TaTME with Cecil Approach

Case Record:

• 1. 76-year-old male

• 2. ADK 6cm from anal verge, clinical staging T3N0

• 3. Submitted to LAR with taTME, with protective ileostomy

Clinical History:

• 1. Changes in bowel habits, with no constitutional symptoms

• 2. Colonoscopy diagnoses and ADK of the low/middle rectum, 6cm from the anal verge

• 3. Staging MRI with localized tumor, T3N0, no signs of bad prognosis

• 4. CT-scan with no distant metastases

• 5. Decided in MDT to go straight to surgery

ABDOMINAL TEAM

• 1. Pneumoperitoneum with umbilical Veress needle

• 2. Placement of umbilical optical trocar (12mm). Remaining trocars with direct visualization (12mm RIF, 5mm RF, 5mm Airseal LF, 5mm subxyphoid)

• 3. Opening of the peritoneum and dissection of the IMA at the origin

• 4. Transanal puncture of the tumor with indocyanine green for visualization of the tumor and lymphatic drainage

• 5. Change to Visioncense optic to identify the tumor and lymph nodes during the procedure (2 times)

• 6. High ligation of the IMA and ligation of the IMV using hemolock clips and Ligasure

• 7. Dissection of the mesocolon, medial to lateral and liberation of the parietocolic adhesions

• 8. Clamping of the sigmoid colon

TRANSANAL TEAM

• 1. Placement of Lone-star retractor and dilation of the anal canal

• 2. Transanal placement of GelPoint platform and insufflation of the rectum, while the abdominal team keeps the sigmoid colon clamped

• 3. Identification of the tumor and placement of a purse-string suture

• 4. Tattooing of the dissection margin using an electrocautery scalpel and dissection of the rectal wall until the mesorectal plane is reached

• 5. Circumferential dissection trough the plane until communication with the abdominal team (”rendez-vous”)

• 6. Complete mobilization of the specimen to the abdominal cavity

ABDOMINAL TEAM

• 1. Pfannenstiel incision and extraction of the specimen

• 2. Transection of the specimen after confirmation of vascularity with ICG and the Visioncense camera

• 3. Reduction of the left colon to the abdominal cavity

• 4. Provisional closure of the Pfannenstiel incision to rebuild the pneumoperitoneum and position the colon for transanal retrieval

TRANSANAL TEAM

• 1. Retrieval of the specimen and construction of an end-to-end manual coloanal anastomosis with interrupted sutures

ABDOMINAL TEAM

• 1. Placement of a drainage and construction of a lateral protective ileostomy in the right flank

Learning Points:

• High ligation of the IMA

• Use of ICG for lymphadenectomy and vascular assessment

• Transanal dissection