Laparoscopic intersphincteric resection using needlescopic instruments.

Intersphincteric resection (ISR) is a procedure designed to preserve anal function in cases with very low rectal cancer. We report our clinical experience with laparoscopic ISR (Lap ISR) performed using needlescopic instruments. First, a camera port is created at the umbilicus. Two 5-mm ports are then inserted at the right upper and lower quadrants. Two needlescopic forceps (Endo-Relief(™) Hope Denshi Co., Chiba, Japan) are inserted at the left upper and lower quadrants. We then perform the following procedures; ligation of the inferior mesenteric artery and vein, total mesorectal excision and dissection of the intersphincteric space. After the transanal intersphincteric dissection, the specimen is extracted through the anus and a hand -sewn coloanal anastomosis is performed. The covering ileostomy is finally created at the right upper port. We performed Lap ISR using needlescopic forceps in two patients with very low rectal cancer. In both cases, we were able to perform this procedure without insertion of an additional port or to change the needlescopic forceps to conventional 5-mm forceps. Lap ISR with needlescopic instruments is a feasible procedure for minimally invasive surgery.

INTRODUCTION

Intersphincteric resection (ISR) is a procedure that aims to preserve anal function in patients with very low rectal cancer.[1] Since the introduction of laparoscopic rectal surgery for rectal cancer, ISR has been performed laparoscopically. Watanabe et al.[2] first described laparoscopic ISR (Lap ISR) in 2000, and a number of cases have since been reported.[345678] We present our clinical experience with Lap ISR performed using needlescopic instruments in two patients with very low rectal cancer.

SURGICAL TECHNIQUE

The patient is placed in the lithotomy position under general anaesthesia. The first port for the camera is placed at the umbilicus using the open technique. Pneumoperitoneum is established with pressure kept at 8-10 mmHg. Two 5-mm ports for the operator are inserted through the right upper and lower quadrants, and the upper port is placed where a diverting stoma would be created. Two needlescopic forceps (Endo-Relief™ Hope Denshi Co., Chiba, Japan) for the assistant are inserted into the left upper, and lower quadrants, such that a total of 5 ports are placed [Figure 1].

Figure 1

The port placement (schema and external view)

The Endo-Relief™ is a new type of needlescopic forceps. The tip of this new forceps has the same shape and size as that of the conventional 5-mm forceps; however, the new forceps type has a shaft measuring 2.4 mm in diameter. During the operation, we assemble five parts of the Endo-Relief™ [Figure 2].

Figure 2

Needlescopic forceps (Endo-Relief™). This needlescopic forceps is assembled from five parts, including the tip which has the same size and shape as the conventional 5-mm forceps and a shaft measuring 2.4 mm in diameter

Assembling and use this forceps as follows.[9]

The Shaft guide Plus™ (Hope Denshi Co., Chiba, Japan) is directly inserted into the abdominal cavity through the abdominal wall.

The top of the guide is passed through a 5-mm port extra-corporeally, and the inner needle is removed.

The forceps end is connected to the shaft guide outer sheath.

The handle parts are finally assembled, and the forceps top is then intra-corporeally pulled through a 5-mm port [Figure 3].

Figure 3

Direct insertion method of the Endo-Relief™. The Shaft guide Plus™ (Hope Denshi Co., Chiba, Japan) is directly inserted into the abdominal cavity through the abdominal wall (a). The top of the guide is passed through a 5-mm port extra-corporeally, and the inner needle is removed (b). The forceps end (arrow) is connected to the shaft guide outer sheath (c). The handle parts are finally assembled, and the forceps top is intra-corporeally pulled through a 5-mm port (d)

After dissection of the rectosigmoid mesentery at the level of the sacral promontory [Figure 4], the lymph nodes around the inferior mesenteric artery (IMA) are dissected using the electrocautery device and laparoscopic coagulating shears. The IMA is divided above the left colic artery, after ligation with the clip, and the inferior mesenteric vein is divided at the same level. Colonic mobilisation is performed using a medial to lateral approach, to preserve the ureter and the gonadal vessels. The mesorectum is carefully mobilized into the pelvis to preserve the hypogastric nerves and pelvic plexus. The needlescopic forceps inserted at the left upper quadrant is pulled cranially with the band or the Gauze tied around the rectum circumferentially, and total mesorectal excision is carried down to the levator ani muscles. The puborectalis and the Hiatal ligament are dissected to the intersphincteric plane, which is about 2 cm distal from the top of the Hiatal ligament. The pelvic dissection is thus completed [Figure 4].

Figure 4

Intraoperative findings. The rectosigmoid mesentery is grasped with the End-Relief™, and then dissected using the electrocautery device (a). The puborectalis and the anococcygeal ligaments (Hiatal ligament) are dissected to the intersphincteric plane, which is about 2 cm distal from the top of the anococcygeal ligament (arrow) (b)

In the transanal dissection, the application of a self-holding retractor (Lone Star Retractor Cooper Surgical Inc., Lone Star Medical Products Inc., TX, USA) is positioned in the anal canal. A circular incision of the mucosa and the internal anal sphincter is performed at the dentate line. After circular dissection of the rectum, the specimen is extracted through the anus. Reconstruction consists of a hand-sewn coloanal anastomosis. A loop ileostomy is created at the right upper port site, and the drainage tube is inserted into the pelvis. After the operation, the only abdominal incisions are limited to the stoma site and the port sites [Figure 5].

Figure 5

Postoperative external view of laparoscopic intersphincteric resection using the needlescopic instruments

RESULTS

We performed Lap ISR for two cases using the End Relief™ . One patient was a 60-year-old woman with a body mass index (BMI) of 22.5. Colonoscopy revealed a rectal tumour and the distal border was located 3.5 cm distal from the anal verge [Figure 6]. The other patient was a 61-year-old man with a BMI of 19.9. Colonoscopy revealed a rectal tumour and the distal border was located 4.5 cm distal from the anal verge [Figure 6]. Operative times were 384 min and 406 min, and blood losses were 10 mL and 55 mL, respectively. There were no intraoperative complications, and we were able to perform this procedure without the need for insertion of an additional port or changing the needlescopic forceps to conventional 5-mm forceps. Neither patient experienced postoperative complications. The postoperative hospital stays were 14 days and 20 days, respectively, because both patients needed to acquire sufficient knowledge of stoma management. The classifications were pT2 and pT1, respectively. Numbers of harvested lymph nodes were 7 and 16, respectively. However, there was no lymph node metastasis in either case. The distant margin and radial resection margin were negative in both cases. The final TNM classification was Stage 1 in both cases.

Figure 6

Colonoscopic findings. Colonoscopy reveals a rectal tumour located 3.5 cm distal from the anal verge in a 60-year-old woman (a). A rectal tumour is located 4.5 cm distal from the anal verge in a 61-year-old man (b)

DISCUSSION

Intersphincteric resection is a sphincter-preserving procedure developed with the aim of avoiding the need for a permanent stoma in cases with very low rectal cancer, and was introduced by Schiessel et al.[1] With the spread of laparoscopic surgery to colon cancer, laparoscopic rectal surgery has been introduced.[10] Lap ISR was first described by Watanabe et al.[2] in 2000. Since then, the feasibility of Lap ISR, in terms of complications, outcomes and anal functions, has been reported.[345678] However, the sample sizes in these reports are relatively small, and only three reports collected >100 cases having undergone Lap ISR.[567] First, this technique is often performed for low rectal cancer at stage 0/1 or clinical T1/T2.[8] Second, the Lap ISR procedure requires greater skill than laparoscopic low anterior resection.

With Lap ISR procedures, it is not necessary to create an extraction site, because the resected specimen is extracted through the anus. Furthermore, in many cases, a diverting ileostomy is created to avoid any potential risk for anastomotic leakage. In the recent literature, a diverting stoma was created in 88-100% of cases,[4678] the exception being the 11% described by Park et al.[5] The stoma site can be used for single-incision laparoscopic surgery (SILS) placement to reduce the number of ports. Hara et al.[11] reported that they created the SILS port in the right lower abdomen, where a diverting stoma would be created, and the other two ports (10 mm port just above the umbilicus, 5 mm port at the left side of the abdomen). Two ports were inserted through the SILS port, such that 4 ports in total were placed.

The concept of reduced port surgery includes not only SILS, but also needlescopic surgery (NS). NS has been introduced for benign abdominal diseases, such as cholecystitis with gallbladder stones and appendicitis. In colorectal cancer surgery, NS is more advantageous as the natural orifice, that is, the rectum or the vagina, can be used for specimen extraction.[12] However, NS is adapted for ISR procedures in order to avoid the creation of an extraction site, because the surgical specimen is extracted through the anus. Moreover, NS does not require expert techniques, as compared with the SILS procedure. Therefore, we apply needlescopic instruments with the End Relief™ when performing Lap ISR.

During the operation, there is no tissue damage due to grasping the mesorectum or rectum with the End Relief™ . Because the needlescopic forceps tip has the same shape and size as those of a conventional 5-mm forceps, the risk of tissue injury with grasping and lifting is reduced. The End Relief™ may have a particular advantage for laparoscopic colorectal surgery, because this procedure involves lifting tissues to maintain the operating field and grasping the large intestine. Furthermore, NS can more easily and safely be applied to laparoscopic colorectal surgery than needlescopic forceps in which both the needle shaft and tip are small. This forceps also has cosmetic advantages and causes less pain than other needlescopic forceps. The skin damage is only 2.4 mm in diameter, with the passage of the 2.4 mm shaft through the abdominal wall, because it can be used without a trocar. Although the End Relief™ is strong enough for grasping tissues, the shaft can easily be slightly bent, when heavy tissues such as the mesorectum are lifted up. Therefore, we remain mindful of the direction of forceps implementation, in order to avoid bending the shaft.

CONCLUSIONS

Laparoscopic ISR is suitable for reduced port surgery, particularly NS, single port surgery, or mixed surgery, because the surgical specimen is extracted through the anus without creating a new extraction site. Our Lap ISR procedure using needlescopic instruments is a feasible procedure for minimally invasive surgery.