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A 54 year-old female patient, with no important surgical or medical history, besides smoking, presents to the emergency department with low fever and gluteal pain. Physical exploration identifies a gluteal abscess and complementary imaging exams diagnoses a suspected rectal tumor. After drainage and antibiotics the patient is derived to surgical consult.
Further exams confirm the diagnosis of a pre-oclusive rectal adenocarcinoma with no distant metastasis. Local staging with MRI shows invasion of the posterior vaginal wall, with final clinical stage of T4N1M0.
The case was discussed in the Multidisciplinary Cancer Committee and patient was proposed for neoadjuvant treatment followed by radical surgery, after initial diverting colostomy.
A transverse colostomy was performed 1 week after the first MRI, and 2 weeks prior to neoadjuvant chemotherapy. After 6 cycles of FOLFOX a new staging MRI was performed showing no important changes in tumor size and invasive status.
The patient was then submitted to a full course chemoradiotherapy, followed by a final staging MRI that suggested a T4 cancer, with invasion of the cervix.
Seven weeks after the final MRI the patient was submitted to radical surgery: Transanal total mesorectal excision + total hysterectomy with transvaginal extraction by the Cecil Approach.
The patient is positioned in lithotomy, and adequate aseptic and antiseptic measures are performed with chlorohexidine and iodine solutions.
The abdominal team, composed by a main surgeon and two assistant surgeons, starts the pneumoperitoneum and inspects the abdominal cavity: the uterus with very large miomas is identify, as is the impression of the rectal tumor in the peritoneal reflexion.
A total of 4 trocars are placed: 12mm supraumbilical optical trocar, 12mm trocar in the right iliac fossa, and 2 more 5mm trocars, midway between both iliac spines and the umbilicus.
The transvaginal/transanal team is composed by a main surgeon and an assistant surgeon.
The abdominal team starts with the dissection and ligation of the suspensory ligament of the ovary, followed by ligation of the broad ligament in both sides, freeing the uterus from its parietal attachments, while the transvaginal/transanal team completes the dissection and liberation of the cervix.
After the communication between both fields and complete mobilization of the anterior aspect of the uterus, the team moves transanally, as the abdominal team starts with sigmoid dissection and clamping, to allow for the construction of the pneumorectum.
After insertion of the platform and construction of the pneumorectum, the transanal team inspects the rectum and identifies the tumor. A purse-string is performed about 2 cm below the tumor, allowing for a perfect view of the distal margin.
The abdominal team is then free to continue with the mobilization of the colon and high ligation of the inferior mesenteric vessels.
The transanal team starts the tattoo to mark the rectal mucosa. The rectal wall is then carefully dissected, circumferentially, clockwise, until reaching the mesorectal plane.
The dissection continues, moving towards the peritoneal reflexion, always carefully, specially in the left anterior plane, where the tumor contacts with the cervix.
The teams rendez-vous in the anterior plane, posterior aspect of the uterus and the rectal specimen is completely freed.
The transanal team moves once more transvaginally, and with an adequate platform helps finishing the uterine dissection and mobilize specimen as a hole.
Transvaginal extraction is performed with help of an Alexis device, to avoid tumor dissemination.
Vascularization of the colon is assessed with ICG before transection. The anvil of the circular stapler is introduced, the colon is closed with a linear stapler and the is reduced to the abdominal cavity.
The vaginal cupula is then closed with a continuous V-lock suture.
The procedure ends with the construction of a latero-terminal circular mechanical anastomosis.
The procedure lasted about 180 min and the blood lost was below 200 mL.
The patient had an uneventful postoperative evolution. Liquid diet was started the same day, with progression according with tolerance. She was discharged at the 3rd post-operative day and derived to follow-up by surgery and oncology.
Pathological analysis of the specimen identified a T4 tumor, with no lymph node metastasis. Mesorectum was complete and a total of 13 nodes were retrieved.