Hüscher Cristiano G S, Lirici Marco Maria
1 Department of Surgery, Rummo Hospital, Benevento, Italy 2 Department of Surgery, San Giovanni Hospital, Rome, Italy.
Dis Colon Rectum. 2017 Oct;60(10):1109-1112. doi: 10.1097/DCR.0000000000000893.
Laparoscopic total mesorectal excision is effective and safe but often technically challenging because of inadequate exposure. Transanal total mesorectal excision was introduced to mitigate this limitation and improve the quality of mesorectal dissection in even the most challenging cases. Currently, the technique for transanal total mesorectal excision dissection is not standardized.
The sequential approach to transanal total mesorectal excision mirrors the principles of the transanal abdominal transanal procedure. It begins with the transanal step, followed by the laparoscopic step, and then the transanal total mesorectal excision. The perirectal space is entered via a full-thickness dissection of the anterior rectal wall. Carbon dioxide is left flowing, widening the embryonic planes between the mesorectal and pelvic fascias, then moving upward through the retroperitoneal space. The surgeon switches to the abdominal field and begins laparoscopic dissection, consisting of inferior mesenteric artery dissection and division, inferior mesenteric vein dissection and division, and possible splenic flexure dissection. Pneumodissection facilitates this procedure by distancing the inferior mesenteric artery from the hypogastric nerves and opening the embryonic fusion plane between the Toldt and Gerota fascias to allow faster division of the left colon lateral attachments. The operation continues with a switch to the perineal field and mesorectal excision.
A total of 102 patients underwent transanal total mesorectal excision as described. Mean operative time was 185.0 + 87.5 minutes (range, 60-480 min), and there was no conversion to open surgery. Postoperative morbidity was 33.3%. Mortality rate at 30 days was 1.96% (2 cases). Quality of mesorectal excision according to Quirke was assessed in all of the specimens and found to be complete in 99 cases (97.1%) and nearly complete in 2.9% of cases.
Transanal total mesorectal excision may benefit from pneumodissection, expedites the laparoscopic step, and the sequential approach facilitates the visualization of the correct dissection planes. The safety and cost-effectiveness of the procedure still warrant consideration. See Video at http://links.lww.com/DCR/A418.
腹腔镜全直肠系膜切除术有效且安全，但由于暴露不充分，技术上往往具有挑战性。经肛门全直肠系膜切除术被引入以减轻这一局限性，并在最具挑战性的病例中提高直肠系膜切除的质量。目前，经肛门全直肠系膜切除术的技术尚未标准化。
经肛门全直肠系膜切除术的序贯方法反映了经肛门-腹部-经肛门手术的原则。它始于经肛门步骤，接着是腹腔镜步骤，然后是经肛门全直肠系膜切除术。通过直肠前壁的全层解剖进入直肠周间隙。持续注入二氧化碳，扩大直肠系膜和盆筋膜之间的胚胎平面，然后向上穿过腹膜后间隙。外科医生切换到腹部视野并开始腹腔镜解剖，包括肠系膜下动脉的解剖和离断、肠系膜下静脉的解剖和离断，以及可能的脾曲解剖。气腹分离通过将肠系膜下动脉与腹下神经分开，并打开Toldt筋膜和Gerota筋膜之间的胚胎融合平面，便于更快地离断左结肠外侧附着，从而促进该手术。手术继续进行，切换到会阴视野并进行直肠系膜切除。
共有102例患者接受了所述的经肛门全直肠系膜切除术。平均手术时间为185.0 + 87.5分钟（范围为60 - 480分钟），无中转开腹手术。术后发病率为33.3%。30天死亡率为1.96%（2例）。对所有标本根据Quirke法评估直肠系膜切除质量，发现99例（97.1%）完整，2.9%的病例接近完整。
经肛门全直肠系膜切除术可能受益于气腹分离，加快了腹腔镜步骤，序贯方法有助于清晰显示正确的解剖平面。该手术的安全性和成本效益仍值得考虑。见视频：http://links.lww.com/DCR/A418 。
