Distal Rectal Transection and Anastomosis of the Rectum

By applying tension to the left side the rectum at the proposed resection line, using the grasping forceps from the left-sided cannulae, the peritoneum and mesorectum at this level are divided using the LCS (Figure 8.5.12). By using the LCS, and by striking a plane between the meso-rectum and the posterior wall of the rectum, injury to the rectal wall can be avoided. Similarly, the mesorectum is dissected on the left side, exposing the rectal wall, and connecting the right and left resection

Meso Rectum
Figure 8.5.9. With careful traction and countertraction by the surgeon and the assistant, the boundary of the left side of the rectum between peritoneum and mesorectum is dissected (arrow).
Peritoneal Incision
Figure 8.5.10. Next, the peritoneal reflection is incised, exposing Denonvilliers' fascia and protecting the seminal vesicles or vaginal wall.
Denonvilliers Fascia
Figure 8.5.11. The lateral ligaments are placed under tension by drawing the rectum to the right side of the pelvis, then this area is dissected, carefully preserving the nerve trunks heading distally.
Distal Rectum Transected
Figure 8.5.12. With tension applied to the left side of the rectum at the proposed transaction line, the mesorectum is divided using the laparoscopic coagulation shears.

lines posteriorly. We perform a distal rectal washout by grasping immediately below the tumor using a long bowel grasper, then perform rectal irrigation through a transanally placed catheter with a cytotoxic solution (e.g., 1% povidone iodine, 500 mL). Next, we introduce an endoscopic linear stapling device at right angles to the long axis of the rectum as much as possible, drawing the rectum cephalad and firing the stapler (Figure 8.5.13). If one cartridge of the stapler does not completely transect the rectum, we apply the second firing so as to overlap the initial suture line on the anal side.

Once the rectum is completely transected, the specimen side of the rectum is securely held using a grasping forceps from the suprapubic port, then this port site is incised to a length of about 3-5 cm in the

Laparoscopic Staplers
Figure 8.5.13. An endoscopic linear stapler is introduced through the suprapubic cannula and fired across the distal resection line at right angles to the bowel.

midline, and the specimen is drawn out of the peritoneal cavity after protecting the wound using a plastic ring drape or lap disk (Hakko Medical, Tokyo, Japan). The proximal resection is performed on the anterior abdominal wall using conventional techniques, and the specimen is removed. The center rod and anvil head are placed into the proximal bowel lumen and secured in place using a 2-0 polypropylene pursestring suture. The bowel is returned into the abdominal cavity, and this wound site is made airtight by placing a continuous suture on the peritoneum or by merely closing the lap disk. The pneumoperito-neum is restored in preparation for the anastomosis. The cavity of lesser pelvis is irrigated copiously, including the rectal stump. We generally use a cytotoxic solution (several 100 mL of povidone iodine 1% initially, then follow with saline). The anvil shaft is placed in the left iliac fossa, then the circular stapler is introduced from the anus. It is recommended that an experienced surgeon do this, and once the stapler is "crowning" at the top of the rectal stump, we attempt to have the spike of the stapler protrude from immediately below or immediately above the center of the suture line (Figure 8.5.14). The anastomosis must be performed very carefully so that the surrounding tissues (vagina, lateral pelvic tissues) are not caught in the anastomotic site. Before firing the stapler, we confirm that there is no torsion in the mesentery of the proximal colon, then the stapler may be fired (Figure 8.5.15). After resection, the staple line must be carefully observed to

Figure 8.5.14. A transanally introduced circular stapler is placed at the top of the rectum and the spike is protruded through the wall just posterior to the linear staple line.

Figure 8.5.14. A transanally introduced circular stapler is placed at the top of the rectum and the spike is protruded through the wall just posterior to the linear staple line.

Stapled Anastomosis

Figure 8.5.15. The double-stapled anastomosis is performed with all surrounding tissues clear of the two bowel ends.

Figure 8.5.15. The double-stapled anastomosis is performed with all surrounding tissues clear of the two bowel ends.

Stapled Anastomosis TechniqueRectal Anastomosis
Figure 8.5.16. After resection, the staples should be evaluated to be sure there has been good "B" formation of the staples [both from laparoscopic and intraluminal (endoscopic) evaluation].

verify that the staples are aligned in a B-shape (Figure 8.5.16). The tissue rings removed by the circular stapler are inspected for completeness, then a leak test is done with air insufflation through the rectum while the pelvis is filled with saline and the bowel above the anastomosis is occluded with a bowel clamp. A closed suction drain is inserted into the pelvis from the port site of the left lower abdominal region, placing it near the anastomosis. The wounds are irrigated with saline and the wounds are closed using absorbable suture. We use a running size 0 or 1 suture for the fascia in the suprapubic area, and all cannula sites 10 mm or greater are closed with size 0 sutures at the fascial level.

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  • haile
    What is a rectal transection?
    7 years ago

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