Step by Step for LAR by laparoscopic approach

This video explains the key steps to perform a LAR with TME by laparoscopic approach.

The patient is in a supine position with the legs wide opened. A total of five trocars are used, one of 12mm in supra umbilical position for a 30º scope, another of 12mm at the right iliac fossa and three of 5mm located at the right iliac fossa, the left flank and the epigastrium.

In cases of narrow pelvis or patients with morbid obesity an extra trocar of 5mm is placed in a supra pubic position.

It is feasible to follow the oncological principles of open surgery by laparoscopy, proper traction of the mesosigmoid allows the dissection of the IVM. The peritoneum is opened and blunt dissection is initiated; this maneuver is improved by the pneumo enhancing the avascular plane.

The retroperitoneal structures should be taken in conscience to avoid vascular and ureteral injuries, it is important to be delicate during these maneuvers. The LigaSure™ and clips were used to section the IVM and avoid bleeding.

Medial to lateral dissection is performed leaving free the posterior aspect of the colon, traction and countertraction movements are essential to accomplish this phase of the surgery.

The colon is pushed towards the anterior abdominal wall exposing the peritoneal reflection and the promontory, this allows the access to the posterior plane of the mesorectum identifying the holy plane. The hook is used to perform a sharp dissection.

The posterior plane is easier to perform by laparoscopy and is used as a landmark to dissect the lateral and anterior planes. For anterior dissection the colon is pushed in direction of the patient’s head, unexpected injuries of the prostate, seminal vesicles and vagina should be avoided.

An extra trocar of 5mm located at the pubis may be used as a working channel for a clinch and improve the visualization by providing better traction and exposure. It is feasible to go as far as to the level of the elevator muscles by laparoscopy.

The section of the distal margin is done with endo staplers, this is one of the technical difficulties of  laparoscopic approach, in some cases is not possible to create a symmetrical stapler line, there is enough evidence to support that an increased number of fires rises the risk of a leak. The transanal approach represents an excellent solution to this issue.

Splenic flexure mobilization is performed in selected cases to mobilize enough colon and accomplish a tension free anastomosis.

The specimen is extracted through a small pfannenstiel incision and the proximal margin is selected above the level of the inferior mesenteric vessels in a well vascularized zone.

A purse string is performed and the anvil shaft is prepared, it is important to supervise that the thread gets tightened. A mechanical end-to-end anastomosis is built under direct laparoscopic vision.

Twisting of the colon is ruled out previous to the firing, the donuts must be evaluated ensuring that they are complete, a drain is placed for postoperative surveillance and a loop ileostomy is done.