Transanal approach for intersphincteric resection of rectal cancer in a patient with a huge prostatic hypertrophy
- 1.7k Downloads
The gold standard of surgical technique for rectal cancer is total mesorectal excision (TME). Laparoscopic TME has been proven to provide surgical safety and oncological outcomes equivalent to open TME. However, dissection of the lower rectum has some inherent difficulties related to a narrow pelvic space. The challenge of TME in the lower rectum was confirmed by the Colorectal Cancer Laparoscopic or Open Resection (COLOR) II trial showing a 9% positive circumferential margin (CRM) rate in laparoscopic TME and a 22% positive CRM rate in open TME. Recently, transanal TME has attracted intense attention as a promising alternative to laparoscopic TME. In this video article, we show the performance of a transanal approach for intersphincteric resection (ISR) of rectal cancer in a patient with a huge prostatic hypertrophy.
KeywordsTransanal approach Total mesorectal excision Intersphincteric resection Rectal cancer Prostatic hypertrophy
The gold standard of surgical technique for rectal cancer is total mesorectal excision (TME) . Laparoscopic TME has been proven to provide surgical safety and oncological outcomes equivalent to open TME [2, 3]. However, dissection of the lower rectum has some inherent difficulties related to a narrow pelvic space. The challenge of TME in the lower rectum was confirmed by the Colorectal Cancer Laparoscopic or Open Resection (COLOR) II trial showing a 9% positive circumferential margin (CRM) rate in laparoscopic TME and a 22% positive CRM rate in open TME . Recently, transanal TME has attracted intense attention as a promising alternative to laparoscopic TME [4, 5, 6, 7, 8]. In this video article, we show the performance of a transanal approach for intersphincteric resection (ISR) of rectal cancer in a patient with a huge prostatic hypertrophy.
First, vascular division and mobilization of the left colon were performed laparoscopically. The transabdominal approach was continued until the anterior dissection of the rectum became difficult due to a huge prostatic hypertrophy. Next, the circumferential rectal incision and subsequent intersphincteric dissection were performed under direct vision to enable attachment of a single port device (GelPoint Mini; Applied Medical). After closure of the anal orifice, the GelPoint Mini was placed to start the transanal approach. Posterior side of the rectum was first dissected until the transanal approach was connected to the dissection layer made by the transabdominal approach. The dissection procedure was extended to the lateral side. Bilateral pelvic splanchnic nerves were identified at the 5 and 7 o’clock positions. At the anterior side, the proper dissection layer cannot be easily identified because of the perineal body and the enlarged prostate. Once the dissection plane between the rectum and the prostate could be identified, it was relatively easy to continue along the same plane. The assistance provided by the laparoscopic approach was useful to determine the appropriate dissection line in the transanal approach.
Transanal TME is not well-established technically, but it has potential advantages, including superior visualization, facilitation of TME of the lower rectum, and shorter surgical time and less morbidity [4, 5, 6, 7, 8]. The factors that can make transanal TME a preferred approach are (1) male sex, (2) very low location (less than 12 cm from the anal verge), (3) narrow and deep pelvis, (4) visceral obesity (BMI > 30 kg/m2), (5) prostatic hypertrophy, (6) large tumor (>4 cm in diameter), (7) distorted tissue planes due to preoperative radiotherapy, and (8) impalpable, low primary tumor . The hybrid approach composed of both transanal and conventional laparoscopic TME can be an especially appropriate choice for difficult cases, such as a huge tumor occupied within a very narrow pelvic space. In this case, extremely huge prostatic hypertrophy made it difficult to determine the appropriate dissection line of TME, especially on the anterior side of the rectum. Transanal TME with the assistance of the conventional laparoscopic approach is very useful to identify the correct TME plane for rectal cancer patients with prostatic hypertrophy.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interests.
Research involving human participants and/or animals
For this type of study, formal consent is not required.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of the journal.
Supplementary material 1 (MP4 96006 kb)
- 2.Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der Pas MH, de Lange-de Klerk ES, Lacy AM, Bemelman WA, Andersson J, Angenete E, Rosenberg J, Fuerst A, Haglind E, COLOR II Study Group (2015) A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 372:1324–1332CrossRefPubMedGoogle Scholar
- 3.Jeong SY, Park JW, Nam BH, Kim S, Kang SB, Lim SB, Choi HS, Kim DW, Chang HJ, Kim DY, Jung KH, Kim TY, Kang GH, Chie EK, Kim SY, Sohn DK, Kim DH, Kim JS, Lee HS, Kim JH, Oh JH (2014) Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 15:767–774CrossRefPubMedGoogle Scholar
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.