We began with the transanal approach in the mesorectum. The
Lone Star retractor was inserted. Exam under anesthesia revealed that the
tumor was anteriorly located, but approximately 3 cm from the sphincter
complex. We used the low-flow retractor and then was able to place a
pursestring suture distal to the tumor. We then incised this with the cautery
and began dissecting transanal, full thickness. Once we were able to do this,
we then placed the TaTME equipment and insufflated. We then in a
circumferential fashion began dissecting and was able to enter the abdomen
anteriorly. At this point, we then packed this area.
At this point, a supraumbilical 5 mm incision was made. Veress needle
inserted. Water drop test flowed easily. Insufflated on low-flow then
high-flow to pressure of 15 mmHg and opening pressure of 2 mmHg. Camera
inserted via an Optiview technique. There was no visceral trauma. No
bleeding. No metastatic disease was noted. At this point, we placed
additional 5 mm ports in the right lower and right upper quadrant. An
assistant port was placed in the left lower quadrant. Attention was placed on
superior rectal. We then incised the superior rectal peritoneum with the
LigaSure and then dissected along the lateral aspects of the rectum. We then
performed medial to lateral dissection and identified the ureter and complete
ureterolysis was performed, keeping it out of harm's way. We then transected
the superior rectal artery. We then began dissecting in the mesorectal plane
posteriorly and then anteriorly. Once we came anteriorly and entered our
previous dissection and dissect it circumferentially. Once we were able to do
this, we then withdrew the entire specimen out of the anus and used IC-Green
evaluation to identify the demarcation. We marked this and then transected at
this area. We then went through the rectum back into the abdomen and then
performed a handsewn coloanal anastomosis with interrupted 3-0 silk sutures
bilateral internal pudendal nerve. At this point, 15 mL of Marcaine was
injected into the pudendal nerve space on the right side and on the left side.
We then identified the ileum and approximately 15 cm proximal to this, we made
a small elliptical incision in the right lower quadrant and made a cruciate
incision in the fascia and brought out the ileostomy. We then matured this in
a Brooke fashion with 3-0 Vicryl sutures.
Lone Star retractor was inserted. Exam under anesthesia revealed that the
tumor was anteriorly located, but approximately 3 cm from the sphincter
complex. We used the low-flow retractor and then was able to place a
pursestring suture distal to the tumor. We then incised this with the cautery
and began dissecting transanal, full thickness. Once we were able to do this,
we then placed the TaTME equipment and insufflated. We then in a
circumferential fashion began dissecting and was able to enter the abdomen
anteriorly. At this point, we then packed this area.
At this point, a supraumbilical 5 mm incision was made. Veress needle
inserted. Water drop test flowed easily. Insufflated on low-flow then
high-flow to pressure of 15 mmHg and opening pressure of 2 mmHg. Camera
inserted via an Optiview technique. There was no visceral trauma. No
bleeding. No metastatic disease was noted. At this point, we placed
additional 5 mm ports in the right lower and right upper quadrant. An
assistant port was placed in the left lower quadrant. Attention was placed on
superior rectal. We then incised the superior rectal peritoneum with the
LigaSure and then dissected along the lateral aspects of the rectum. We then
performed medial to lateral dissection and identified the ureter and complete
ureterolysis was performed, keeping it out of harm's way. We then transected
the superior rectal artery. We then began dissecting in the mesorectal plane
posteriorly and then anteriorly. Once we came anteriorly and entered our
previous dissection and dissect it circumferentially. Once we were able to do
this, we then withdrew the entire specimen out of the anus and used IC-Green
evaluation to identify the demarcation. We marked this and then transected at
this area. We then went through the rectum back into the abdomen and then
performed a handsewn coloanal anastomosis with interrupted 3-0 silk sutures
bilateral internal pudendal nerve. At this point, 15 mL of Marcaine was
injected into the pudendal nerve space on the right side and on the left side.
We then identified the ileum and approximately 15 cm proximal to this, we made
a small elliptical incision in the right lower quadrant and made a cruciate
incision in the fascia and brought out the ileostomy. We then matured this in
a Brooke fashion with 3-0 Vicryl sutures.