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A 41-year-old female with no allergies or relevant medical or surgical record, a past smoker. She suffered from rectal bleeding and was diagnosed with a mriT1 adenocarcinoma 4cm from the anal verge.
A TAMIS procedure was performed in another hospital and she developed a recto vaginal fistula as a complication. The pathology report of the specimen was a T2 adenocarcinoma. They performed a loop colostomy to control fistula symptoms. As radical surgery was indicated and she suffered a complication from the TAMIS approach she was referred to our center.
In the preoperative assessment we were able to confirm that there was an ulcer in the anterior rectal wall just above the dentate line and the recto vaginal fistula, 6cm from the anal verge. An MRI was performed, finding a thickening of the anterior rectal wall with no extramural compromise of any lymph nodes. A functional study by manometry revealed a slight insufficiency of the sphincteric apparatus.
Radical treatment was performed using the Cecil approach with the patient in the Lloyd Davies position and two surgical teams working simultaneously by MIS (one transabdominal and one trans anal). We started with the abdominal field, inspecting the peritoneal cavity. No metastases were found; the left flank colostomy involved the inferior mesenteric vessels and the large myomatous uterus could hinder the procedure, so we decided to fix it to the abdominal wall.
The abdominal team started the mesocolon dissection with a medial to lateral approach by opening the peritoneum and identifying the avascular plane, while waiting for the transanal team to start the pneumorectum. Meanwhile Lone star positioning and rectal touch were used to confirm tumor and fístula location. Because it was a very low lesion it was necessary to customize the transanal access platform and make a mark at 12 hours.
We proceeded to perform anal dilation before introducing and setting the ports in the platform. The assistant surgeon takes care of keeping the platform in place while showing the surgical field with a 3D camera. The pneumorectum began once the abdominal team had clamped the sigmoid colon, to avoid its distention and continuous leak through the colostomy. After achieving a stable pneumorectum, we inspected the rectum and localized the fistula and tumor.
Then a tattoo of the rectal mucosa was performed with a cautery hook to ensure the distal margin of resection and guide the initial phase of the dissection. The goal is to reach the holy plane and to mobilize enough rectal wall to build a pursestring and seal the rectal lumen. Special attention is given to the dissection of the rectal wall as it is affected by the fistula and the neoplastic lesion.
Hemostasis should be maintained to ensure a clear surgical field. Laparoscopic Debakeys may be used to perform traction of the rectal wall and improve exposure. The main tip to find the lateral plane of dissection is to have control at the anterior or posterior margin and then follow it to the lateral margin. Special focus is applied to the fistula as it should be removed during dissection.
Notice that there is plenty of fibrotic tissue due to the previous TAMIS and the fistula which may hinder the identification of the correct plane. Having a stable working field clear from smoke, with depth perception provided by a 3D scope, smooth movements from the leading surgeon and their assistant makes this dissection feasible.
The dissection is performed circumferentially, keeping the same height. This is a key principle for proper transanal dissection. Notice the differences between tissues: the anterior tissue is still affected by fibrosis and the lateral tissue is normal. To make sure that you are in the correct plane improve exposure with the Debakeys and find the angel’s hairs described by Professor Heald.
Now we have mobilized enough rectal wall and we build a pursestring by means of a 0 prolene. This will close the rectal lumen and build a sealed cavity that maintains pressure and the necessary exposure to continue dissecting. This enables the transabdominal team to resume their work. The IMA is dissected with the energy devices close to its root and sectioned by sealing twice close to the aorta and sectioning above, medial to lateral mobilization advances and you can see that the gonadal vessels and the ureter are respected and left in a posterior plane.
The lateral attachment of the rectosigmoid junction is sectioned using the hook, a maneuver that will facilitate identification of the lateral margins from above. The transabdominal team start the TME from above by mobilizing the posterior plane, which is usually the easiest one. The traction from the surgeon's left hand is essential. Now both teams are performing simultaneous TME.
You can see that both teams are dissecting the anterior margin. In this case the correct plane is more obvious for the transanal team which is able to identify and remove the part of the vagina involved in the fistula. You can see that once the fistula has been removed the holy plane is identified and the TME continues on the correct plane, in this case the transanal approach is definitely an advantage that ensures a correct dissection. Can you imagine performing this by MIS from above?
A gauze in the transanal field pushed against the rectum provides the required exposure. Notice that we are high in the pelvis and we maintain the circumferential mesorectal dissection. A gauze in the vagina seals the cavity and reduces pneumo leakage through the genitals. Once healthy tissue is reached the dissection becomes easier and faster. This is healthy vaginal wall.
We close the rectal wall defect with a vicryl knot to decrease the contamination of the surgical field. In this phase of the surgery both teams join their dissection by connecting the anterior margin. This is great because now they can assist each other to improve traction and identify the correct plane. Now the transabdominal team has the correct angle and uses the energy device supervised by the transanal team to avoid unexpected injuries.
A nice maneuver is that the distal margin of the rectum gets pushed to the abdominal cavity. This exposes the posterior plane for the trans anal team that has great visualization. At this height the correct posterior plane is higher than it seems: remember the curve of the pelvis while dissecting. Now the posterior plane from the transanal team is connected with the work performed from the abdomen and clarifies the limits for the lateral dissection.
See once again how both teams help each other: the team with the better angle uses the energy device and the other team is in charge of improving exposure and supervising to avoid injuries to surrounding structures. After completing the TME the vaginal defect is repaired by a continuous barbed suture. The specimen was extracted through the colostomy wound and the descending colon was delivered to the pelvis and a manual coloanal anastomosis and a loop ileostomy were built.
Surgery took 270 minutes with less than 200ml of blood loss. The patient had an uneventful postoperative course, resumed oral intake on the first postoperative day and left hospital five days after the surgery.
Pathological examination of the specimen revealed a 2.2 cm low grade adenocarcinoma. The mesorectum had a defect in the area involved in the fistula. All margins were negative.
It was classified as a pT2N0 lesion and 13 nodes were harvested.
Digital examination found that the anastomosis and the vagina were intact. A water soluble enema performed two months after the procedure confirmed the integrity of the anastomosis and excluded fistula relapse. The loop ileostomy will be reversed.
