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Leroy J, Ntourakis D, Marescaux J. Transanal Total Mesorectal Excision (TME) with mechanical side-to-end coloanal anastomosis in a female patient. Epublication: WeBSurg.com, Feb 2013;13(2). URL: http://www.websurg.com/ref/doi-vd01en3903.htm

J Leroy (France), D Ntourakis (France), J Marescaux (France)

English - 18'33''
February 2013

The authors demonstrate how to perform a transanal total mesorectal excision using the TEO® device (Karl Storz) as well as a hemorrhoid stapler in a stepwise manner.
This pure transanal approach was performed because of a suspicion of a T2 lesion on a large villous rectal tumor at 10/12 cm from the anal verge. The originality of the technique is shown with exceptional quality views during the posterior and lateral mobilization of the root of the sigmoid mesocolon. A mechanical side-to-end pure transanal coloanal anastomosis is also perfectly shown.

Keywords: Transanal Total Mesorectal Excision, TME, mechanical side-to-end coloanal anastomosis, female patient

00'16'' Introduction
The objective of this film is to show the technique used to resect the rectum along with its meso in a transanal fashion in a woman in her sixties. Her previous history includes recent constipation and hemorrhage for which the work-up was evocative of a suspicion of T2N0 lesion both on MRI and on endoscopic ultrasound. However, biopsies did not evidence any cancer cell over a wide villous area situated at about 10 to 12cm from the anal verge. As can be seen on these images, there is an enormous villous area that requires an extensive excision removing at least the meso to analyze the lymph nodes, and especially so as there is a suspicion of T2 lesion.
01'16'' Exclusion of distal rectum
The first surgical step consists in excluding the distal rectum. To do so, once the Transanal Endoscopic Operating (TEO®) instrumentation manufactured by Karl Storz has been introduced, a purse-string is fashioned using a non-absorbable suture, grasping the mucosal wall in its entire thickness. Knots are tied extracorporeally in order to achieve a good quality purse-string. Once the distal stump has been cleansed, still through the Transanal Endoscopic Operating (TEO®) System, the Ligasure™ Advance™ vessel-sealing device is used. This instrument allows for monopolar dissection by means of computer-controlled energy both using minimal electric monopolar current and bipolar cautery by means of the Ligasure™ system.
02'44'' Opening of retro- and peri-mesorectal plane
The posterior part of the rectum is opened underneath the purse-string in order to enter the presacral space as can be seen here in these images. Entrance is made underneath the mesorectum and posteriorly to it. In order to complete the dissection laterally and anteriorly, the anterior part of the rectal stump is half-opened and one can progressively see the freeing of the space under carbon dioxide pressure insufflated through the TEO®. Laterally to the right, one can progressively see nerve branches heading to the rectum. Tension is placed on these branches originating from lateral pelvic floors. The incision is completed anteriorly and to the left of the patient to reach the previous incision. Dissection is carried on the left part, and progressively contact is made with Denonvilliers’ aponeurosis by following a lateral course. Here, one can see the division of a nerve branch heading to the rectum and originating from the pelvic plexus. Dissection is pursued by following the medial part of the lateral pelvic fascia to search for visceral nerve branches and also branches of the inferior hypogastric plexus. It is recommended not to rapidly open Douglas’s pouch. Denonvilliers’ aponeurosis is followed and attention must be paid to preserve it as much as possible since carbon dioxide pressure will help with the dissection of the entire space.
Once Denonvilliers’ aponeurosis has been identified, one can clearly see Douglas’s pouch, which comes into sight under carbon dioxide pressure. Dissection is continued in order to free the posterior surface of the mesorectum as much as possible to reach the sacral promontory. It is necessary to stay anteriorly to the presacral fascia. This space is found once again very progressively during the dissection. It is sometimes necessary to mobilize more anteriorly in order to cranially retract the rectum and open the posterior rectal space.
Here, one can see that dissection is carried on anteriorly. The rectum may be retracted cephalad.
06'52'' Opening of Douglas’s pouch and division of mesosigmoid root
Once the posterior dissection has been sufficiently performed, Douglas’s pouch can be opened as can be seen at this time of the procedure. The rectum can be retracted into the abdominal cavity. This maneuver is facilitated by the Trendelenburg position of the patient placed in a gynecological position. The Trendelenburg position is exaggerated in order to retain the small bowel loops above the promontory as performed in open surgery or in laparoscopic surgery. Once the rectum has been placed in a recurved position into the abdominal cavity, dissection can be pursued cranially to enter the retroperitoneal space. From then onwards, dissection is performed in contact with the plexus, coming very close to the hypogastric nerve plexus, left and right branch on the other side. Caution must be taken during this dissection and the parietalization of the plexus can progressively be seen. Here the abdominal cavity and the root of the sigmoid mesocolon are clearly visible caudally at the level of the promontory. This dissection is also visible thanks to energy devices such as the Ligasure™ Advance™ system. Dissection is safe and clearly visible, and all the more so, as a 4mm scope is used, hence providing an excellent view at the level of the abdominal cavity.
The use of a High-Definition camera also helps to provide excellent visualization. One can progressively see that the root of the sigmoid mesocolon will be freed to the right and to the left, and the danger for nerve roots can be anticipated at this level. The superior hypogastric trunk is visible here. The plexus is progressively parietalized.

At that moment, the operation progresses upwards, towards the retroperitoneal space, by detaching the sigmoid mesocolon from the retroperitoneal fascia, which merges with the opposite side at its middle part. The freeing is performed step by step, by working solely within the retroperitoneal space. Luckily, the loops can be maintained within the upper part of the abdominal cavity in this patient, but mobilization is performed within the retroperitoneal space, by parietalizing the branches of the hypogastric plexus. The sigmoid mesocolon is freed from its attachments laterally in order to perform an anastomosis at the level of the landmark stitch at the top of the sigmoid loop, a stitch which had been made earlier, after choosing this bowel segment.
12'06'' Mobilization of proximal sigmoid mesocolon
Mobilization is continued laterally, proceeding towards the left parietocolic gutter, continuing the dissection within the retroperitoneal space. At this moment of the procedure, no intra-abdominal port has been used. A mere Veress needle has been used in order to control intra-abdominal pressure. Insufflation is performed by the TEO® instrumentation. The dissection is continued, and the pneumatization of the retroperitoneal space facilitates the mobilization of the sigmoid mesocolon. The mobilization is carried on by progressing along the ureter, and we get closer to the root of the sigmoid mesocolon, and especially to the inferior mesenteric vessels, which are divided by means of the Ligasure™ vessel-sealing device. The ligature is performed distally after the origin of the splenic artery. The vein has been divided at the same time. Once the maneuver has been completed, the whole package should be exteriorized transanally. The exteriorization is significant.
14'01'' Coloanal side-to-end anastomosis with hemorrhoid stapler
The future anastomotic area has been identified and shall be prepared. Preparation is achieved by dividing the meso, and by introducing the anvil of a 33mm EEA™ hemorrhoid stapler (by Covidien) equipped with a long shaft, which will facilitate the mechanical side-to-end anastomosis.
Preparation of the anastomosis is completed by securing the exteriorization opening site. Distal closure of the colon is performed through this entry site and the distal colon attached to the anvil is reintroduced into the abdominal cavity.
As soon as a new TEO-type system has been introduced, lavage is performed and hemostasis is controlled. The plexuses are controlled as can be seen here. Hemostasis may be completed prior to the fashioning of a purse-string onto the distal stump, onto the margins of the rectal stump. The purse-string is performed using a non-absorbable 2/0 suture (Ethibond®) using an extracorporeal knotting technique. Before closing this purse-string, the anvil’s shaft will be retrieved as can be seen here. This maneuver may be facilitated by tying a thread on its extremity or by placing a small catheter, which will extend the anvil’s shaft.
The purse-string is closed onto the shaft, and under the control of retractors, one must make sure that the purse-string is securely closed. The anvil is placed paying attention to properly retract the sphincter, and making sure not to staple and divide it inadvertently. One can see the final result of this anastomosis. Hemostasis is controlled once again. Doughnuts will be controlled too. The side-to-end anastomosis is clearly visible here.
17'55'' Conclusions
Postoperative findings demonstrated the presence of a benign villous tumor. A precancerous tumor is ruled out. An oncologic TME was confirmed on the specimen and 24 negative nodes were removed.
The patient is discharged on postoperative day 5. First bowel movement return was on day 1 and return to normal bowel habits was on day 3.
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Joël Leroy 

Dimitrios Ntourakis 

Jacques Marescaux