JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 00, Number 00, 2017 Technical Report

ª Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2016.0633

Laparoscopic Rectal Dissection Assisted

by Transanal Endoluminal Videoendoscopy
Through a Blunt Tip Trocar

Emanuele Asti, MD, Andrea Lovece, MD, and Luigi Bonavina, MD

Abstract

Background and Aims: Laparoscopic resection is a well-established approach for colorectal cancer surgery. In
patients with rectal cancer treated by neoadjuvant chemoradiotherapy, it may be difficult to identify a clear
safety margin for endostapling and subsequent anastomosis. We designed an innovative technical approach to
assist colorectal anastomosis in these patients.
Technique: A four-trocar laparoscopic approach is used. After exploration of the abdominal cavity, the left
colic flexure is completely mobilized. Using a medial to lateral approach, the inferior mesenteric artery and vein
are divided between clips, and the left colon proximal to the tumor is transected with a linear stapler. A total
mesorectal excision is performed. At this point, if the free margin distal to the tumor site cannot be clearly
identified, a blunt tip trocar (BTT, 10 mm; Medtronic, Minneapolis, MN) is inserted into the anus and the
proximal foam sponge is secured to the anal verge to avoid displacement and gas leakage. Under low flow rate
gas insufflation, a 0 scope inserted into the trocar allows a clear observation of the distal margin of the lesion
and guides the low rectal laparoscopic dissection and the precise placement of the stapler. The BTT is then
removed to perform the transanal colorectal anastomosis; at the end of the procedure, the BTT can be reinserted
to check the anastomosis for bleeding and leakage.
Results: We used this novel technique on 3 patients who underwent neoadjuvant therapy for T3 rectal cancer. In
all of them, identification of the distal tumor margin was difficult at laparoscopy. All surgical procedures were
safely completed and resulted in R0 resection. The average length of stay was 6 days. All patients were free from
recurrences at 1 year follow-up.
Conclusion: Endoluminal videoendoscopy through a transanal BTT is a useful ancillary technique to achieve a
safe free margin during low rectal resection.

Keywords: rectal carcinoma, total mesorectal excision, laparoscopic anterior resection, colorectal anastomosis

Introduction Laparoscopy has become the preferred approach to rectal

cancer in high-volume centers, but intraoperative evaluation
H igh-resolution magnetic resonance imaging has
been shown to be superior to computed tomography and
endoluminal ultrasound for staging rectal tumors, especially
of the distal tumor margin remains difficult, especially in the
presence of a narrow pelvis or in obese patients. We describe
the feasibility of transanal endoluminal videoendoscopy
those originating from the upper rectum.1 Gold standard
through a blunt tip trocar (BTT) as a useful ancillary technique
therapy for these patients is radical surgical resection with an
to achieve a safe free margin during low rectal resection.
oncological free margin of the rectal stump through a total
mesorectal excision (TME), with or without neoadjuvant
radiochemotherapy.2 However, precise assessment of the Materials and Methods
tumor distance from the anal sphincter is challenging and this Mechanical bowel preparation with polyethylene glycol is
could increase the difficulties of safely performing both the given the day before surgery. Cefazolin 2 g and metronida-
resection and the anastomosis. zole 500 mg are injected intravenously at the induction of

Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan Medical School, Milano, Italy.

1
2 ASTI ET AL.
FIG. 1. Placement of the transanal blunt tip trocar (a) and introduction of the 0 scope (b).
anesthesia and 4 hours later. The patient is placed in the
lithotomy position, and both surgeons stand on her or his right
side. The pneumoperitoneum is generally induced with a
Veress needle. Four trocars (two 12 mm and two 5 mm) are
placed, and a 10 mm 30 scope is used. After exploration of
the abdominal cavity, the left colic flexure is completely
mobilized. The left colon dissection is conducted from me-
dial to lateral with a high vascular ligation (Hem-o-lok;
Teleflex, Wayne, PA). The left colon proximal to the tumor is
transected with a 60 mm Endo GIA Tri-staple purple car-
tridge (Medtronic, Minneapolis, MN).
Once the laparoscopic rectal dissection is completed, if the
free margin distal to the tumor is not clearly identified, an
additional laparoscopic tower is required to perform the
transanal procedure. After rectal wash out, a BTT (10 mm;
Medtronic) is used to access the anus (Fig. 1). The blunt tip is
completely atraumatic and, once passed the sphincter, its in-
ternal flap valve can be inflated to permit gas insufflation
inside the rectum. The proximal foam sponge is secured to the
anal verge to avoid displacement and gas leakage. The BTT is
connected to the laparoscopic insufflator using low pressure
and rate of insufflation (3–5 mmHg, 5 L/min). A 10 mm 0
scope is inserted into the trocar to allow observation of the
distal margin of the lesion (Fig. 2) and to guide the laparo-
scopic phase of low rectal dissection and stapler placement
(Fig. 3). The lower rectum is transected with a 60 mm
Endo GIA stapler. The specimen is retrieved through a
FIG. 2. Intraoperative videoendoscopic evaluation of the
distal tumor margin (inset) before low rectal stapling.
Pfannestiel incision and is inspected to verify the surgical
margins. The BTT is removed to perform the transanal anas-
tomosis by using a 29 mm curved intraluminal stapler (Ethicon,
Cincinnati, OH). The anastomotic rings are checked and the
BTT is reinserted to check for bleeding and leakage (Fig. 4). No
loop ileostomy is performed in patients with normal anasto-
motic findings.
Results
We used this novel technique on 3 patients, 2 males and 1
female with a mean age of 68 years and a body mass index of
28. All of them had undergone neoadjuvant chemoradiation
(45 Gy) therapy for a T3 carcinoma of the upper mid rectum.
After neoadjuvant therapy, the mean distance of the lower
margin of the tumor was 9 cm from the anus.
Identification of the distal tumor margin was difficult
during laparoscopy in all patients. All surgical procedures
were completed safely and resulted in R0 resection. The
average length of stay was 6 days. Patients were all free from
recurrences at 1 year follow-up.
Discussion
Rectal adenocarcinoma accounts for about 28% of large
bowel tumors. Over the past three decades, management of
this disease has become multidisciplinary and improvements
in patient survival have been encouraging. Neoadjuvant
FIG. 3. Endoluminal appearance of rectal closure (inset)
at the site of stapler application.
TRANSANAL ENDOLUMINAL VIDEOENDOSCOPY
FIG. 4. Endoluminal control of the colorectal anastomosis.
therapy is effective, although a complete pathological re-
sponse without residual tumor cells has been reported in up to
16% of patients randomly assigned to chemoradiation ther-
apy in phase 3 trials. Therefore, owing to the difficulty to
accurately predict a complete pathological response, radical
surgical resection should still be offered and observation
reserved to patients who are unfit or refuse surgery.3
TME has been validated as the safest and most effective
surgical treatment of this type of carcinoma.4 Current clinical
evidence shows that laparoscopic TME can be performed
with equivalent oncological outcomes compared with open
TME by surgeons with necessary technical expertise and
experience.5 According to the last guidelines published by the
Japanese Society for Cancer of the Colon and Rectum in 2015,
a TME or TSME (tumor-specific mesorectal excision) rep-
resent the standard of care when preoperative staging indi-
cates a greater than cT1 cancer located distal to the peritoneal
reflection.6 A 2 cm distal mural margin has been shown to be
adequate for most rectal cancers when combined with TME;
for cancers located at or below the mesorectal margin, a 1 cm
distal mural margin is acceptable. In fact, distal intra-
mural spread is found beyond 1 cm in less than 10% of rectal
cancers.3,7 Occasionally, in patients with narrow pelvis, bulky
tumors, previous pelvic surgery, and morbid obesity, it may be
difficult to adhere to these principles. In laparoscopic surgery,
the limited stapler articulation and the angle of stapler entry
3
may represent an additional risk factor that may reduce the
chance to achieve a safe free margin.
Endoluminal videoendoscopy through a transanal BTT is a
useful ancillary technique to achieve a safe free margin during
low rectal resection. The procedure is simple, safe, not ex-
pensive, and allows more surgical precision especially in pa-
tients with narrow pelvis and in those with very distal lesions.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Luigi Bonavina, MD
Division of Surgery
IRCCS Policlinico San Donato
Piazza Malan 1
San Donato Milanese
Milano 20097
Italy
E-mail: luigi.bonavina@unimi.it