A New Technique to Achieve Sufficient Mesorectal Excision in Upper Rectal Cancer

Abstract

Background: Appropriate partial mesorectal excision (PME) is extremely important for prevention of local recurrence even in upper rectal cancer. However, it is not always easy to conduct PME in the narrow pelvic cavity. We devised a new surgical technique that involves a rectal transection followed by PME. Methods: After rectal mobilization in the layer targeted for total mesorectal excision, only the rectal wall was bluntly dissected at an appropriate distance from the tumor. Initial transection of the rectum allows drawing the rectum toward the anal side so that the mesorectum can be confirmed with a good visual field. Excision of the mesorectum was easy, and it could be resected in a short time. Results: This technique was conducted on seven patients with upper rectal cancer and on four patients with rectosigmoid cancer. Separation of the rectal wall was comparatively easy, and we had no incidence of wall injury. The average distance from the rectal stump to the distal mesorectum in the freshly resected specimen was 15 mm, indicating satisfactory PME. Conclusions:This easily performed method is a promising procedure for achieving sufficient PME in upper rectal cancer.

Surgical technique for mesorectal division during robot-assisted laparoscopic tumor-specific mesorectal excision (TSME) for rectal cancer using da Vinci Si surgical system: the simple switching technique (SST)

“…The present study presented and evaluated a novel for mesorectal division method in RALS TSME. Although for mesorectal division in TSME is difficult, only a small number of reports have described methods of mesorectal division, even in open and laparoscopic surgery [3,8], and to our knowledge, no reports have evaluated this procedure in RALS. Ours is the first report evaluating a useful mesorectal division method during RALS TSME, which we named SST.…”

“…Surgeons have several choices when dividing the mesorectum during RALS, namely, whether the console surgeon or the patient-side surgeon divides the mesorectum and with what devices. Regarding the devices used during mesorectal division, staplers; advanced bipolar clamps, such as the LigaSure™ (Medtronic, Minneapolis, MN); and a Harmonic Scalpel are all options to avoid bleeding [3,6,8]. In this study, we evaluated the usefulness of SST compared with two other methods (non-SST): division using the EndoWrist ® Vessel Sealer instrument by the console surgeon and division using a Harmonic Scalpel by the patientside surgeon.…”

“…SST is economical and eco-friendly because the technique requires only the first three necessary instruments to completely perform RALS TSME. For other methods, additional devices such as the Ligasure™, staplers, or the Harmonic Scalpel are usually required to divide the mesorectum [3,6,8]. In addition, instruments used in SST are all reusable after autoclave sterilization, although there is a 10-use limit, while staplers and almost all vessel sealing devices such as the Ligasure™ and the Harmonic Scalpel are disposable.…”

“…Depending on the location of rectal cancer, tumor-specific mesorectal excision (TSME), which the procedure of mesorectal division distal to the tumor is required, is selected rather than total mesorectal excision (TME) [1,2]. At the level at which TME is conducted, the mesorectum is thin, usually precluding the need for special treatment of the mesorectum; on the other hand, the mesorectum at the site of TSME for upper rectal cancer is thick [3]. In a narrow pelvic cavity, successfully accomplishing sufficient TSME is not always easy, and there is a risk of local recurrence when TSME is inadequate [1,4,5].…”

A New Laparoscopic Surgical Procedure to Achieve Sufficient Mesorectal Excision in Upper Rectal Cancer

“…To overcome these difficulties, we have introduced a technique to transect the rectum before resection of the mesorectum during conventional open surgery [10]. This technique assures an adequate distance between the tumor and resected stump on the anal side and sufficient TSME corresponding appropriately to the T-stage of the tumor.…”