Laparoscopic Low Anterior Resection
John Migaly
Harvey G. Moore
INDICATIONS/CONTRAINDICATIONS
The indications for a laparoscopic low anterior resection (LAR) are primarily for middle to low tumors of the rectum. Middle rectal tumors are defined as tumors between 5 and 10 cm from the anal verge and distal tumors are those tumors 5 cm or less from the anal verge.
Absolute contraindications for a laparoscopic LAR include systemic sepsis, unstable hemodynamics, and feculent peritonitis.
The decision to proceed with a laparoscopic approach to LAR is dependent on many factors that are surgeon specific and should guide the choice of operative approach. First, the surgeon should be an expert in the concept and performance of a total mesorectal excision (TME), because the conduct and quality of the TME is one of the more important determinants of oncologic outcome. Second, the surgeon should be an expert in advanced laparoscopy for colon resection, because the laparoscopic LAR is one of the more challenging resections in colon and rectal surgery.
Contingent on experience, a multidisciplinary approach should be strongly considered for patients in whom the tumor is felt to involve contiguous organs such as the vagina, uterus, bladder, and prostate, and in bulky tumors or in tumors that threaten the lateral resection margin.
Also contingent on expertise, potential relative contraindications to a laparoscopic LAR include morbid obesity, cirrhosis, coagulopathy, severe cardiac or pulmonary disease, intra-abdominal abscess, or phlegmon. Prior surgery is not a contraindication for laparoscopic LAR, and, when possible, a diagnostic laparoscopy should be performed to evaluate the extent of intra-abdominal adhesions and feasibility of a laparoscopic approach, including the anticipated time commitment required for the adhesiolysis.
PREOPERATIVE PLANNING
The essential principles involved in the preoperative planning of a laparoscopic LAR begin at the first visit. Complete history and physical examination are the mainstays of any evaluation, but, more importantly, the precise characterization of the tumor during digital rectal examination and direct visualization during proctoscopy and magnetic resonance imaging (MRI) are necessities. Digital rectal examination identifies tumor location and allows the surgeon to evaluate sphincter tone and function. There are no data to support the routine use of anal manometry to preoperatively evaluate the sphincter; thus, function and anal manometry is not any more useful than is physical examination. Proctoscopy is useful in characterizing the location of the tumor in relation to the upper portion of the anorectal ring and allows the surgeon to judge whether reconstruction is possible. In addition, the evaluation of the T and N stage allow for the addition of preoperative multimodality neoadjuvant therapy where appropriate. Current recommendations advocate the use of neoadjuvant chemoradiotherapy for T3 tumors with threatened margins or T4 tumors.
A complete blood count, chemistry assessment, liver function tests, and carcinoembryonic antigen are routinely collected. Computed tomography (CT) with contrast of the chest, abdomen, and pelvis complete the metastatic evaluation, possibly with a proton emission tomography (PET) scan. Patients should meet with the ostomy nurse in advance of surgery, to better prepare for and acclimate to the idea of a temporary diverting loop ileostomy (DLI) or possibly a permanent colostomy. Patients are marked for a stoma in advance of surgery. Internal medicine evaluation is scheduled before surgery, with pulmonary, cardiac, renal, or anesthesia assessment included, as necessary.
We routinely use a cathartic/purgative preoperative bowel preparation for surgery in addition to oral neomycin and erythromycin. Current population-based literature demonstrates that the addition of preoperative oral antibiotics reduces the rate of surgical site infection (SSI) and readmission.
Patients are given a carbohydrate drink immediately before surgery and a single dose of intravenous (IV) ertapenem before the incision is made. Heparin 5,000 U is subcutaneously administered immediately before intubation.
The authors also utilize goal-directed intraoperative fluid therapy to try to maintain ideal or maximal stroke volume while minimizing fluid resuscitation via esophageal Doppler or various other commercially available noninvasive hemodynamic monitoring devices.
SURGERY
The room setup, equipment, and personnel are essential to the success of this procedure. Three monitors are optimal for this procedure; one monitor should be over the patient’s right shoulder, the second over the left shoulder, and the third near the left foot. Once the ports are placed, both the assistant and the surgeon stand to the patient’s right side, with the assistant standing above the surgeon while controlling the laparoscope and assisting via the left-sided ports. It is usually unnecessary to have an additional assistant with this setup.
Positioning
The patient is placed in the supine position; and after intubation, the patient is placed into the low lithotomy position with both arms tucked. The knees should be no higher than the shoulders to minimize the potential for interference with the instruments during splenic flexure mobilization. The perineal area and buttocks should overhang the edge of the bed by about 3 inches so that access to the perineum and anus is not obstructed and so the stapler can be easily angulated upward or downward. The chest is secured to the bed to allow for the extreme Trendelenburg and lateral tilt required during a laparoscopic LAR.
Conduct of Procedure
After a bladder catheter is placed, the abdomen is prepped and draped in the usual sterile manner, a Veress needle is placed in the left upper quadrant, and the abdomen is insufflated with CO2. After achieving pneumoperitoneum, the Veress needle is replaced with a 5-mm port. Diagnostic laparoscopy is then performed to ensure that there is no evidence of peritoneal carcinomatosis, liver metastasis, or other factors that may alter the operative plan. After exploration, the following ports are placed under direct laparoscopic visualization: a supraumbilical 12-mm trocar, a 5-mm left iliac fossa trocar, a 5-mm right upper quadrant port, and a 12-mm right iliac fossa trocar. The 5-mm camera is usually upsized to a 10-mm, 30-degree laparoscope because the 10-mm laparoscope provides a better quality image and requires fewer camera exchanges.
The sigmoid colon is placed on tension such that the inferior mesenteric artery (IMA) is clearly identified down to its origin. Electrocautery is used to incise the investing layer at the root of the rectosigmoid mesentery. The mesentery is scored at a point just above the sacral promontory but beneath the superior rectal artery and the incision is taken toward the root of the IMA. The loose areolar plane between the underside of the sigmoid mesentery and the retroperitoneum is identified and the dissection proceeds laterally with the goal of identifying the left ureter and the left gonadal vessels. The origin of the IMA is skeletonized and the ureter is once again identified before performing a high ligation of the IMA. The inferior mesenteric vein (IMV) is then ligated proximal to any branch point. The high ligation of the IMA and the IMV is necessary not only from an oncologic perspective but also to ensure that the left colon conduit can reach easily into the pelvis for a tension-free anastomosis.
The dissection is then continued underneath the sigmoid and the left colon mesentery until the left abdominal sidewall is encountered. The left/sigmoid colon is displaced and the white line of Toldt (now purple in color) easily taken with the scissors or an energy device.
The next task is to perform a complete laparoscopic mobilization of the splenic flexure. The lesser sac is entered and the splenic flexure is mobilized from the transverse colon side and from the left gutter. Attention is then turned toward the rectal dissection.
Rectal Dissection
The assistant carefully retracts the rectosigmoid junction toward the abdominal wall and slightly leftward. The operating surgeon retracts the rectum upward and toward the pubic symphysis to accentuate
the plane between the presacral fascia and the fascia propria of the rectum; this plane is referred to as “the holy plane.” Posteriorly, the left and right hypogastric nerves are identified and kept out of harm’s way. The loose areolar fibers are posteriorly divided, identically in the manner of a TME, past the tip of the coccyx, dividing Waldeyer’s fascia until the superior portion of the levators are encountered. The lateral stalks are divided in the same manner down to the pelvic floor. Anteriorly, the plane between the rectum and the seminal vesicles/prostate or vagina must be carefully dissected so as not to injure the prostate/vagina or the sexual function controlling nerves that lie adjacent to Denonvilliers’ fascia. The rectum must be anteriorly freed down to the pelvic floor so that a stapler can be used to transect the rectum flush with or even distal to the levators. The rectum is carefully retracted upward out of the pelvis and leftward, and then a laparoscopic bowel stapler is brought in through the right iliac fossa 12-mm trocar and articulated so that the angle between the staple line and rectum is as close to 90 degrees as possible. If the pelvis is not wide enough to accommodate a 60-mm stapler, a 45-mm- or 30-mm-long stapler can be used. The stapler is advanced across the rectum as far as possible and is then fired. It is rare that the rectum can be completely transected with one staple fire; however, minimizing the number of fires will minimize the number of crossing staple lines and subsequently the likelihood of a staple line leak. Once the rectum is transected, the specimen is exteriorized through any one of a number of incisions such as a periumbilical incision, a left lower quadrant incision, or from the site that will be used for the ileostomy. After extracting the specimen, the colon is divided proximally at the sigmoid colon/left colon junction. Usually, if the exteriorized left colon can reach the pubic symphysis, there is sufficient length for a low colorectal anastomosis. Indocyanine green (ICG) perfusion assessment can be used to help verify blood supply.
the plane between the presacral fascia and the fascia propria of the rectum; this plane is referred to as “the holy plane.” Posteriorly, the left and right hypogastric nerves are identified and kept out of harm’s way. The loose areolar fibers are posteriorly divided, identically in the manner of a TME, past the tip of the coccyx, dividing Waldeyer’s fascia until the superior portion of the levators are encountered. The lateral stalks are divided in the same manner down to the pelvic floor. Anteriorly, the plane between the rectum and the seminal vesicles/prostate or vagina must be carefully dissected so as not to injure the prostate/vagina or the sexual function controlling nerves that lie adjacent to Denonvilliers’ fascia. The rectum must be anteriorly freed down to the pelvic floor so that a stapler can be used to transect the rectum flush with or even distal to the levators. The rectum is carefully retracted upward out of the pelvis and leftward, and then a laparoscopic bowel stapler is brought in through the right iliac fossa 12-mm trocar and articulated so that the angle between the staple line and rectum is as close to 90 degrees as possible. If the pelvis is not wide enough to accommodate a 60-mm stapler, a 45-mm- or 30-mm-long stapler can be used. The stapler is advanced across the rectum as far as possible and is then fired. It is rare that the rectum can be completely transected with one staple fire; however, minimizing the number of fires will minimize the number of crossing staple lines and subsequently the likelihood of a staple line leak. Once the rectum is transected, the specimen is exteriorized through any one of a number of incisions such as a periumbilical incision, a left lower quadrant incision, or from the site that will be used for the ileostomy. After extracting the specimen, the colon is divided proximally at the sigmoid colon/left colon junction. Usually, if the exteriorized left colon can reach the pubic symphysis, there is sufficient length for a low colorectal anastomosis. Indocyanine green (ICG) perfusion assessment can be used to help verify blood supply.
A purse string is placed at the open end of the left colon and the anvil of the circular stapler is placed into the colon and secured with the purse string. The colon is reduced back into the abdomen and the abdomen is reinsufflated. The colon is grasped and extreme care is taken to ensure that the colon and mesentery are not twisted. An anvil grasper is used to lower the anvil into the pelvis. The assistant then transanally passes the stapler and engages it with the trocar under direct laparoscopic visualization. In female patients care must be taken to exclude the posterior wall of the vagina as the stapler is closed; a vaginal examination is helpful.
The stapler is then fired and the anastomotic donuts are examined for completeness. The pelvis is then filled with irrigant such that the anastomosis is under the water level. The colon proximal to the anastomosis is then occluded, pushing it against the sacral promontory, and the assistant insufflates the rectum using the rigid proctoscope or flexible sigmoidoscopy. In case of a positive air leak, many a time the air leak can be transanally repaired. ICG perfusion assessment can be performed before and/or after firing the circular stapler.
The creation of an ileostomy is recommended for patients who have had neoadjuvant chemoradiotherapy. Under laparoscopic visualization, an ileostomy is created by bringing out a loop of terminal ileum approximately 25-40 cm proximal to the ileocecal valve.
POSTOPERATIVE CARE
All patients undergoing open and laparoscopic colon and rectal resection at Duke University Medical Center (DUMC) follow a defined enhanced recovery after surgery (ERAS) protocol that emphasizes preoperative education, optimization of premorbid conditions and nutritional status, minimal preoperative fasting and carbohydrate loading immediately before surgery, goal-directed intraoperative fluid management, use of thoracic epidural analgesia, early initiation of oral diet, and early mobilization. The Duke Enhanced Recovery Program was based initially on the principles presented by the Enhanced Recovery After Surgery (ERAS) Society guidelines for elective rectal/pelvic surgery. The Duke colorectal ERAS protocol is summarized in Table 14-1.
Following laparoscopic LAR, initial pain control is achieved with epidural analgesia. Intraoperatively placed orogastric tubes are removed at the conclusion of the procedure, and surgical drains are not routinely used. Patients are offered an oral ad libitum diet (postsurgical bland) starting 4 hours after surgery. Oral nutritional supplements may be added when clinically indicated. All patients receive multimodality prophylaxis against postoperative nausea and vomiting with antiemetic medications. Patients are encouraged to be out of bed for 2 hours on the day of surgery and for 6 hours on each successive postoperative day. Transurethral bladder catheters are typically removed on the morning of postoperative day 1, regardless of whether an epidural catheter is in place. Other adjuncts to minimize postoperative ileus include routine use of the peripherally acting µ-opioid receptor antagonist alvimopan (Entereg), judicious use of oral laxatives, and chewing gum. Once patients are tolerating
PO, their epidural catheters are “paused” and they undergo a trial of PO pain medication. Patients whose pain is adequately controlled with PO pain medication have their epidural catheters removed. Adjunct analgesics including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and Neurontin are utilized to minimize the requirement for PO narcotics. Patients receive deep venous thromboembolism (VTE) prophylaxis before, during, and after surgery with low-molecular-weight heparin (LMWH). All colorectal cancer patients undergoing major abdominal/pelvic surgery are discharged with LMWH for a total of 28 postoperative days.
PO, their epidural catheters are “paused” and they undergo a trial of PO pain medication. Patients whose pain is adequately controlled with PO pain medication have their epidural catheters removed. Adjunct analgesics including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and Neurontin are utilized to minimize the requirement for PO narcotics. Patients receive deep venous thromboembolism (VTE) prophylaxis before, during, and after surgery with low-molecular-weight heparin (LMWH). All colorectal cancer patients undergoing major abdominal/pelvic surgery are discharged with LMWH for a total of 28 postoperative days.
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