Hasegawa Suguru, Okada Tomoaki, Hida Koya, Kawada Kenji, Sakai Yoshiharu
Department of Surgery, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo, Kyoto-city, Kyoto-fu, 606-8507, Japan.
Surg Endosc. 2016 Oct;30(10):4620-1. doi: 10.1007/s00464-015-4736-2. Epub 2015 Dec 30.
Recently, the efficiency of transanal minimally invasive surgery (TAMIS) for rectal cancer has been demonstrated (Velthuis et al. in Surg Endosc 28:3494-3499, 2014; Fernandez-Hevia in Ann Surg 261:221-227, 2015; Atallah et al. in Tech Coloproctol 18:473-480, 2014). We present our procedure of TAMIS for extralevator abdominoperineal excision (ELAPE) (Holm et al. in Br J Surg 94:232-238, 2007).
The patient had a rectal cancer located 4 cm from the anal verge with suspected invasion of the levator ani (cT4bN0M0). A skin incision was made around the tightly closed anus, and a GelPOINT device was placed. The fat tissue of the ischioanal fossa was divided until the levator ani muscle was widely exposed. Anterior dissection was performed just behind the transverse perineal muscle, and the arms of the puborectalis sling were identified at 1 and 11 o'clock. The levator muscle was divided from the posterior to bilateral sides, and dissection was entered into the mesorectal plane. Posterior dissection was performed until the sacral promontory was reached. Bilateral pelvic splanchnic nerves were identified at the 5 and 7 o'clock positions, and special care was taken to preserve them. At the anterior side, the arms of the puborectalis sling and perineal body were divided. Special care should be taken to avoid inadvertent injury to the anterior tissues (urethra or prostate) because the dissection tends to go toward the anterior-lateral side of the prostate in this approach. Once the dissection plane behind the prostate was established, it was easy to dissect the mesorectum circumferentially while preserving the pelvic autonomic nerves. Vascular division, mobilization of left colon and stoma creation were performed laparoscopically.
This approach provides better exposure of the surgical field, especially at the anterior side, compared with the conventional perineal approach of ELAPE. Since January 2014, we have performed seven cases using this procedure. There was no conversion to the conventional approach, and no major complication was encountered.
TAMIS is a promising approach for the perineal phase of ELAPE.
最近，经肛门微创手术（TAMIS）治疗直肠癌的有效性已得到证实（Velthuis等人，《外科内镜杂志》28:3494 - 3499，2014年；Fernandez - Hevia，《外科学年鉴》261:221 - 227，2015年；Atallah等人，《技术性结肠直肠病学》18:473 - 480，2014年）。我们展示了我们采用TAMIS进行经腹会阴联合切除（ELAPE）（Holm等人，《英国外科杂志》94:232 - 238，2007年）的手术方法。
该患者患有距肛缘4 cm的直肠癌，怀疑侵犯肛提肌（cT4bN0M0）。在紧闭的肛门周围做皮肤切口，置入GelPOINT装置。切开坐骨直肠窝的脂肪组织，直至广泛暴露肛提肌。在会阴横肌后方进行前方解剖，在1点和11点位置识别耻骨直肠肌吊带的臂。从后向前至双侧切断肛提肌，进入直肠系膜平面。进行后方解剖直至到达骶岬。在5点和7点位置识别双侧盆内脏神经，并特别注意予以保留。在前方，切断耻骨直肠肌吊带的臂与会阴体。应特别小心避免意外损伤前方组织（尿道或前列腺），因为在此手术入路中，解剖往往会朝向前列腺的前外侧。一旦在前列腺后方建立了解剖平面，就很容易在保留盆腔自主神经的同时沿圆周方向解剖直肠系膜。通过腹腔镜进行血管离断、左半结肠游离和造口术。
与传统的ELAPE会阴手术入路相比，该手术入路能更好地暴露手术视野，尤其是在前侧。自2014年1月以来，我们使用此手术方法进行了7例手术。无1例转为传统手术入路，也未发生重大并发症。
TAMIS是ELAPE会阴阶段一种有前景的手术入路。
