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A New Laparoscopic Surgical Procedure to Achieve Sufficient Mesorectal Excision in Upper Rectal Cancer

A New Laparoscopic Surgical Procedure to Achieve Sufficient Mesorectal Excision in Upper Rectal... Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2011, Article ID 708439, 4 pages doi:10.1155/2011/708439 Clinical Study A New Laparoscopic Surgical Procedure to Achieve Sufficient Mesorectal Excision in Upper Rectal Cancer Seiji Ohigashi, Takashi Taketa, Kazuki Sudo, Hironori Shiozaki, and Hisashi Onodera Department of Gastroenterological Surgery, St. Luke’s International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo 104-8560, Japan Correspondence should be addressed to Seiji Ohigashi, ohigashiseiji@ab.auone-net.jp Received 2 May 2011; Accepted 22 August 2011 Academic Editor: C. H. Yip Copyright © 2011 Seiji Ohigashi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. Mesorectal excision corresponding to the location of a tumor, termed tumor-specific mesorectal excision (TSME), is commonly performed for resection of upper rectal cancer. We devised a new laparoscopic procedure for sufficient TSME with rectal transection followed by mesorectal excision. Operative Technique. After mobilization of the sigmoid colon and ligation of inferior mesenteric vessels, we dissected the mesorectum along the layer of the planned total mesorectal excision. The rectal wall was carefully separated from the mesorectum at the appropriate anal side from the tumor. After the rectum was isolated and transected using an endoscopic linear stapler, the rectal stump drew immediately toward the anal side, enabling the mesorectum to be identified clearly. In this way, sufficient TSME can be performed easily and accurately. This technique has been successfully conducted on 19 patients. Conclusion. This laparoscopic technique is a feasible and reliable procedure for achieving sufficient TSME. 1. Introduction difficult to perform and the dissection line is likely to be in zigzags. Of course, TSME shifting toward the oral side Total mesorectal excision (TME) is recognized as an ex- from the starting line is inappropriate and should be strictly tremely important surgical technique for the prevention avoided in order to prevent local recurrence (Figure 1). of localrecurrenceofrectalcancer[1–3]. On the other To overcome these difficulties, we have introduced a hand, TME is not necessarily applicable in every case of technique to transect the rectum before resection of the rectal cancer: for upper rectal cancer, mesorectal excision for mesorectum during conventional open surgery [10]. This limited lengths of 5 cm from a tumor toward the anal side is technique assures an adequate distance between the tumor widely conducted, and this method is reportedly associated and resected stump on the anal side and sufficient TSME cor- with adequate rates of cure [4, 5]. This technique is referred responding appropriately to the T-stage of the tumor. This to as partial mesorectal excision (PME), but rather should be technique is also applicable to the laparoscopic approach, whichwereporthere. called tumor-specific mesorectal excision (TSME) reflecting its correspondence to the localization or T-stage of the tumor [5]. In a narrow pelvic cavity, performing sufficient TSME 2. Operative Technique is difficult, and there is a risk of local recurrence when TSME is inadequate [6–8]. Whether surgery is performed The most appropriate indication for this technique is the laparoscopically or via a conventional open route, TSME is treatment of upper rectal cancer of stage T-2 and higher. usually conducted obliquely to the anal side, introducing Here, we report details of the techniques used in our laparo- unnecessary rectal resection which may lead to postoperative scopic procedure. bowel malfunction [9]. In addition, there is of the potential A trocar for laparoscope was inserted just beneath the for slippage of the TSME between the right and left sides umbilicus; we used four working ports as shown in Figure 2. of the rectal wall. Particularly in the case of laparoscopic Surgery commenced with mobilization of the sigmoid colon surgery, straight and sharp dissection of the mesorectum is with a preference for the approach from median to lateral 2 International Journal of Surgical Oncology Rectum Mesorectum Figure 1: (A) Ideal resection line of the mesorectum. (B) and (C) Figure 3: Separation of the rectum is started from the right side of Inappropriate resection line of the mesorectum. the mesorectum. rectum, Denonvilliers’ fascia should be deliberately resected with the rectum [12]. Finally, lateral attachments on both left and right sides were resected to accomplish mobilization of the rectum enveloped within the fascia propria recti. Afterthe aboveprocedure wascompleted,wemoved on to separation of the rectal wall from the mesorectum with an adequate distance from the tumor in accordance Operator with its T-stage. Prior to the operation, tattoo in black ink Assistant was applied to the nearest site of the tumor endoscopically. 3 5 In addition, during the operation, we directly painted the Scopist 1 rectum about 5 cm from the tattoo toward the anal side 2 4 with crystal violet. The separation was usually begun from the right wall of the rectum at the marked site. With laparoscopy, every vessel could be observed precisely because of its magnifying effect [13] and use of the curved shears (Harmonic Ace; Ethicon Endosurgery Inc.), enabling safe and rapid resection of the vessels. In order to provide enough space to insert an endoscopic linear stapler, only the 1 12 mm 4 5mm mesorectum just underneath the rectal wall was excised for 2 5 5mm 12 mm about 3 cm in width along the rectal tube (Figure 3). The 5mm mesorectal excision should be conducted from the right side Figure 2: A total of five trocars are used. as much as possible. Lastly, the mesorectum just underneath the rectal wall was excised in order to separate the rectal wall completely from the mesorectum. [11]. After having freed sigmoid colon thoroughly from the After the rectal wall was sufficiently separated from the retroperitoneum, the inferior mesenteric artery (IMA) was mesorectum, the rectum was closed by a clamped forceps ligated for lymph nodes dissection. The inferior mesenteric to irrigate inside the rectum with 2 liters of saline via the vein was ligated at the level of the IMA origin. anus. Then, the rectum was transected using an endoscopic Next, we started to dissect the mesorectum at the poste- linear stapler (Figure 4). In most cases, the rectum was rior site. After visually confirming the left and right hypogas- transected by the first firing, because only the rectal wall tric nerves, we dissected the mesorectum in the layer just without mesorectum had been dissected. When the rectum above the nerve leaving the nerve intact as if to draw a was transected, the distal rectal stump was drawn toward semicircular line. In case of TSME, there was no need to the anal side; moreover, by pulling the proximal rectum dissect as deeply as to the point where the levator ani was toward the cranial side, several centimeters of mesorectum exposed, and thus, we aimed to dissect several centimeters that did not adhere to the rectum could be confirmed visually more toward the anal side from the scheduled mesorectal (Figure 5). This area of mesorectum was then resected using excision line. Then, we proceeded to the anterior site. In cases the Harmonic Ace. This made it easy to sharply and precisely with anastomosis planned under the peritoneal reflection, excise the mesorectum along a straight line from the distal we tried to dissect the dorsal site of Denonvilliers’ fascia; rectal stump on the anal side toward the sacrum in a short however, if the tumor was located at the anterior wall of the period of time. According to the specimen, the mesorectum International Journal of Surgical Oncology 3 Tattoo Mesorectum Mesorectum Figure 4: After the rectum is completely separated from the me- Figure 6: The mesorectum is sufficiently resected with the speci- sorectum, the rectum is transected using linear staplers. men. The arrow heads show the proximal rectal stump. The rectum was successfully transected by an endoscopic linear stapler in one attempt in 17 out of 19 patients. Firing was required twice for 2 patients. Postoperative anastomotic leakage occurred in one patient and diverting colostomy was performed. The average distance from the rectal stump to the distal mesorectum in freshly resected specimen was 20 mm (range 8–30 mm), indicating satisfactory TSME. Mesorectum 4. Discussion The main goal of TME is to resect the mesorectum, especially the anal side of small metastatic lesions termed tumor deposits and the area surrounding the mesorectum en block [1, 2]. This technique contributes largely to reducing post- Figure 5: After transection of the rectum, the mesorectum can be operative local recurrence of colon cancer [3, 8]. Generally, observed clearly. The arrow heads show the distal rectal stump. the mesorectum becomes thinner as it gets closer to the levator ani, and in case of TME for lower rectal cancer, there is often no need for special treatment of the mesorectum. was resected as if a large volume of it were drawn out of the However, in case of TSME, the primary tumor site is either rectal stump, showing satisfactory TSME (Figure 6). in the rectosigmoid or upper rectum and the mesorectum Lastly, a small incision of 3-4 cm was made above the at the scheduled resection line about 5 cm toward the anal pubic bone, and the specimen was transected outside the side from the primary cancer is thick [5, 14]. Because of this, abdomen. After having inserted the anvil head of a circular in the conventional procedure, the mesorectum is resected stapler into the sigmoid colon, intracorporeal anastomosis first, and, after having exposed the rectal wall, the rectum was performed using double stapling techniques. As long as is transected. In a narrow pelvic cavity, it is not always easy the donuts were checked and a complete ring was confirmed to conduct appropriate mesorectal excision at an adequate after the anastomosis, no drain was placed, and no diverting distance from the tumor; the mesorectum is likely to be stoma was performed. resected obliquely toward the anal side. In addition, it is difficult to sharply resect the mesorectum laparoscopically, and the resection tends to proceed in a zigzag line. Also, 3. Results in an attempt to avoid injuries to the rectal wall during Laparoscopic TSME using this technique was conducted laparoscopic surgery, the mesorectal excision is likely to be on 19 patients from April 2008 to March 2011. Tumor insufficient. This is one factor leading to the repeated use of localization was the distal sigmoid colon in 5 patients and a linear stapler for transection of the rectum. Needless to say, the upper rectum in 14 patients. There were 10 men and there is increased risk of anastomotic leakage with repeated 9 women; mean age was 67 years (range 46–79). Mean stapler firing [15, 16]. blood loss was 86 ml (range, 15–320 ml) and mean operating The merits of this procedure are as follows: (1) separating time was 3 hours and 47 minutes (range, 2 hours 45 min– the rectum in advance allows rectal transection at the 5 hours 11 min). There was no incidence of rectal wall injury targeted line, leaving an adequate distance along the anal during the separation of the rectum from the mesorectum. side; (2) the mesorectal excision is made easy and secure by 4 International Journal of Surgical Oncology a good visual field provided by the rectal transection; (3) cancers of the upper rectum,” Surgery, vol. 124, no. 4, pp. 612– 618, 1998. there is more chance of transecting the rectum successfully [5] S. Zaheer, J. H. Pemberton, R. Farouk, R. R. Dozois, B. G. of the linear stapler, because the rectal wall has already been Wolff, and D. Ilstrup, “Surgical treatment of adenocarcinoma separated. With regards to mesorectal excision especially, of the rectum,” Annals of Surgery, vol. 227, no. 6, pp. 800–811, the mesorectum to be resected can be identified with a good visual field when a rectal stump draws toward the [6] T. E. Pakkastie, P. E. Luukkonen, and H. J. Jarvinen, “Anasto- anal side after cutting off the rectum. At the same time, motic leakage after anterior resection of the rectum,” European the proximal rectum is pulled toward the cranial side. The Journal of Surgery, vol. 160, no. 5, pp. 293–297, 1994. mesorectal excision after this is extremely easy, and the [7] A. Chiappa, R. Biffi, E. Bertani et al., “Surgical outcomes after use of energy devices such as the Harmonic Ace makes it total mesorectal excision for rectal cancer,” Journal of Surgical possible to conduct a sharp and straight linear excision of Oncology, vol. 94, no. 3, pp. 182–193, 2006. the mesorectum in a short period of time. The resected [8] I. J. Adam, M. O. Mohamdee, I. G. Martin et al., “Role of specimen also shows that the mesorectal excision is more circumferential margin involvement in the local recurrence of rectal cancer,” The Lancet, vol. 344, no. 8924, pp. 707–711, sufficient by this method than when done in a conventional way. When the conventional method is performed, after [9] A.C.Lowry,C.L.Simmang,P.Boulos et al., “Consensus state- transecting the rectum, a rectal stump sometimes slips into ment of definitions for anorectal physiology and rectal cancer: mesorectal fat, and we know by experience that by pushing in report of the tripartite consensus conference on definitions for a shaft of circular stapler from the anus, the rectal stump that anorectal physiology and rectal cancer,” Diseases of the Colon is forced out with the mesorectum can be finally identified. and Rectum, vol. 44, no. 7, pp. 915–919, 2001. By this new method, however, because the mesorectum is [10] S. Ohigashi, N. Hayashi, G. Shimada, and H. Onodera, “A new sufficiently resected, a rectal stump can always be identified technique to achieve sufficient mesorectal excision in upper visually, and the shaft can be easily maneuvered. It also rectal cancer,” Digestive Surgery, vol. 24, no. 3, pp. 173–176, can be used as proof that the mesorectal excision has been sufficiently conducted. [11] C. A. Sartori, A. Dal Pozzo, B. Franzato, M. Balduino, A. For surgical resection of rectal cancer, adequate mesorec- Sartori, and G. L. Baiocchi, “Laparoscopic total mesorectal excision for rectal cancer: experience of a single center with tal excision is important. Especially in case of upper rectal a series of 174 patients,” Surgical Endoscopy,vol. 25, no.2,pp. cancer, TME is not necessary; instead, TSME is sufficient 508–514, 2011. [4, 5, 14]. Many surgeons may feel that it is not always easy [12] Y. Kinugasa, G. Murakami, K. Uchimoto, A. Takenaka, T. to conduct TSME in a narrow pelvic cavity. The method Yamaji, and K. Sugihara, “Operating behind Denonvilliers’ presented here is helpful in lessening such burdens and is fascia for reliable preservation of urogenital autonomic nerves still compatible with the concept of TME, which places much in total mesorectal excision: a histologic study using cadaveric emphasis on dissecting sufficient mesorectum on the anal specimens, including a surgical experiment using fresh cadav- side and removal of tumor deposits en block. Whether this eric models,” Diseases of the Colon and Rectum, vol. 49, no. 7, method has any effect on decreasing the local recurrence pp. 1024–1032, 2006. rate is unknown; randomized controlled trials are needed [13] J. Leroy, F. Jamali, L. Forbes et al., “Laparoscopic total to investigate this. In this paper, the authors would like mesorectal excision (TME) for rectal cancer surgery: long- term outcomes,” Surgical Endoscopy, vol. 18, no. 2, pp. 281– to emphasize the merit of this method. As accuracy is an 289, 2004. important factor in TSME, this method can provide a good [14] W. L. Law and K. W. Chu, “Anterior resection for rectal visual field when the mesorectal excision is conducted. cancer with mesorectal excision: a prospective evaluation of 622 patients,” Annals of Surgery, vol. 240, no. 2, pp. 260–268, Conflict of Interests [15] J. S. Kim, S. Y. Cho, B. S. Min, and N. K. Kim, “Risk factor None of the authors has any conflict of interests to disclose. for Anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with a double stapling technique,” Journal of the American College of Surgeons, vol. 209, no. 6, pp. References 694–701, 2009. [1] R. J. Heald, B. J. Moran, R. D. H. Ryall, R. Sexton, and J. [16] M. Ito, M. Sugito, A. Kobayashi, Y. Nishizawa, Y. Tsunoda, K. MacFarlane, “Rectal cancer: the Basingstoke experience of and N. Saito, “Relationship between multiple numbers of total mesorectal excision, 1978–1997,” Archives of Surgery, vol. stapler firings during rectal division and Anastomotic leakage 133, no. 8, pp. 894–899, 1998. after laparoscopic rectal resection,” International Journal of [2] W. E. Enker, H. T. Thaler, M. L. Cranor, and T. Polyak, “Total Colorectal Disease, vol. 23, no. 7, pp. 703–707, 2008. mesorectal excision in the operative treatment of carcinoma of the rectum,” Journal of the American College of Surgeons, vol. 181, no. 4, pp. 335–346, 1995. [3] E. Kapiteijin, C. A. Marijnen, I. D. Nagtegaal et al., “Preopera- tive radiotherapy combined with total mesorectal excision for resectable rectal cancer,” The New England Journal of Medicine, vol. 345, no. 9, pp. 638–646, 2001. [4] F.Lopez-Kostner,I.C.Lavery, G. R. Hool, L. A. Rybicki, and V. W. 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A New Laparoscopic Surgical Procedure to Achieve Sufficient Mesorectal Excision in Upper Rectal Cancer

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Hindawi Publishing Corporation
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Copyright © 2011 Seiji Ohigashi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2011, Article ID 708439, 4 pages doi:10.1155/2011/708439 Clinical Study A New Laparoscopic Surgical Procedure to Achieve Sufficient Mesorectal Excision in Upper Rectal Cancer Seiji Ohigashi, Takashi Taketa, Kazuki Sudo, Hironori Shiozaki, and Hisashi Onodera Department of Gastroenterological Surgery, St. Luke’s International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo 104-8560, Japan Correspondence should be addressed to Seiji Ohigashi, ohigashiseiji@ab.auone-net.jp Received 2 May 2011; Accepted 22 August 2011 Academic Editor: C. H. Yip Copyright © 2011 Seiji Ohigashi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. Mesorectal excision corresponding to the location of a tumor, termed tumor-specific mesorectal excision (TSME), is commonly performed for resection of upper rectal cancer. We devised a new laparoscopic procedure for sufficient TSME with rectal transection followed by mesorectal excision. Operative Technique. After mobilization of the sigmoid colon and ligation of inferior mesenteric vessels, we dissected the mesorectum along the layer of the planned total mesorectal excision. The rectal wall was carefully separated from the mesorectum at the appropriate anal side from the tumor. After the rectum was isolated and transected using an endoscopic linear stapler, the rectal stump drew immediately toward the anal side, enabling the mesorectum to be identified clearly. In this way, sufficient TSME can be performed easily and accurately. This technique has been successfully conducted on 19 patients. Conclusion. This laparoscopic technique is a feasible and reliable procedure for achieving sufficient TSME. 1. Introduction difficult to perform and the dissection line is likely to be in zigzags. Of course, TSME shifting toward the oral side Total mesorectal excision (TME) is recognized as an ex- from the starting line is inappropriate and should be strictly tremely important surgical technique for the prevention avoided in order to prevent local recurrence (Figure 1). of localrecurrenceofrectalcancer[1–3]. On the other To overcome these difficulties, we have introduced a hand, TME is not necessarily applicable in every case of technique to transect the rectum before resection of the rectal cancer: for upper rectal cancer, mesorectal excision for mesorectum during conventional open surgery [10]. This limited lengths of 5 cm from a tumor toward the anal side is technique assures an adequate distance between the tumor widely conducted, and this method is reportedly associated and resected stump on the anal side and sufficient TSME cor- with adequate rates of cure [4, 5]. This technique is referred responding appropriately to the T-stage of the tumor. This to as partial mesorectal excision (PME), but rather should be technique is also applicable to the laparoscopic approach, whichwereporthere. called tumor-specific mesorectal excision (TSME) reflecting its correspondence to the localization or T-stage of the tumor [5]. In a narrow pelvic cavity, performing sufficient TSME 2. Operative Technique is difficult, and there is a risk of local recurrence when TSME is inadequate [6–8]. Whether surgery is performed The most appropriate indication for this technique is the laparoscopically or via a conventional open route, TSME is treatment of upper rectal cancer of stage T-2 and higher. usually conducted obliquely to the anal side, introducing Here, we report details of the techniques used in our laparo- unnecessary rectal resection which may lead to postoperative scopic procedure. bowel malfunction [9]. In addition, there is of the potential A trocar for laparoscope was inserted just beneath the for slippage of the TSME between the right and left sides umbilicus; we used four working ports as shown in Figure 2. of the rectal wall. Particularly in the case of laparoscopic Surgery commenced with mobilization of the sigmoid colon surgery, straight and sharp dissection of the mesorectum is with a preference for the approach from median to lateral 2 International Journal of Surgical Oncology Rectum Mesorectum Figure 1: (A) Ideal resection line of the mesorectum. (B) and (C) Figure 3: Separation of the rectum is started from the right side of Inappropriate resection line of the mesorectum. the mesorectum. rectum, Denonvilliers’ fascia should be deliberately resected with the rectum [12]. Finally, lateral attachments on both left and right sides were resected to accomplish mobilization of the rectum enveloped within the fascia propria recti. Afterthe aboveprocedure wascompleted,wemoved on to separation of the rectal wall from the mesorectum with an adequate distance from the tumor in accordance Operator with its T-stage. Prior to the operation, tattoo in black ink Assistant was applied to the nearest site of the tumor endoscopically. 3 5 In addition, during the operation, we directly painted the Scopist 1 rectum about 5 cm from the tattoo toward the anal side 2 4 with crystal violet. The separation was usually begun from the right wall of the rectum at the marked site. With laparoscopy, every vessel could be observed precisely because of its magnifying effect [13] and use of the curved shears (Harmonic Ace; Ethicon Endosurgery Inc.), enabling safe and rapid resection of the vessels. In order to provide enough space to insert an endoscopic linear stapler, only the 1 12 mm 4 5mm mesorectum just underneath the rectal wall was excised for 2 5 5mm 12 mm about 3 cm in width along the rectal tube (Figure 3). The 5mm mesorectal excision should be conducted from the right side Figure 2: A total of five trocars are used. as much as possible. Lastly, the mesorectum just underneath the rectal wall was excised in order to separate the rectal wall completely from the mesorectum. [11]. After having freed sigmoid colon thoroughly from the After the rectal wall was sufficiently separated from the retroperitoneum, the inferior mesenteric artery (IMA) was mesorectum, the rectum was closed by a clamped forceps ligated for lymph nodes dissection. The inferior mesenteric to irrigate inside the rectum with 2 liters of saline via the vein was ligated at the level of the IMA origin. anus. Then, the rectum was transected using an endoscopic Next, we started to dissect the mesorectum at the poste- linear stapler (Figure 4). In most cases, the rectum was rior site. After visually confirming the left and right hypogas- transected by the first firing, because only the rectal wall tric nerves, we dissected the mesorectum in the layer just without mesorectum had been dissected. When the rectum above the nerve leaving the nerve intact as if to draw a was transected, the distal rectal stump was drawn toward semicircular line. In case of TSME, there was no need to the anal side; moreover, by pulling the proximal rectum dissect as deeply as to the point where the levator ani was toward the cranial side, several centimeters of mesorectum exposed, and thus, we aimed to dissect several centimeters that did not adhere to the rectum could be confirmed visually more toward the anal side from the scheduled mesorectal (Figure 5). This area of mesorectum was then resected using excision line. Then, we proceeded to the anterior site. In cases the Harmonic Ace. This made it easy to sharply and precisely with anastomosis planned under the peritoneal reflection, excise the mesorectum along a straight line from the distal we tried to dissect the dorsal site of Denonvilliers’ fascia; rectal stump on the anal side toward the sacrum in a short however, if the tumor was located at the anterior wall of the period of time. According to the specimen, the mesorectum International Journal of Surgical Oncology 3 Tattoo Mesorectum Mesorectum Figure 4: After the rectum is completely separated from the me- Figure 6: The mesorectum is sufficiently resected with the speci- sorectum, the rectum is transected using linear staplers. men. The arrow heads show the proximal rectal stump. The rectum was successfully transected by an endoscopic linear stapler in one attempt in 17 out of 19 patients. Firing was required twice for 2 patients. Postoperative anastomotic leakage occurred in one patient and diverting colostomy was performed. The average distance from the rectal stump to the distal mesorectum in freshly resected specimen was 20 mm (range 8–30 mm), indicating satisfactory TSME. Mesorectum 4. Discussion The main goal of TME is to resect the mesorectum, especially the anal side of small metastatic lesions termed tumor deposits and the area surrounding the mesorectum en block [1, 2]. This technique contributes largely to reducing post- Figure 5: After transection of the rectum, the mesorectum can be operative local recurrence of colon cancer [3, 8]. Generally, observed clearly. The arrow heads show the distal rectal stump. the mesorectum becomes thinner as it gets closer to the levator ani, and in case of TME for lower rectal cancer, there is often no need for special treatment of the mesorectum. was resected as if a large volume of it were drawn out of the However, in case of TSME, the primary tumor site is either rectal stump, showing satisfactory TSME (Figure 6). in the rectosigmoid or upper rectum and the mesorectum Lastly, a small incision of 3-4 cm was made above the at the scheduled resection line about 5 cm toward the anal pubic bone, and the specimen was transected outside the side from the primary cancer is thick [5, 14]. Because of this, abdomen. After having inserted the anvil head of a circular in the conventional procedure, the mesorectum is resected stapler into the sigmoid colon, intracorporeal anastomosis first, and, after having exposed the rectal wall, the rectum was performed using double stapling techniques. As long as is transected. In a narrow pelvic cavity, it is not always easy the donuts were checked and a complete ring was confirmed to conduct appropriate mesorectal excision at an adequate after the anastomosis, no drain was placed, and no diverting distance from the tumor; the mesorectum is likely to be stoma was performed. resected obliquely toward the anal side. In addition, it is difficult to sharply resect the mesorectum laparoscopically, and the resection tends to proceed in a zigzag line. Also, 3. Results in an attempt to avoid injuries to the rectal wall during Laparoscopic TSME using this technique was conducted laparoscopic surgery, the mesorectal excision is likely to be on 19 patients from April 2008 to March 2011. Tumor insufficient. This is one factor leading to the repeated use of localization was the distal sigmoid colon in 5 patients and a linear stapler for transection of the rectum. Needless to say, the upper rectum in 14 patients. There were 10 men and there is increased risk of anastomotic leakage with repeated 9 women; mean age was 67 years (range 46–79). Mean stapler firing [15, 16]. blood loss was 86 ml (range, 15–320 ml) and mean operating The merits of this procedure are as follows: (1) separating time was 3 hours and 47 minutes (range, 2 hours 45 min– the rectum in advance allows rectal transection at the 5 hours 11 min). There was no incidence of rectal wall injury targeted line, leaving an adequate distance along the anal during the separation of the rectum from the mesorectum. side; (2) the mesorectal excision is made easy and secure by 4 International Journal of Surgical Oncology a good visual field provided by the rectal transection; (3) cancers of the upper rectum,” Surgery, vol. 124, no. 4, pp. 612– 618, 1998. there is more chance of transecting the rectum successfully [5] S. Zaheer, J. H. Pemberton, R. Farouk, R. R. Dozois, B. G. of the linear stapler, because the rectal wall has already been Wolff, and D. Ilstrup, “Surgical treatment of adenocarcinoma separated. With regards to mesorectal excision especially, of the rectum,” Annals of Surgery, vol. 227, no. 6, pp. 800–811, the mesorectum to be resected can be identified with a good visual field when a rectal stump draws toward the [6] T. E. Pakkastie, P. E. Luukkonen, and H. J. Jarvinen, “Anasto- anal side after cutting off the rectum. At the same time, motic leakage after anterior resection of the rectum,” European the proximal rectum is pulled toward the cranial side. The Journal of Surgery, vol. 160, no. 5, pp. 293–297, 1994. mesorectal excision after this is extremely easy, and the [7] A. Chiappa, R. Biffi, E. Bertani et al., “Surgical outcomes after use of energy devices such as the Harmonic Ace makes it total mesorectal excision for rectal cancer,” Journal of Surgical possible to conduct a sharp and straight linear excision of Oncology, vol. 94, no. 3, pp. 182–193, 2006. the mesorectum in a short period of time. The resected [8] I. J. Adam, M. O. Mohamdee, I. G. Martin et al., “Role of specimen also shows that the mesorectal excision is more circumferential margin involvement in the local recurrence of rectal cancer,” The Lancet, vol. 344, no. 8924, pp. 707–711, sufficient by this method than when done in a conventional way. When the conventional method is performed, after [9] A.C.Lowry,C.L.Simmang,P.Boulos et al., “Consensus state- transecting the rectum, a rectal stump sometimes slips into ment of definitions for anorectal physiology and rectal cancer: mesorectal fat, and we know by experience that by pushing in report of the tripartite consensus conference on definitions for a shaft of circular stapler from the anus, the rectal stump that anorectal physiology and rectal cancer,” Diseases of the Colon is forced out with the mesorectum can be finally identified. and Rectum, vol. 44, no. 7, pp. 915–919, 2001. By this new method, however, because the mesorectum is [10] S. Ohigashi, N. Hayashi, G. Shimada, and H. Onodera, “A new sufficiently resected, a rectal stump can always be identified technique to achieve sufficient mesorectal excision in upper visually, and the shaft can be easily maneuvered. It also rectal cancer,” Digestive Surgery, vol. 24, no. 3, pp. 173–176, can be used as proof that the mesorectal excision has been sufficiently conducted. [11] C. A. Sartori, A. Dal Pozzo, B. Franzato, M. Balduino, A. For surgical resection of rectal cancer, adequate mesorec- Sartori, and G. L. Baiocchi, “Laparoscopic total mesorectal excision for rectal cancer: experience of a single center with tal excision is important. Especially in case of upper rectal a series of 174 patients,” Surgical Endoscopy,vol. 25, no.2,pp. cancer, TME is not necessary; instead, TSME is sufficient 508–514, 2011. [4, 5, 14]. Many surgeons may feel that it is not always easy [12] Y. Kinugasa, G. Murakami, K. Uchimoto, A. Takenaka, T. to conduct TSME in a narrow pelvic cavity. The method Yamaji, and K. Sugihara, “Operating behind Denonvilliers’ presented here is helpful in lessening such burdens and is fascia for reliable preservation of urogenital autonomic nerves still compatible with the concept of TME, which places much in total mesorectal excision: a histologic study using cadaveric emphasis on dissecting sufficient mesorectum on the anal specimens, including a surgical experiment using fresh cadav- side and removal of tumor deposits en block. Whether this eric models,” Diseases of the Colon and Rectum, vol. 49, no. 7, method has any effect on decreasing the local recurrence pp. 1024–1032, 2006. rate is unknown; randomized controlled trials are needed [13] J. Leroy, F. Jamali, L. Forbes et al., “Laparoscopic total to investigate this. In this paper, the authors would like mesorectal excision (TME) for rectal cancer surgery: long- term outcomes,” Surgical Endoscopy, vol. 18, no. 2, pp. 281– to emphasize the merit of this method. As accuracy is an 289, 2004. important factor in TSME, this method can provide a good [14] W. L. Law and K. W. Chu, “Anterior resection for rectal visual field when the mesorectal excision is conducted. cancer with mesorectal excision: a prospective evaluation of 622 patients,” Annals of Surgery, vol. 240, no. 2, pp. 260–268, Conflict of Interests [15] J. S. Kim, S. Y. Cho, B. S. Min, and N. K. Kim, “Risk factor None of the authors has any conflict of interests to disclose. for Anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with a double stapling technique,” Journal of the American College of Surgeons, vol. 209, no. 6, pp. References 694–701, 2009. [1] R. J. Heald, B. J. Moran, R. D. H. Ryall, R. Sexton, and J. [16] M. Ito, M. Sugito, A. Kobayashi, Y. Nishizawa, Y. Tsunoda, K. MacFarlane, “Rectal cancer: the Basingstoke experience of and N. Saito, “Relationship between multiple numbers of total mesorectal excision, 1978–1997,” Archives of Surgery, vol. stapler firings during rectal division and Anastomotic leakage 133, no. 8, pp. 894–899, 1998. after laparoscopic rectal resection,” International Journal of [2] W. E. Enker, H. T. Thaler, M. L. Cranor, and T. Polyak, “Total Colorectal Disease, vol. 23, no. 7, pp. 703–707, 2008. mesorectal excision in the operative treatment of carcinoma of the rectum,” Journal of the American College of Surgeons, vol. 181, no. 4, pp. 335–346, 1995. [3] E. Kapiteijin, C. A. Marijnen, I. D. Nagtegaal et al., “Preopera- tive radiotherapy combined with total mesorectal excision for resectable rectal cancer,” The New England Journal of Medicine, vol. 345, no. 9, pp. 638–646, 2001. [4] F.Lopez-Kostner,I.C.Lavery, G. R. Hool, L. A. Rybicki, and V. W. 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International Journal of Surgical Oncology – Hindawi Publishing Corporation

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