Laparoscopic total mesorectal excision of low rectal cancer with preservation of anal sphincter: a report of 82 cases

Abstract

Aim: To assess the feasibility and efficacy of laparoscopic total mesorectal excision (LTME) of low rectal cancer with preservation of anal sphincter.

Methods: From June 2001 to June 2003, 82 patients with low rectal cancer underwent laparoscopic total mesorectal excision with preservation of anal sphincter. The lowest edge of tumors was below peritoneal reflection and 1.5-7 cm from the dentate line (1.5-5 cm in 48 cases, 5-7 cm in 34 cases).

Results: LTME with anal sphincter preservation was performed on 82 randomized patients with low rectal cancer, and 100 % sphincter preservation rate was achieved. There were 30 patients with laparoscopic low anterior resection (LLAR) at the level of the anastomosis below peritoneal reflection and 2 cm above from the dentate line; 27 patients with laparoscopic ultralow anterior resection (LULAR) at the level of anastomoses 2 cm below from the dentate line; and 25 patients with laparoscopic coloanal anastomoses (LCAA) at the level of the anastomoses at or below the dentate line. No defunctioning ileostomy was created in any case. The mean operating time was 120 minutes (ranged from 110-220 min), and the mean operative blood loss was 20 mL (ranged from 5-120 mL). Bowel function was restored and diet was resumed on day 1 or 2 after operation. The mean hospital stay was 8 days (ranged from 5-14). Postoperative analgesics were used in 45 patients. After surgery, 2 patients had urinary retention, one had anastomotic leakage, and another 2 patients had local recurrence one year later. No interoperative complication was observed.

Conclusion: LTME with preservation of anal sphincter is a feasible, safe and minimally invasive technique with less postoperative pain and rapid recovery, and importantly, it has preserved the function of the sphincter.

Figure 1

The "lateral" ligaments (→) of rectum containing middle rectal artery or its branches, and mesorectum (←) were dissected completely with a harmonic scalpel (↓).

Figure 2

The left pelvic splanchnic nerves were preserved intact as far as possible. Inset shows the inferior hypogastric nerve nerve fibers (←) and the ureter (→).

Figure 3

Denonvilliers fascia (↓)was dissected along the space (↑) between the posterior wall of vagina (→) and the rectum (←).

Figure 4

The cross clamping of the rectum (←) was performed 1.5~3.5cm below the tumor with endo-cutter (→). Pelvic floor 'muscularization' was shown (↓).

Figure 5

The puncturing cone (→) of the circular stapler pricked through the midpoint of occluding line of the distal rectum(←). Levator ani muscles were exposed (↓).

Figure 6

The dorsal mesorectum (→) and distal mesorectum (↓) of the rectal specimen were shown (6a); The anterior side of the specimen and distal margin (←) were shown (6b).

Figure 7

The anastomotic ring (→) could be shown easily in the patient receiving colo-anal anastomosis (a); Satisfactory contractive function of the saved anus (↑) was achieved in the patients receiving laparoscopic TME with anal sphincter preservation at the first day after operation (b).