or in case of a positive insufflation test (→ p. 75, V-13). If no stoma is needed, proceed with nodal point 17. Select a suitable bowel segment for ileostomy with two atraumatic grasping forceps (T3, T4) under laparoscopic guidance. Then grasp the selected bowel segment with an atraumatic grasping forceps (T4). Widen the right upper incision of T4 to a length of 2–4 cm with a scalpel or use the preoperatively designated stoma site. For extraction of the selected bowel segment, hold it with the atraumatic grasping forceps (T4) while pulling it out together with the trocar. Secure the ileal loop outside the abdomen with a silicone drain. Open the ileal loop with a HF electrode and clean the mucosa with an antiseptic solution using a mounted swab. Then fix the ileal opening of the afferent and efferent loop in the skin incision around its circumference with interrupted sutures. Test the patency of the ileostomy with one finger.

Placing a protective stoma Finishing the operation

66

Alternative: If there are difficulties placing an ileostomy, perform a transverse colostomy instead.

Selecting a suitable bowel segment for ileostomy

Trocar T4

Atraumatic grasping forceps

Ileum

Placing the protective stoma

Ileostomy

Silicone drain

Protective stoma

Ileostomy

67

IV Nodal points Nodal point 17

Finishing the operation

Exploring the abdominal cavity Identifying the anatomical landmarks Dissecting the lymph nodes and the sigmoid mesentery Dividing the inferior mesenteric vessels Mobilizing the sigmoid and the descending colon Mobilizing the splenic flexure

T1 Scope T3 – T4 Stoma, if necessary – Fascia sutures 2 absorbable, polyfilament – Subcutaneous sutures 3–0 absorbable, polyfilament, if necessary – Skin sutures 4–0 or 5–0 absorbable, monofilament – Dressings – Stoma bag, if necessary

T4

T1

T2 T3

Identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum

Remove working trocars T3 and T4 carefully under vision if still in place.

Dissecting the anterior mesorectum

Remove the scope and open the valve on the trocar for the scope (T1) for deflation. Then remove the trocar for the scope.

Dividing the rectum Performing a mini-incision and extracting the rectosigmoid Dividing the proximal colon Preparing the anastomosis extra-abdominally Preparing the anastomosis intra-abdominally Anastomosing colon and rectum Verifying the anastomosis Placing a protective stoma Finishing the operation

68

Control the trocar incisions with regard to possible bleeding (→ p. 71, V-2).

Close the fascia where 10/12 mm trocars have been introduced and if the trocar for the scope was located in the midline. Then close all incisions and cover the wounds with sterile dressings following disinfection. If there is a stoma, apply a stoma bag.

Closing of incisions

Trocar incision

Dressings

Dressings

Stoma bag

69

Management of difficult situations and complications

V

Management of difficult situations and complications In principle, the decision to proceed to laparotomy should be made too early rather than too late! Convert immediately if the situation cannot be controlled laparoscopically!

Adhesions

1

Blood vessel injuries

2

Organ injuries

3

Separate adhesions using Harmonic® shears or bipolar scissors as close to the abdominal wall as possible so as not to injure any organs.

a) Diffuse bleeding / bleeding from minor vessels Coagulate the bleeding vessel with Harmonic® shears. If this does not terminate the bleeding, place a clip on the bleeding vessel. b) Bleeding from major vessels If large vessels such as the aorta, portal vein or vena cava are injured during the operation, open the abdomen immediately for vascular surgical treatment of the injury!

In case of injuries in which the extent cannot be determined with certainty, open the abdominal cavity for open management of the injury!

a) Greater omentum Injury of the greater omentum can occur when the Veress needle is inserted too deeply and/or without elevation of the abdominal wall. All the safety tests may be positive so that the complication can be identified only when the trocar for the scope and the scope are inserted. Manage any bleeding that occurs with Harmonic® shears. If, as a result of the insertion, the greater omentum is inflated like a tent, withdraw the trocar for the scope as far as the peritoneal margin and tap the abdomen with the flat hand. The omentum should then separate from the inside of the abdominal wall and collapse.

71

V

Management of difficult situations and complications

b) Bowel Bowel injuries are the most frequent organ injuries in minimally invasive surgery. They are usually caused by instruments, especially by the Veress needle. Undissected adhesions can also be a cause of bowel injuries. Manage bowel injuries by laparoscopic oversewing. If sufficient closure of the injury is not guaranteed, perform laparotomy. Irrigate the operating field gently with an antiseptic solution. As bowel resections always require a systemic antibiotic (single dose), the patient should already have antibiotic coverage (→ p. 21, I). c) Spleen The splenic capsule is usually injured by traction when the colon is in close proximity to the spleen. Reduction of splenic injury risk can be achieved by • early (posterior) dissection of the splenocolic ligament before medialization of the splenic flexure and • dissection of the flexure close to the colonic wall. Bleeding from the spleen is ideally treated with Harmonic® shears. Alternatively, apply hemostyptic. Laparotomy is the exception. d) Stomach If the gastric wall has been injured or perforated, oversew the affected area. If necessary, perform an intra-operative gastroscopy. e) Liver Manage minor bleeding from the liver by brief compression with a swab, point contact with Harmonic® shears. In the case of major hemorrhage which can still be controlled laparoscopically, apply a hemostyptic. f ) Pancreas Manage minor bleeding from the pancreas by brief compression with a swab, point contact with Harmonic® shears. In the case of major hemorrhage which can still be controlled laparoscopically, apply a hemostyptic. g) Prostate, seminal vesicles, vagina Prostate, seminal vesicles and vagina, respectively, can be injured during anterior dissection of the mesorectum. Reduction of injury risk can be achieved through identification of these organs during detachment. Bleeding from these organs is ideally treated with Harmonic® shears. Alternatively, apply a hemostyptic. If the vaginal wall has been injured or perforated, oversew the affected area.

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Preperitoneal air emphysema

4

a) Veress needle If emphysema has occurred because of an incorrectly placed needle, remove the needle and reinsert it as described above (→ p. 30, II c). Ensure particularly that the angle of insertion is vertical and that the abdominal wall is lifted. b) Trocar Withdrawing a trocar so far that its opening comes to lie in front of the peritoneum is another cause of emphysema. In this case, under vision push the trocar back into the correct position through the existing incision.

Losing a swab in the abdominal cavity

5

After losing a swab, fix the trocar in its last position and, under vision, look for the swab where it was lost, using an atraumatic grasping forceps. Do not change the patient's position, and do not irrigate the abdominal cavity!

If necessary, search for the swab with the C-arm or perform a laparotomy to retrieve the swab.

Difficulties when identifying the inferior mesenteric artery

6

In some patients identifying the inferior mesenteric artery can be difficult from the medial approach. To pull the inferior mesenteric artery pedicle away from the surface of the aorta, retract the sigmoid colon strongly out of the pelvis, then retract it anterolaterally. Feel the sacral promontory with laparoscopic instruments and start the dissection from there to enter the avascular plane posterior to the inferior mesenteric artery and move cranially up to the inferior mesenteric artery.

Extensive adhesions of the sigmoid to the abdominal wall

7

Inflammation of the sigmoid in diverticulitis often results in extensive adhesions of the sigmoid to the abdominal wall. In this case, lateral mobilization can be difficult and there is a danger of injuring the ureter. Perform the dissection and the connection of the two dissection planes from medial to lateral to avoid ureter damage.

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V

Management of difficult situations and complications

8

Injury of the left sympathetic trunk The left sympathetic trunk adheres to the posterior aspect of the inferior mesenteric pedicle and consequently may be transected when the inferior mesenteric artery is divided. Visualize the trunk and sweep it away in a posterior direction. Make the initial mesenteric window wide enough to achieve adequate visualization. Do not skeletonize the surface of the aorta and its bifurcation!

9

Injury of the autonomic nerve plexus The autonomic nerve plexus is situated anterior to the aortic bifurcation. Then the nerves run medially and posteriorly to the ureters and laterally along the pelvic wall. One part travels towards the anterior portion of Denonvilliers' fascia. Identify the autonomic nerve plexus carefully during the dissection of the sigmoid mesentery and the mesorectum!

10

Injury of the left ureter With a medial approach, it can easily happen that the dissection is too deep and the left ureter is injured. If the ureter is injured during mobilization or devascularization of the left colon, make a mini-incision in the left lateral abdomen immediately above the area of ureteral injury. The ureter may then be stented and repaired under direct vision. Following repair of the ureter, the mini-incision is used for specimen extraction, resection and completion of the anastomosis.

11

Injury of the iliac vessels If the iliac vessels are injured during dissection of the sigmoid mesentery perform laparoscopic compression of the vessels and make a mini-incision in the left lower abdomen immediately above the iliac vessel injury. Repair the injured vessels under direct vision.

12

Difficulties when clipping a) Incorrectly positioned clips If an incorrectly positioned clip is the cause of bleeding from the inferior mesenteric artery, take care of the bleeding by compressing the vessel using an atraumatic grasping forceps, and then place a new clip at the correct position or ligate the vessel.

74

b) Insecurely positioned clips If the lumen of the structure to be clipped is too big for complete closure, use a vascular stapler. c) Lost and slipped clips In case a previously placed clip has slipped, first of all replace it. Then find the slipped clip and remove it from the abdominal cavity.

Positive anastomotic leak test

13

If a leak test is positive, the anastomosis must be repaired or revised depending on the size of the leak. If the site of leakage is small and visible and is located on the anterior aspect of the colon, try to place laparoscopic sutures for repair and repeat the leak test. Form a protective stoma. If the site of the leakage is difficult to identify, perform intra-operative sigmoidoscopy to locate the leak and to determine its size. If the leak is too big to repair, dissect and divide the rectum distal to the anastomosis and redo the anastomosis. In cases where laparoscopic repair is not feasible, make a small laparotomy (either a Pfannenstiel incision or low midline incision) and redo the anastomosis with an open technique.

Rotation of the left colon

14

Spastic colon

15

During laparoscopic total mesorectal excision, in rare cases, the proximal segment of the colon can be rotated when the specimen is being removed through a small incision. Rotation of the left colon will cause tension on the colonic anastomosis. Therefore, it is advisable to inspect the position of the colon after the colon has been replaced into the abdomen and before the stapler is fired. If the colon is rotated after the anastomosis is performed, it is mandatory that the colon is derotated and the anastomosis is redone.

If the sigmoid colon is in spasm, inject scopolamine. If the colon is still in spasm, either perform the anastomosis higher (descending colon) or fashion a side-to-end-anastomosis (Baker anastomosis), a transverse coloplasty pouch or a colonic J-pouch. Be aware that a colonic pouch always requires complete mobilization of the left colon!

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V

Management of difficult situations and complications

16

Spread of tumor cells In general, the majority of rectal tumors are not prone to port-site recurrences. The following surgical techniques have been shown to prevent spread of tumor cells: • Avoid significant CO2 leakage around the trocar site by making an adequate skin incision before placing the trocar. If CO2 leakage is present, control the leak with a transfascial suture with a suture passer. Make sure the suture is held securely with a hemostat during the procedure. • Minimize trauma at the trocar site by ensuring that the port is placed at a right angle to the peritoneal side of the trocar site. • Fix the trocars with sutures to prevent trocar dislocation. • Avoid direct handling of the tumor with the instruments. • Use a wound protector (waterproof plastic-coated drape) while extracting the tumorous specimen. • Close the peritoneum carefully after the procedure, as peritoneal fluid has been shown to contain viable tumor cells.

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Anatomical variations VI

Anatomical variations Vascular variations Inferior mesenteric artery, left colic artery and sigmoid arteries branch off from the same point

Sigmoid arteries branch off from left colic artery

77

VI Anatomical variations

Vascular variations Sigmoid arteries branch off from the superior rectal artery

The medial rectal arteries branch off from the internal iliac arteries

These branches are infrequent, unilateral in 25% of the cases, and occasionally multiple. The size of these arteries is variable, most often they are inversely proportional to the size of the superior rectal artery. There can be one or more branches of the medial rectal arteries found in the lateral portion of the mesorectum.

78

Vascular variations Inferior mesenteric vein running into the splenomesenteric trunk

Inferior mesenteric vein running into the splenoportal confluence

79

VI Anatomical variations

Vascular variations Inferior mesenteric vein running into the superior mesenteric vein

80

Sigmoid position variations Short and straight sigmoid, obliquely protracted into the pelvis Left colic ( splenic) flexure Transverse colon Descending colon

Sigmoid colon

Rectum

The sigmoid colon forming a loop to the right

Left colic ( splenic) flexure Transverse colon Descending colon Sigmoid colon

Rectum

81

VI Anatomical variations

Sigmoid position variations The sigmoid colon ascending highly

Left colic ( splenic) flexure Transverse colon Descending colon Sigmoid colon

Rectum

82

Appendices

Sample operation note Bibliography List of key words

83

Appendices

Sample operation note

Date:

Operating surgeon:

Patient's name:

Assistant:

Operation diagnosis: Rectal carcinoma

Scrub nurse:

Operation: Laparoscopic assisted, low-anterior rectum resection with total mesorectal excision (TME), diverting loop-ileostomy

Anesthetist:

Patient under general anesthesia, placed in lithotomy position. Skin disinfection and sterile draping, followed by a left, supraumbilical skin incision. The Veress needle is inserted transmuscular through the incision and the usual safety tests are carried out. Pneumoperitoneum is then established. A 10 mm trocar is placed through this incision. The camera is brought into the abdomen and a 360° view reveals no signs of peritoneal spreading or liver metastases. Under direct visualization a 10 mm and 12 mm trocar are placed in the right upper respectively right lower quadrant and a third 10 mm trocar is placed in the left lower quadrant. The patient is then placed in steep Trendelenburg position with the left side tipped up. The sigmoid colon is retracted anterior and laterally. Then the peritoneum is incised medially from the colon in the region of the inferior mesenteric artery and vein until the promontory. The inferior mesenteric artery, left ureter, the autonomic preaortic nerve plexus and the iliac vessels are identified. The inferior mesenteric artery is dissected free from the surrounding tissue and clipped with two central clips and one distal clip. It is divided with Harmonic® shears. The inferior mesenteric vein is identified, clipped, and divided at the level of the inferior border of the pancreas. The sigmoid colon is then retracted medially and mobilized with the left colon along the lateral peritoneal reflection. The left ureter, the gonadal blood vessels and the hypogastric nerve are identified and preserved. The patient is placed in the reverse Trendelenburg position and the splenic flexure is then mobilized with division of the splenocolic ligament. After the patient is placed in steep Trendelenburg position again the pelvic dissection is undertaken. The peritoneal incision is extended caudally and anteriorly until the rectovesical pouch. The rectum mesentery is dissected free from Waldeyers' fascia down to the pelvic floor while protecting the hypogastric nerves and the left ureter keeping the mesorectal fascia intact. The lateral attachments to the rectum are also divided. On the anterior side of the rectum the rectovesical pouch is incised and the rectum is dissected along Denonvillier's fascia preserving the seminal vesicles. Anterior mobilization is continued below the prostate gland. The rectum is divided approximately 2 cm distal from the tumor with the endoscopic linear cutter. The resected rectum is then secured with an atraumatic grasping forceps. The incision in the left lower quadrant is lengthened and the distal end of the specimen is brought out under protection of the incision with a plastic-coated drape. The remaining sigmoid mesentery is divided extra-corporeal. The proximal colon is divided with a linear cutter in a well-perfused region. The specimen is approximately 30 cm in length. The distal end of the sigmoid colon is incised between the taenia and a hand-sewn purse-string suture is made. Following disinfection of the colonic lumen, the anvil for a 33 mm circular stapler is brought into the proximal bowel and secured with the purse-string suture. The bowel is then dropped back into the abdominal cavity and the peritoneum and abdominal layers of the incision is closed.

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Sample operation note The pneumoperitoneum is re-established. The pelvis is irrigated and there are no signs of bleeding. The anus is then manually dilated to 3 finger widths and the shaft of the circular stapler is introduced transanally. The rectal stump is perforated in the ideal position above the staple line. The distal colon reaches easily down into the pelvis. The distal colon is then oriented so that there are no twists. The anvil is connected to the trocar shaft of the circular stapler. Anastomosis is performed without any difficulties. The anastomosis is tension-free and well-perfused. The “doughnuts” from the anastomosis are complete. The insufflation test does not show any leakage. For the protective stoma the terminal ileum is identified and a loop is secured with an atraumatic grasping forceps. The incision in the right upper quadrant is lengthened for the diverting ileostomy. The loop of ileum is then brought through the abdominal wall. The ileostomy is then performed. The working trocars are removed under vision. After removal of the trocar for the scope, fascia and skin of the incisions are closed. A stoma bag is applied to the ileostomy and the incisions are dressed with sterile dressings.

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List of key words Abdomen 66, 71, 75, 84 – left lateral 74 – lower 38, 39, 74 – patient's 26 – quadrant 32, 46, 84, 85 – right 38 – upper 30, 32, 36, 38, 46 Abdominal – cavity 28, 30, 31, 34, 36, 52, 58, 71, 73, 75, 84 – intra 30, 31 – layers 30, 58, 84 – wall 29–32, 40, 44, 54, 71, 73, 85 Adhesions 20, 28, 30, 31, 36, 46, 71, 72 – left lateral embryonic 44, 45 – omental 46, 47 – sigmoid 44, 45, 73 Adnexa 36–38, 62 Anastomosis 26, 56, 60, 62–64, 66, 74, 75, 85 – Baker 75 – end-to-end 56 – extra-abdominally 34, 58 – incomplete 64 – insufflation test 64, 66, 85 – intra-abdominally 34, 60 – positive leak test 75 – side-to-end 56, 75 – stenosis 62 – tension-free 46, 60, 62, 85 – verifying 34, 64 Anatomical – landmarks 24, 34, 38 – overview 39, 49 – variations 20, 77–82 Antibiotic prophylaxis 21, 72 Anus 60, 62, 85 Anvil 58, 59, 62, 84, 85 – forceps 22, 60, 62 – shaft 62, 63 Aorta 40–42, 73, 74 – injuries 30, 71 Approach 20 – lateral 44 – medial 44, 73, 74 Artery(ies) – aorta 30, 40–42, 71, 73, 74 – iliac 30 – inferior mesenteric 38, 40–43, 73, 74, 77, 78, 84

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– internal iliac 78 – left colic 77, 78 – medial rectal 48, 78 – sigmoid 41, 77, 78 – superior rectal 77, 78 Autonomic nerve plexus 40, 74, 84 Axillary nerve 24 Bladder 36, 37 – emptying 24 Bleeding 20, 36, 68, 71, 72, 74, 85 – diffuse 71 – from major vessels 71 – from minor vessels 71 C-arm 73 Carpenter effect 17 Catheter – transurethral 24 Cecum 36–38 Circular stapler 22, 60, 62 – anvil 58, 59, 62, 84, 85 – trocar shaft 60–62, 85 Clip(s) 22, 42, 48, 71, 74, 84 – applier 22, 42 – central 42, 43, 84 – incorrectly positioned 74 – insecurely positioned 75 – lost and slipped 75 – peripheral 42, 43, 84 Clipping 43 – difficulties 74 Colon 21, 45, 56, 58, 62, 72, 74, 75, 84 – anastomosing 34, 62, 63 – ascending 36 – descending 34, 36, 44, 47, 60–62, 81, 82, 75 – mesentery 46 – proximal 34, 46, 56, 60, 62, 64, 75, 84 – right flexure 36 – rotation 75 – sigmoid 36–39, 41, 56–59, 63, 65, 73, 75, 81, 82, 84 – spastic 60, 62, 75 – splenic flexure 34, 36, 38, 39, 44, 46, 47, 62, 72, 81, 82, 84 – transverse 36, 38, 39, 46, 81, 82 Colonic – lumen 58, 84 – pouch 56, 75 – rings 64, 65 – wall 46, 72

Colostomy – transverse 66 Complications 25, 60 – management 20, 71–76 Diagnostic laparoscopy 32, 37 Diaphanoscopy 32 Disinfection – bowel 66, 72 – colonic lumen 58, 84 – skin 19, 25, 68, 84 Doughnuts 64, 85 Dressings 21, 68, 69, 85 Emptying the bladder 24 Equipment – setting up 19, 25 Fascia 28–30, 48, 49, 85 – Denonvilliers' 49–51, 74, 84 – Gerota's 44, 45 – mesorectal 48, 49, 84 – sutures 21, 68 – Waldeyers' 48, 49, 84 Gastroscopy 72 Gonadal blood vessels 44, 84 Greater omentum 31, 36, 46, 71 Harmonic® shears 22, 36, 38, 40– 42, 44, 46, 48, 50, 71, 72, 84 Hasson – method 19, 21, 27, 28 – trocar 21, 28 Hemostyptic 72 Heparin – low-molecular-weight 21 Hernial orifice 36 Hypogastric nerve(s) 34, 48–50, 84 – structure 44 Ideomotion 17 Ileostomy 66, 67, 84, 85 Ileum 36, 66, 67, 85 Iliac – artery 30, 78 – fossa 32, 38 – internal artery 78 – spine 25, 32 – vessels 40, 44, 74, 84 Imagining movement 17 Incision 36, 54, 66, 68, 69, 73, 75, 84, 85 – mini- 34, 54, 55, 74 – peritoneal 28, 48, 84 – Pfannenstiel 54, 55, 75 – skin 28–32, 55, 66, 76, 84, 85 – trocar 36, 68, 69

List of key words Inferior mesenteric – artery 38, 40–43, 73, 74, 77, 78, 84 – pedicle 42, 74 – vein 40–43, 79, 80, 84 – vessels 34, 42 Injury(ies) 20, 32 – aorta 30 – autonomic nerve plexus 40, 74 – axillary nerve 24 – bladder 24 – blood vessels 29–32, 44, 48, 71 – Denonvilliers' fascia 50 – hypogastric nerve(s) 44, 48, 50 – iliac vessels 30, 40, 44, 74 – left sympathetic trunk 42, 74 – left ureter 40, 42, 44, 48, 73, 74 – mesorectum 48, 50 – organ 29, 31, 36, 46, 48, 50, 60, 71 – Veress needle 30 Instruments 20, 22, 32, 36, 72, 76 – additional 19, 22, 23 – basic 19, 21, 23 – dissecting 22 – for first access 21 – for total mesorectal excision 22, 23 Insufflation test 64, 66, 85 Jejunum 36, 38 Laparotomy 21, 71–73, 75 Left colic – artery 77, 78 – flexure 81, 82 – vein 42, 79, 80 Left sympathetic trunk 42, 74 Linear cutter 22, 56, 57, 84 – endoscopic 22, 42, 52, 53, 84 Lithotomy position 24, 26, 60, 84 Liver 36, 37, 72, 84 Losing a swab in the abdominal cavity 73 Lymph nodes 34, 40, 42, 48, 50 Magical number seven 20 Mental training 17–19 Mesocolon 46 Mesorectum 48–51, 74 – anterior 34, 50, 51, 72 – lateral 34, 48, 78 – posterior 34, 48 Mini-incision 34, 54, 55, 74 Nerve(s)

– autonomic nerve plexus 40, 74, 84 – axillary 24 – hypogastric 34, 44, 48–50, 84 – left sympathetic trunk 42, 74 Neutral electrode 19, 25 Nodal point(s) 17–20, 24, 34, 66 – anastomosing colon and rectum 34, 62 – dissecting the anterior mesorectum 34, 50 – dissecting the lymph nodes and the sigmoid mesentery 34, 40 – dividing the inferior mesenteric vessels 34, 42 – dividing the proximal colon 34, 56 – dividing the rectum 34, 52 – exploring the abdominal cavity 34, 36 – finishing the operation 34, 68 – identifying the anatomical landmarks 34, 38 – identifying the hypogastric nerves and dissecting the lateral and posterior mesorectum 34, 48 – mobilizing the sigmoid and the descending colon 34, 44 – mobilizing the splenic flexure 34, 46 – overview 35 – performing a mini-incision and extracting the rectosigmoid 34, 54 – placing a protective stoma 34, 66 – preparing the anastomosis extraabdominally 34, 58 – preparing the anastomosis intraabdominally 34, 60 – verifying the anastomosis 34, 64 Operating team 19, 26 – camera assistant 26, 30, 84 – monitor 26 – position 26 – scrub nurse 26, 84 – second assistent 26 – surgeon 26, 32, 84 Operation note 20, 84, 85 Organ injuries 29–31, 71, 72 – bowel 72 – greater omentum 46, 71 – liver 72

– pancreas 46, 72 – prostate 50, 72 – seminal vesicles 50, 72 – spleen 46, 72 – stomach 72 – vagina 50, 62, 72 Pancreas 39, 41 – inferior border 40, 42, 46, 84 – injuries 46, 72 – tail 46, 47 Pelvis 36, 40, 44, 48, 49, 64, 65, 73, 81, 85 Peritoneum 21, 28, 29, 40, 41, 44, 49, 58, 59, 73, 76, 84 Plastic-coated drape 22, 54, 55, 76, 84 Pneumoperitoneum 60, 84, 85 – creating 19, 27–31 Port site recurrences 76 Positioning of the operating team 19, 26 Positioning of the patient 19, 24 – arms 24 – legs 24 – lithotomy position 24, 26, 60, 84 – reverse Trendelenburg 46, 84 – shoulder support 24 – Trendelenburg 24, 38, 48, 84 – vacuum mattress 24 Positive anastomotic leak test 75 Pouch – colonic 56, 75 – coloplasty 75 – of Douglas 36 – J-shaped colonic 75 – rectouterine 48–51 – rectovesical 48–50, 84 Preparations for the operation 19, 21–26 Preperitoneal air emphysema 73 – trocar 73 – Veress needle 73 Presacral venous plexus 48 Promontory 40, 48, 73, 84 Prostate 50, 72, 84 Purse-string suture 21, 22, 28, 58, 59, 84 Rectal – medial artery 48, 78 – rings 64, 65 – stump 26, 60, 61, 85

95

Appendices

List of key words – superior artery 77, 78 – superior vein 79, 80 – tumor 76, 84 – wall 48, 50 Rectosigmoid 34, 52, 54, 55 – junction 38 Rectum 34, 38, 39, 49–53, 60, 62–64, 75, 81, 82, 84 Reducer cap 22, 32 Retroperitoneum 42 Rotation of the left colon 75 Sacrum 48, 49 Scope 22, 29, 32, 36, 38, 40, 42, 44, 46, 48, 50, 52, 54, 60, 62, 64, 66, 68, 71 Seminal vesicles 50, 72, 84 Shaving 19, 25 Sigmoid 40, 44, 73, 81 – adhesions 44, 45, 73 – arteries 41, 77, 78 – colon 36–39, 41, 56–59, 63, 65, 73, 75, 81, 82, 84 – loop 44, 81 – mesentery 34, 40, 56, 57, 74, 84 – position variations 81, 82 – veins 79, 80 Sigmoidoscopy – intra-operative 75 – standard rigid 21 Silicone drain 22, 64, 66, 67 Skin incision 28–32, 55, 66, 76, 84 – Pfannenstiel 54, 55, 75 Small intestine 38 Specimen 54, 56, 57, 74–76, 84 Spleen 36–39, 41, 46, 47, 72 Splenic flexure 34, 36, 38, 39, 44, 46, 47, 62, 72, 81, 82, 84 – high 46 Splenocolic ligament 46, 72, 84 Splenomesenteric trunk 79 Splenoportal confluence 79 Spread of tumor cells 36, 54, 76 Sterile draping 19, 25, 84 Stoma – bag 22, 68, 69, 85 – protective 21, 22, 32, 34, 66–68, 75, 85 Stomach 36, 37, 72 Superior – mesenteric vein 79, 80 – rectal artery 77, 78 – rectal vein 79, 80

96

Suture(s) 21, 58, 75, 76 – colon 21 – fascia 21, 68, 76 – for ligatures 21, 56 – for protective stoma/ileostomy 22, 66 – peritoneum 21, 58 – purse-string 21, 22, 28, 58, 59, 84 – retaining 21, 28 – skin 21, 68 – subcutaneous 21, 68 Swab 21, 22, 66, 72 – losing 73 Test – aspiration 30 – injection 30 – insufflation 64, 66, 85 – manometer 31 – positive anastomotic leak 75 – rotation 31 – safety 30, 31, 71, 84 – slurp 31 Thromboprophylaxis 21 Trocar(s) 22, 55, 66–68, 73, 76 – for the scope 19, 22, 27–33, 68, 71, 85 – Hasson 21, 28 – incisions 36, 68, 69 – placing 19, 27–33, 46, 76, 84 – positions 19, 20, 33 – reducer cap 22, 32 – removal 28, 30, 68, 71, 85 – with optical obturator 19, 21, 22, 27, 29, 31 – working 19, 22, 32, 33, 68, 85 Tumor 36, 52, 54, 56, 76, 84 – cells 36, 54, 58, 76 Ureter 45, 73 – left 40, 42, 44, 48, 74, 84 Uterus 36–39, 65 Vagina 50, 62, 72 Vaginal wall 62, 72 Variations – anatomical 20, 77–82 – sigmoid position 81, 82 – vascular 77– 80 Vein(s) – inferior mesenteric 40–43, 79, 80, 84 – left colic 42, 79, 80 – portal 71 – presacral venous plexus 48

– sigmoid 79, 80 – splenic 79, 80 – superior mesenteric 79, 80 – superior rectal 79, 80 Veress needle 19, 21, 27, 30, 31, 71–73, 84 – tests 30, 31 Vessel(s) 32, 74 – arcade 57 – gonadal blood 44, 84 – iliac 40, 44, 74, 84 – inferior mesenteric 34, 42 – injuries 29–31, 71 X-ray contrast strip 21