The Mesentery in Robot-Assisted Total Mesorectal Excision

Abstract

In recent decades, surgery for rectal cancer has evolved from an operation normally performed under poor vision with a lot of blood loss, relatively high morbidity, and mortality to a safer operation. Currently, minimally invasive rectal procedures are performed with limited blood loss, reduced morbidity, and minimal mortality. The main cause is better knowledge of anatomy and adhering to the principle of operating along embryological planes. Surgery has become surgery of compartments, more so than that of organs. So, rectal cancer surgery has evolved to mesorectal cancer surgery as propagated by Heald and others. The focus on the mesentery of the rectum has led to renewed attention to the anatomy of the fascia surrounding the rectum. Better magnification during laparoscopy and improved optimal three-dimensional (3D) vision during robot-assisted surgery have contributed to the refinement of total mesorectal excision (TME). In this chapter, we describe how to perform a robot-assisted TME with particular attention to the mesentery. Specific points of focus and problem solving are discussed.

Keywords

robot-assisted total mesorectal excision - surgical technique - mesentery

Publikationsverlauf

Artikel online veröffentlicht:
10. August 2022

• References

• 1 Culligan K, Walsh S, Dunne C. et al. The mesocolon: a histological and electron microscopic characterization of the mesenteric attachment of the colon prior to and after surgical mobilization. Ann Surg 2014; 260 (06) 1048-1056
• 2 Coffey JC, O'Leary DP. The mesentery: structure, function, and role in disease. Lancet Gastroenterol Hepatol 2016; 1 (03) 238-247
• 3 Chapuis P, Bokey L, Fahrer M, Sinclair G, Bogduk N. Mobilization of the rectum: anatomic concepts and the bookshelf revisited. Dis Colon Rectum 2002; 45 (01) 1-8 , discussion 8–9
• 4 Heald RJ. The 'Holy Plane' of rectal surgery. J R Soc Med 1988; 81 (09) 503-508
• 5 Heald RJ, Moran BJ. Embryology and anatomy of the rectum. Semin Surg Oncol 1998; 15 (02) 66-71
• 6 Kinugasa Y, Sugihara K. Topology of the fascial structures in rectal surgery: complete cancer resection and the importance of avoiding autonomic nerve injury. Semin Colon Rectal Surg 2010; 21 (02) 95-101
• 7 Kinugasa Y, Murakami G, Suzuki D, Sugihara K. Histological identification of fascial structures posterolateral to the rectum. Br J Surg 2007; 94 (05) 620-626
• 8 Miskovic D, Ahmed J, Bissett-Amess R. et al; European Academy for Robotic Colorectal Surgery (EARCS). European consensus on the standardization of robotic total mesorectal excision for rectal cancer. Colorectal Dis 2019; 21 (03) 270-276
• 9 Yang XF, Li GX, Luo GH, Zhong SZ, Ding ZH. New insights into autonomic nerve preservation in high ligation of the inferior mesenteric artery in laparoscopic surgery for colorectal cancer. Asian Pac J Cancer Prev 2014; 15 (06) 2533-2539
• 10 Sekimoto M, Takemasa I, Mizushima T. et al. Laparoscopic lymph node dissection around the inferior mesenteric artery with preservation of the left colic artery. Surg Endosc 2011; 25 (03) 861-866
• 11 Goh N, Fong SS, How KY, Wong KY, Loong TH, Tay GT. Apical lymph node dissection of the inferior mesenteric artery. Colorectal Dis 2016; 18 (06) O206-O209
• 12 Wang GJ, Gao CF, Wei D, Wang C, Meng WJ. Anatomy of the lateral ligaments of the rectum: a controversial point of view. World J Gastroenterol 2010; 16 (43) 5411-5415
• 13 Kim NK, Kim HS, Alessa M, Torky R. Optimal complete rectum mobilization focused on the anatomy of the pelvic fascia and autonomic nerves: 30 years of experience at Severance Hospital. Yonsei Med J 2021; 62 (03) 187-199
• 14 Walsh PC, Schlegel PN. Radical pelvic surgery with preservation of sexual function. Ann Surg 1988; 208 (04) 391-400
• 15 Kinugasa Y, Murakami G, Uchimoto K, Takenaka A, Yajima T, Sugihara K. Operating behind Denonvilliers' fascia for reliable preservation of urogenital autonomic nerves in total mesorectal excision: a histologic study using cadaveric specimens, including a surgical experiment using fresh cadaveric models. Dis Colon Rectum 2006; 49 (07) 1024-1032
• 16 Lindsey I, Warren BF, Mortensen NJ. Denonvilliers' fascia lies anterior to the fascia propria and rectal dissection plane in total mesorectal excision. Dis Colon Rectum 2005; 48 (01) 37-42
• 17 Wei B, Zheng Z, Fang J. et al. Chinese Postoperative Urogenital Function (PUF) Research Collaboration Group. Effect of Denonvilliers' fascia preservation versus resection during laparoscopic total mesorectal excision on postoperative urogenital function of male rectal cancer patients: initial results of Chinese PUF-01 randomized clinical trial. Ann Surg 2020; 274 (06) e473-e480
• 18 Gavriilidis P, Wheeler J, Spinelli A, de'Angelis N, Simopoulos C, Di Saverio S. Robotic vs laparoscopic total mesorectal excision for rectal cancers: has a paradigm change occurred? A systematic review by updated meta-analysis. Colorectal Dis 2020; 22 (11) 1506-1517
• 19 Phan K, Kahlaee HR, Kim SH, Toh JWT. Laparoscopic vs. robotic rectal cancer surgery and the effect on conversion rates: a meta-analysis of randomized controlled trials and propensity-score-matched studies. Tech Coloproctol 2019; 23 (03) 221-230
• 20 Jayne D, Pigazzi A, Marshall H. et al. Robotic-assisted surgery compared with laparoscopic resection surgery for rectal cancer: the ROLARR RCT. Efficacy and Mechanism Evaluation 2019 PMID: 31556981