A 64-year-old male patient diagnosed with a cT4N0M0 low rectal cancer affecting the sphincter received neoadjuvant therapy and then a laparoscopic MILES procedure that was uneventful.
On the 8th month of follow up the patient displayed a perineal mass and pain. A CT Scan revealed a perineal herniation that contained loops of small bowel.
Surgical repair was performed using a laparoscopic approach; the patient was placed in the supine position with open legs, with the leading surgeon and the assistant standing to the right of the patient. A total of 4 trocars were used: a 12mm trocar in a supraumbilical position for a 30° scope, a 12mm trocar very low at the right iliac fossa and two 5mm trocars, one on each flank.
The first part of the procedure is the most technically challenging one. The small bowel was attached to the pelvis and the surgeon started the mobilization using the scissors. Working deep in the pelvis is uncomfortable, especially in male patients.
The LigaSure™ was used to finish the mobilization. The small bowel was incidentally injured and required resection. The last loop was individualized and finally the pelvis was freed. A lavage was performed to clean the working field and verify hemostasis.
The bipolar was used to control the bleeding. Introducing a gauze helps to improve visualization of the bleeding point and enables the surgeon to be more accurate with the hemostatic maneuvers. A 10cm ribbon was used to measure the distance between the pelvic muscles, the pubis and the pre sacrum to select the size of the mesh.
A GORE® DUALMESH® was used. It has two surfaces: a textured surface, designed to encourage host tissue incorporation, and a smooth surface which can be in contact with the gut as it minimizes tissue attachment.
Fixation was accomplished by using absorbable takers and knots. Non-absorbable ones should be avoided as they may lead to an intestinal fistula. It may be necessary to make Prolene knots when there is no good angle to place the taker.
It is important to bear in mind the vascular, nervous and urinary structures at the pelvis to avoid injuries. The surgeons must ensure that the mesh is properly displayed exposing only the layer that is allowed to be in contact with the gut.
The takers are introduced through the contralateral trocar in order to have the best direction and accomplish a correct placement. Separate Prolene knots were used to complete mesh fixation.
The surgery took 190 minutes. The patient started oral intake 48 hours after the procedure and left hospital on the 3rd postoperative day with no complications.
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