Dr. Constantino Fondevila

Cecil Approach to rectal cancer and synchronous liver mets

Case A  56-year-old female patient with no medical record. As a surgical history, she had a caesarean 28 years before. A study was initiated due to abdominal pain and altered bowel movements. A colonoscopy was performed, finding a stenosing rectal lesion 7 cm from the anal verge (pathology reported infiltrating adenocarcinoma, KRAS wild type). The study was completed with the following additional tests: Toraco abdominal Colono CT: which found a 1.2 cm subcapsular hypodense nodule at liver segment VII. The MRI confirmed that it was a metastasis. There were no other pathological findings. Rectal MRI: the tumor infiltrated the mesorectal fascia and the anterior peritoneal reflection and signs of extramural venous invasion. Uterus involvement was dubious (mri T4aN1) We also performed a transanal ultrasound and a PET scan which confirmed the diagnosis. Long course neoadjuvant treatment was given with 5 FU plus 45 Gy of RT. The re-staring MRI showed a slight decrease in the longitudinal diameter of the tumor, with persistent involvement of the mesorectal fat, the anterior peritoneal reflection and probably the uterus. This is a case of a stage IVa rectal cancer. As the liver mets required a minor liver resection, simultaneous surgery was attempted. Treatment The patient was placed in the Lloyd Davies position and a transanal access platform was placed. We introduced the GelPoint path transanally using 3 trocars (one for the 3D Olympus scope and two work trocars). A total of 4 trocars were placed in the abdomen: a 12mm port above the umbilicus for a 30○ scope. One 5mm port was placed at the right iliac fossa and a 5 mm port was placed on each flank. TRANSABDOMINAL PHASE: The patient was placed in Trendelenburg position, slightly to the right. First we made a silk stitch from the uterus to the abdominal wall, fastening it to improve exposure of the pelvis. Then we mobilized some of the sigmoid colon by means of sharp dissection using the hook. The left hand of the surgeons performs traction of the colon by pulling from an epiploic appendix and the right hand used the hook The bowel was accommodated to expose the mesosigma. The inferior mesenteric vessels were identified and dissected using the hook. It is important that the assistant surgeon maintain vessel traction to improve the visualization of the avascular planes. We observed the ureter before ligating the vessels for safety and to prevent unnoticed injuries. High tie arterial ligation was safely  performed using a LigaSure™. The sigma was dissected, reaching the peritoneal reflection and leaving the colon free from the surrounding fat tissue. The descending colon was mobilized, from medial to lateral. Then we continued with the mobilization of the mesocolon to the rectum. The surgeon and its assistant should be synchronized to improve traction and exposure. At this point we realized that the cervix was affected, so it was decided to complete the surgery with a hysterectomy, bilateral salpingo oophorectomy. We used the LigaSure™ for this procedure. We completed the dissection of the uterus to perform an en bloc resection with the rectum. TRANSANAL PHASE: Meanwhile the transanal approach was under way. After the placement of the transanal device the pneumorectum was started, the tumor was identified and a ProleneⓇ pursetring was made setting the distal margin. The first step was to make the circumferential tattoo on the rectum wall.  The dissection of the mesorectum began after sectioning the rectal wall. This maneuver must be performed perpendicularly to the rectal lumen and in a circumferential manner. The surgery progressed down-to-up while the abdominal team dissected the inferior mesenteric vessels and mobilized the sigmoid colon.  The collaboration between the two teams is crucial at the highest part of the rectum. This helps to improve control of the specimen and prevents unexpected injuries. SIMULTANEOUS PHASE: Simultaneous work by both teams is important at this point, when they are working to improve exposure and clarify the planes in the same area. At the level of the anterior part of the rectum we had to cut the cervix to perform a block resection of the rectum and other structures affected. Finally we completed the surgery, removing the specimen. The specimen was extracted through a Pfannenstiel incision.  An L-T stapled anastomosis was created under laparoscopic supervision with a 33 mm EEA.  Finally a loop ileostomy  was performed, ending the colorectal surgery. LIVER RESECTION: Then we performed liver surgery by a 3D laparoscopic approach. We placed another 4 trocars: 12mm ports on the right upper quadrant and the left flank, and 5 mm ports at the epigastrium and right subcostal. First we proceeded to section the falciform ligament and round ligament. Then we released the right hepatic lobe to right hepatic vein, and performed the section of the the right triangular ligament using the LigaSure. We dissected hepatic hilum to prepare it in case a Pringle maneuver was necessary. We used a ribbon to clamp  the vascular hilum. Then we finally mobilized the right liver and held it using a liver retractor. Subcapsular hepatic metastases were identified in segment VII. The Pringle maneuver was performed for 11 minutes. Wedge resection of hepatic segment VII was performed leaving a sufficient free margin around the lesion.  We used the Ligasure for the resection too. We extracted the specimen using an Endocath through the Pfannenstiel incision.  We performed a cautious hemostasis of the liver using argon and perclot, ending the surgery. Outcome The surgery took 165 minutes. The patient started oral intake 24 hours after the surgery. During the postoperative period the patient presented with an urinary tract infection that was treated with an antibiotic. She did not present with fever. There were no other complications. She left the hospital on the 8th postoperative day.   Pathological examination showed a pT4bN2a rectal adenocarcinoma. Hepatic resection was compatible with metastatic adenocarcinoma. Disease-free margins were found in both specimens. Two months later the patient is in good condition and receiving adjuvant therapy with FOLFOX.