Observational Study
Copyright ©The Author(s) 2017.
World J Gastrointest Surg. Jun 27, 2017; 9(6): 153-160
Published online Jun 27, 2017. doi: 10.4240/wjgs.v9.i6.153
Table 1 Stepwise approach to rectal dissection
1Port positions: 10-12 mm - sub-umbilical, RUQ (camera), RIF and LIF; patient in Lloyd-Davies position
2Omentum to supracolic compartment and small bowel stacking
3Identify right ureter
4Start medial dissection at the promontory
5Identify left ureter, then left gonadal, pelvic nerves
6Protect left ureter with surgicel® and Pedicle dissection
7Identify ureter through both windows of mesentery either side of pedicle
8Transect pedicle, confirm haemostasis
9Left lateral dissection, identify left ureter and proceed up to peritoneal reflection; IMV high tie and splenic flexure mobilisation, if required
10Mesorectal Dissection and preparation of rectum for division1
Right mesorectal dissection up to peritoneal reflection
Posterior dissection (presacral plane down to levator), keep left ureter in view
Divide peritoneal reflection anteriorly and dissect till seminal vesicles/vaginal fornix
Complete both lateral dissection, identify the ureters all the way
Anterior dissection keeping to the plane just posterior to the vesicles/vagina
Rectal Cross stapling (achieve antero-posterior staple line) or proceed to perineal dissection1
11Intra-corporeal cross stapling of rectum at appropriate level protecting lateral and anterior structures and Grasp stapled end of specimen
12Left iliac fossa port extended as a transverse incision for specimen delivery; protect wound and deliver specimen by the stapled end
13Complete mesenteric ligation, proximal bowel division and prepare proximal bowel for anastomosis
14Close wound, re-establish pneumoperitoneum
15Intra-corporeal bowel anastomosis with no tension, no twist and vital structures protected
16Close incisions
Table 2 Operations (n = 133)
OperationsLaparoscopic (conversion)OpenTotal
Anterior resections66 (2)672
TME + I25 (1)429
TME Hartmann’s1 (1)1
APER26 (2)127
Table 3 Post-op stage (n = 133)
Post-op stagen
R0 resection124
R1 resection (CRM + ve)9
R2 resection0
Table 4 Comparison of circumferential resection margin positive
Type of operationDutch TME trial[6]CLASICC trial[5]MR CRO7 trial[9]Our series
Sphincter saving resection13%10%8%3% (4/106)
APER29%21%17%18% (5/27)
Table 5 Comparison of local recurrence
Meta-analysis[4] (n = 1544)Dutch TME trial[6] (n = 1586)CLASICC trial[5] (n = 400)MRC CR07 trial[9] (n = 1350)Our series (n = 133)
Local recurrence13%8%6.80%7%3% (4/133)