Table of Contents
Laparoscopic low anterior resection (LAR) is a complex surgical procedure used for resecting the distal sigmoid colon or rectum while preserving sphincter function. The patient is a 37-year-old, obese male with rectal cancer. Abdominal access is gained through four laparoscopic port sites. The omentum is freed from the transverse colon to enter the lesser sac. The splenic flexure and descending colon are mobilized from the retroperitoneum. The left colic artery is identified and divided. Following proximal mobilization, the dissection is carried towards the pelvis. The sigmoid colon is mobilized, and the presacral space is entered. The inferior mesenteric artery is divided between clips. The dissection in this case could not be carried down low enough in a laparoscopic fashion, and a lower midline incision was made. A suitable area on the descending colon is identified and the marginal artery divided. The proximal bowel is then divided with a stapler. A flexible colonoscope is then used to confirm tumor location and the rectum is divided below the tumor. Finally, a Baker type side-to-end anastomosis is performed with a powered EEA stapler, and its integrity verified endoscopically under water. A diverting loop ileostomy is then created at a previously marked site and the abdomen closed. In this video, we demonstrate the surgical steps of this procedure and provide insight into our intraoperative decisions.
Low anterior resection; colorectal cancer; open surgery, side-to-end anastomosis.
Colorectal cancer, encompassing carcinomas of the colon and rectum, is among the most common cancer diagnoses in the US and across the globe. Arising from the glandular epithelial cells lining the rectum, it is estimated that approximately 45,000 new cases of rectal cancer are diagnosed in the US annually.1 Rectal cancer is the 10th most lethal cancer responsible for over 300,000 deaths globally each year, despite a substantial number of deaths miscategorized as due to colon cancer.2, 3
Adenocarcinomas represent most of all rectal cancers and can be clinically silent or present due to rectal bleeding, altered bowel habits, fatigue, and weight loss. Risk factors including both non-modifiable and modifiable factors like age, familial syndromes, IBD, obesity, smoking, diet, and history of radiation; they are similar to those of colon cancer.4 Pathogenesis of rectal cancer has been described using Adenomatous polyposis coli (APC) gene adenoma-carcinoma progression, ulcerative colitis induced dysplasia and hereditary nonpolyposis colorectal cancer (HNPCC) pathways.5–7 However, the precise underlying mechanisms and mutations leading to the development of rectal cancer are still unknown. Colonoscopy has led to a notable decline in incidence and mortality among older individuals; however, cases of rectal cancer in those younger than 50 years have significantly risen.8 Rectal cancer accounts for over 37% of cases of colorectal cancers in those under the age of 50 years and 36% of cases in those aged 50–64 years.9
Surgical resection remains the mainstay of curative therapy for rectal cancer.10 Staging for rectal cancer patients consists of chest and abdominal CT scanning as well as a rectal MRI or endoluminal ultrasound. Transanal excision (TAE) or transanal endoscopic surgery (TES) can be performed for localized T1 disease. However, the results of these techniques are poor for T2 disease and associated with high recurrence and nodal metastases.10, 11 Locally advanced patients with T3 or greater and/or clinical stage 3 with local adenopathy greater than 1 cm on imaging usually receive total neo-adjuvant therapy (TNT). Approximately 20–25% of these patients may achieve a complete pathologic response and potentially avoid surgical resection. However, the majority will need either a LAR with a total mesorectal excision (TME) or an abdominoperineal resection (APR).12–15 The 5-year-survival rate for early-stage localized disease is over 90% and with regional lymph node involvement is 73%. However, for patients with stage 4 disease the 5-year survival rates are about 15%.1, 16, 17
In this video, we perform a LAR with diverting loop ileostomy for a 37-year-old male with locally advanced rectal cancer. During the procedure, a laparoscopic TME was done with conversion to an open approach and a distal Baker type side-to-end anastomosis was performed.
The patient is a 37-year-old male presenting with stage III rectal cancer. Patient has no relevant past medical or surgical history. His body mass index (BMI) was 38.6 and American Society of Anesthesiologist (ASA) score 2.
The patient was examined in the office and was in no apparent distress with normal vital signs. Abdominal exam was normal with an obese but soft abdomen, with no distension or tenderness to palpation.
Various pathogenic pathways and genetic mutations have been investigated in the development of colorectal cancer. Alterations of colonic and rectal epithelia lead to the development of benign polyps, which can further progress into invasive carcinoma over time. The underlying genetic mechanisms for these sequential changes have been attributed to hypermethylation, DNA mismatch repair genes, and/or microsatellite instability.18–20 The APC adenoma-carcinoma pathway associated with familial adenomatous polyposis (FAP); and the involvement of DNA repair genes (MLH1, MSH2, MSH6, PMS2) in Lynch syndrome, are among the most commonly recognized hereditary syndromes, alongside IBD-triggered dysplastic changes that lead to the development of colorectal cancer. Once invasive cancer has developed, malignant cells can invade local surrounding organs, or metastasize to distant sites through lymphatic, perineural, and hematogenous spread. Based on the stage and spread of the tumor, rectal cancer can be asymptomatic or present with various bowel and/or systemic symptoms. Serious tumor-related emergencies for rectal cancer can present with bleeding, perforation, and obstruction needing immediate attention.
Surgical resection is the only curative therapy for rectal cancer. However, the utilization of TNT for rectal cancer patients has led to complete clinical response rates ranging between 15–80%.21–23 These patients can be managed with watchful waiting instead of surgery, with similar survival rates, and lower morbidity and mortality rates.24, 25 Following accurate pretreatment disease staging, the most appropriate treatment options are selected based on patient factors and surgeon preferences. Surgical approaches range from local excisions (TAE, TES) to abdominal procedures like LAR, APR, or multivisceral resections. These procedures often include TME to reduce risk of local recurrences and improve patient outcomes.26, 27 For locally advanced rectal cancers, multimodal management including neo-adjuvant or adjuvant chemotherapy and radiotherapy are employed routinely. Patients receiving TNT prior to surgical resection have significantly higher overall survival, pathological complete response, and complete clinical response rates.28–31
The rationale for surgical resection is complete eradication of malignant tissue with goal to cure and improve quality of life. In rare cases with malignant or recurrent disease, palliative surgical procedures are performed to relieve patient distress and symptoms.
Depending on the staging of rectal cancer and individual patient factors, an appropriate resection technique and surgical approach are determined by the surgeon. Contraindications to curative surgery are limited to patients with significant medical comorbidities like cardiopulmonary, renal, and/or advanced metastatic disease.
As shown in the video, the main surgical steps for this procedure are: (1) Abdominal access with four laparoscopic port sites, (2) entry into lesser sac to mobilize the splenic flexure and descending colon with division of the left colic artery, (3) mobilization of the sigmoid colon and rectum, (4) isolation and clipping of the Inferior mesenteric artery, (5) continued distal mobilization in an attempt to get distal to the tumor, (6) midline laparotomy for conversion to open approach because we could not get distal to the tumor, (7) marginal artery and proximal bowel division with GIA 100 stapler, (8) extension of incision, (9) perform TME, (10) division of rectum with Contour 4.5-mm stapler, (11) distal side-to-end anastomosis with Covidien 31-mm EEA stapler and endoscopic leak test, and (12) prepare the loop ileostomy site and close the abdomen. This technique of LAR results in extensive mobilization of the colon, to aid adequate resection with a subsequent tension-free distal anastomosis and diverting loop ileostomy. The blood flow through the marginal artery of Drummond is preserved to ensure adequate supply to the colon.
Surgical approaches for treatment of rectal cancer have evolved considerably over the years. Historically, the LAR approach was first described by Hartmann in 1921.32 Subsequent modifications to LAR technique have established it as a safe and effective treatment option for rectal cancer. Two notable improvements include the improvement of sphincter sparing LAR surgery and transanal stapling techniques allowing for effective low pelvic anastomosis. Sphincter sparing LAR with TME resection achieves adequate negative margins and is associated with significantly low recurrence rates (< 10%).33,34
Laparoscopic, robotic, and open approaches have been used for LAR surgery with comparable oncological outcomes.35 The decision for the most appropriate approach is determined by the surgeon based on patient factors and intraoperative circumstances. As observed in this case, owing to patient factors like severe obesity, the pelvic access was very limited. In order to appropriately identify and dissect the distal margin of the rectal tumor, the laparoscopic approach was converted to an open LAR procedure. This was done to allow for adequate tumor resection with negative margins. Furthermore, the open approach ensured sufficient margins to close with a tension-free anastomosis. The most frequently encountered postoperative complications of LAR are anastomotic leakage and hemorrhage. Intraoperative anastomotic integrity testing and creation of diverting loop ileostomy after LAR are two established techniques known to lower rates of postoperative morbidity, consequences of anastomotic leaks and need for reoperations.11,36
Areas of ongoing investigation are focused on discovering novel diagnostic and therapeutic modalities for rectal cancer. Utilization of concurrent fluoropyrimidine chemotherapy (CRT) and immunotherapy agents like PD-1 inhibitors have shown promising results in the treatment of various stages of rectal cancer.37,38 Continued advancements in medical therapies may aid the curative effects of surgery and have substantial effects on patient outcomes including quality of life.
- Covidien laparoscopic harmonic scalpel
- Endo GIA™ 100 stapler
- Contour 4.5-mm stapler
- Covidien 31-mm end-to-end anastomosis stapler
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
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- Keller DS, Berho M, Perez RO, Wexner SD, Chand M. The multidisciplinary management of rectal cancer. Nat Rev Gastroenterol Hepatol. 2020;17(7):414-429. doi:10.1038/s41575-020-0275-y.
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Cite this article
Pannu PR, Berger D. Laparoscopic low anterior resection with diverting loop ileostomy for rectal cancer with conversion to open approach. J Med Insight. 2023;2023(342). doi:10.24296/jomi/342.
Table of Contents
- Free and Elevate Omentum
- Pull Transverse Colon Down and Enter Lesser Sac
- Descending Colon and Splenic Flexion Mobilization
- Clip and Divide Left Colic Artery
- Finish Proximal Mobilization
- Sigmoid Colon and Rectum Mobilization
- Isolation and Division of IMA Pedicle
- Continue Distal Mobilization
- Marginal Artery Division
- Check Tumor Location with Colonoscope
- Prepare Loop Ileostomy Exit Site
- Close Abdomen
- Staple Port Incisions
- Inject Local Anesthetic
- Staple Midline Laparotomy Incision
- Mature Loop Ileostomy
My name is David Berger. I'm a surgeon at Massachusetts General Hospital, and today I will be performing a laparoscopic low anterior resection with a laparoscopic ileostomy for a rectal cancer in an obese male.
All right, can we have a knife. Let's see. Here. Okay. Yep. There's that back? Gas on, please. The gas is on. Thank you. Do you wanna start with a 12? Yeah, thank you. All right. All right, let's see if we can get up here.
Celeste, do you think we're paralyzed? I believe you if you are, I'm just ... Okay. All right, let's flip this up. Okay, take that out there. and then right up here under here. Okay, now come back. Gotta see if we can get this to go up and stay up. Uh-huh, right here. And then right here. Gotta be careful, man. That's bowel right there. That was remarkably close. Again. Celeste, do you think you could give me a little bit of T-berg? Just a touch. Thank you. You don't have to be in, you just need to center, right? There you go. All right, pull back your camera. We gotta see if we can get this up, the omentum up. All right, that's looking better. Come on over again.
I can finally see the colon, which is helpful. Yeah. Yep. Yep. Closer to the bowel. No, the bite didn't get much, but, all right. Let's go this way. Yeah. Way out here. Lower. Lower a little. Lower, lower. It's underneath that stuff, yeah. Okay, now look over towards the bowel. Closer to the bowel. Closer to the bowel. Yeah. Now careful, bring your camera in, yep. Yeah. So, see that right there? No, no, lower, lower, the underneath part. No, no, no, no, no. I'm showing it to you, all right. It's right there. Sideways, other way. No, no, no. You gotta separate this. Yep. See, this is the mesentery, and that was stuck to that. Now, come back up here. No, no, no. This is actually free, just, but it's not a huge bite. Yep. Yeah, and then it's up here, and not a huge bite. It's nothing that bite, but yeah. Okay, now let's go back. Yeah. Yep. Yep. Up out near me. Handle up this stuff right here. Okay, let's see if we can get up the side now.
This isn't gonna be easy. Wow. Okay, under here. Can I have the introducer, please? Pull it back for him, please. Don't change the angle if you can, right? Need that, right down there. Well... Okay, can somebody hold this, right there. You gotta have your tip underneath and you gotta slide up. All right, you have to take this. Well, that was good. Okay, now come back. Now we gotta see if we can get in there, right? You want to be right here. Just right over here. Handle needs to be a little bit up, Travis. You're not giving 'em a picture. No, towards me, Travis, yeah. Pull back. Pull back your camera. Come on in with your camera. Okay, go get it. Okay, that's fine. But the problem, Travis is over here, right? No, no, no, Travis. It's over here. Right here, this. No, that's wrong, Travis. This way. Okay, pull back. All right, now come in. Now you see where you need to be? Mm-hmm. You're not looking there with the camera. Further off by a millimeter. Yeah, that was 2 mm or 3. Yeah. Okay, pull back your camera a second, please. Pull back your camera a little. Okay, see where you need to be? Yep. Come back and get under here. Okay, hold on. Now, hold on. You gotta get back over here now. We don't have enough here, right? Nope, no, no, no, no. It's this line right here. Yeah. No. Yep. No, I can't see. If I can't see Travis, you can't see. That's the whole thing, right? Like that's the whole gig. You're just a millimeter too high, man. Today. That's right. Right there, see it? It's too lateral, right? Look, closer to me. All right, leave it. Let's work here. Lift your handle up, there you go. Okay, now let's go back up here. Up here. So it's right... It's right here, this stuff. You're not - I can't see. Nope, that's the pancreas, right? This up here is pancreas. So we gotta be working this way. Yeah, that's right. Now you gotta go back and get what you left behind, and then you gotta get the low part. Yeah, but if I can't see Travis, thank you. Oh, that's good. Now we gotta come back again. No, Travis, we're looking out here. You're not even looking in the right spot. Yeah, no. You want this stuff, no. Right there, right in the center of the frame. Yep. Okay. Okay, good. Now, let's go back over here. Okay, you see what needs to be gotten there? Okay. Handle up, Travis. Okay. Okay, let's see now. Okay, let's go through that free space. This way.
The left colic's gonna be there, so you just kind of want to come over this, right? Into that space. Can I have some clips, please? Yep. No. Take that back. You realize you caught something from behind in there, right?
Okay, right there. Skinny this right here. It's fine. Okay, just take a look over here now. All right, see that right there? Right under here? Yep. No, that was right. Yeah, it's just stuck. Uh-uh-uh. No, angle's wrong, right there. Yep. And now you gotta get the top part. Okay, good. Now, come back. We gotta get the stomach free off the mesentery, right? All right. Up here. Yep. Higher, yeah. Mm-hmm. Lower. Yep. Yep. Lower, yeah. Yep. Yeah, come back over here. Yep, perfect. Okay, let's see here. Yep. Lower. Is there any chance you're going to open? I don't know, there's always a chance. All right, let's look up here. We're still looking right up here. I want to make sure the back wall of the stomach is free. Okay, right there, see it? And then lower across that. Yeah, lower. Okay, good. Let's see if I can get this up again. Higher, yeah. Okay. Yep, it's higher, yep. Now this right over here. All right, now let's see right down here. Yep. I think that has it now. Yeah, there we go. Okay, good. Now, we're pretty free here. Pretty free here. Until we're stuck. Okay, let's switch.
Celeste, position number two, please. We need to be up here now. Mm-hmm. Higher to the bowel, yep. Higher to the bowel. To the bowel, yep. To the bowel, so it's up. To the bowel, I don't want any of the white in it. Now, it come - it's right here. High to the bowel, to the bowel, yep. And then this here. Right at, see this stuff right here? Right there. Nope, too high. Yep. Uh-huh, now let's come back over here. Handle back. Handle back. You're too far in with your scope. Up by me. Up high by me. Yeah, but you're not, honestly ... Mm-hmm, right there, see it? Don't dig deep. Okay. Uh-uh-uh, you can't... Okay, now go get it. Okay, right there, see it? Push down, okay. Pull back your camera. Yep. Right here. Right here. You're angling this way. You're a millimeter to that way, it's up higher. Yep. Carry it right down there. Yep, hold on. Okay, see the plane right there? Higher. Yeah, well, yeah. Mm-hmm. No, no, no, no, no, there's nerves. You can see them right there. Spin it up to the mesentery. Higher, higher. Yep. Right there. Mm-hmm, high. Spin it up higher. There you go, push. Okay, I'll take that there. Spin it. Okay, pull back. Let's go on this side for a second. Okay, right there. High, uh-uh-uh-uh, higher. No, no, no, up high, look where I am. Yeah, you cut across a plane there, but, okay, go ahead. Look, it goes this way, right? Not up. Yep. Yep. Mm-hmm. Right here. I don't know, man. No, no, no, no. It's above that plane. Okay, pull back your camera, please. Okay, get the middle there. No. No, no. You want me to come up and clean the camera? Sure. Okay, let's look at this side over here now. Way back here. Uh - yeah, I may - it's gonna get tough down in the pelvis. Let's see. Okay, somebody hold that. Okay, so this is where we haven't finished yet. Here and just give it to me from this side. Thank you.
All right, so this is the IMA pedicle right here, right? I think you're gonna have to come in from the side, Travis, please. Okay, let's see. I think the artery is right there. Of course, I'm not seeing it really well. There's a vein right there. I can see the artery going right there. Can I have a clip? Over here. I'm gonna need another, yeah. All right. All right, that's the vessel. Clips. All right.
Okay. Okay, get right up in there. Up high now. Bring your camera in. High. Too high. Yep. Okay, keep going, next door to it, push. Yep. Do it again. Higher, no, no... Okay, you can do that, yes, yeah. Yep, keep going. Mm-hmm, pull back. Yep, right in the middle there. Higher. Okay, you gotta go to your side. Do it again, same thing. Push, uh-huh, right there on the side. Push. Yep, okay. Okay, now let's come - pull out. Thank you. Okay, we gotta take this. Higher to the bowel. Push. Okay, hold on. Push. Yeah, that's okay. That's the right plane, right there. Okay, pull back now. Okay, now let's get this side, right here. Push. Inside me, there. Push to the bowel. Mm-hmm. Pull back your camera. It's right here, right? Push. Hold on. Push. Okay, now, right there in the middle, see it? Don't pull back. Okay, get in the middle. Hold on, hold on, pull back. Right in the middle, you see it? Push. Right there. Push, right there. Pull back. Okay, right there. Let's clean the camera off, please. I don't think we're gonna be able to finish this laparoscopically, but let's see what we can do. Mm-hmm, right there, see it? Well, so, okay, wouldn't you put your tips the other way for that if you were gonna do that? Like the arc of the thing is directly to the arc of the bowel, right? I know it's hard. I really, really do, but I need it to be in tight, yeah. Uh-huh, now you gotta go in tight in there, see it? Yep. Push. Okay, now under there. You're the camera. Yeah. Uh-huh, hold on, pull back. We're not getting through that space very much more. Let's see if we can come across the top. We can't even really do that, can we? Can get right there, connecting the dots. No, no, no, stop. Look where the dots are. Yeah, you had it, and you moved it. Yep. No, no. All right, we're gonna have to stop.
All right, can we open from here to here? Yep. Do you want me to open the general retractor set? Yeah, definitely. Mm-hmm. Okay. Yep. That's the peritoneum. Mm-hmm. Can open this down to here. That's good. You gonna be at the belly button. Here come these. All right, let's see how well we did. Can't even get my hand in there. All right, we got a ways to go, but we do have plenty of bowel this way. All right, so let's just to get this out of the way.
Just make sure that'll go. So let's go right here. Careful, that's bowel wall. Pickups, please. Mm-hmm. Okay, can we have Schnidts, please?
Yep. Metz, please. And that's the marginal artery again. No different just because it's a big case. GIA 100, please. Cut. Stapler, please. Okay. Yep. Yep. Just push one side. Okay, so we can get rid of that.
Now we're gonna have to see... We're gonna have to open this, connect the dots. Go through. Okay, that's a big hole.
But otherwise we're not gonna get underneath there. No. All right, so can we have the big Deaver. All right, get your harmonic. So with one hand, I want you to hold that. Put that down. Don't, nope, you're twisting it. Keep it straight like that. Your other hand. I want that to go under there. You gotta pull pretty hard on that though, nope. Yeah, this is the one you gotta learn from. Nope, he's not in deep enough, hold on. I have to do it myself. Nope. I don't even know if you can get in there. All the way down there. Okay, so you gotta get way under there. Push, yep. You gotta get through those attachments down there. Okay, I'll do it again right next door to it. Push. Better, it's right down in the middle. You feel that? Yeah. You just gotta go get that. There's like nothing else to do. Stay in the middle, yep. Do it again. Again, in the middle. We got that band. What? I said we got that band. Yep. Now take a feel, and you'll see how much higher out we are. Right? So now you're down at the levators posteriorly. Yeah. All right, now the question is, where's the residual tumor? We're gonna have to do a little bit of prostate stuff. Get the light as best you can in there. Up here. All right, we need to set up the colonoscope, please. Uh-huh, now let's spin it the other way, mm-hmm. Now on this side, good. And then up here. Okay, great. That was good. Now what I want you to do is feel on this side out here. Yeah, I feel that band. Feel the band? Uh-huh. Okay, that's what we gotta get with the harmonic. Closer to my fingers. This way, away from myself. Take a feel. Yeah, that's great. Take that out for a second, please. Okay, now take a feel on this side. Pretty far, though. Pretty far, but we see the same bands there, right? Yeah, it's more... No, same band. Yeah. All right, let's get it a colonoscope. I think we're way below it. I think I feel the residual tumor up here.
All right, Travis, come on in. Uh-huh. No, no, no, keep going. It's right there. See it? Yeah. Okay, so that's tumor. Now, hold on. Now I can be down, way down below you. Okay, so here's tumor, pull back. All right, so that's free. So if I go here, I'm significantly below the tumor. Okay, all right, you can come back up. Suck it out. Do you guys see the tumor? Do y'all see the tumor? Show 'em the tumor again, Travis. To the right, See that big dark circle? That's tumor. That whole area. Yeah, all right. Okay, suck it up. All right. So a hand-held, and then give him the harmonic. Okay, with one hand, I need you to do this. And with the other, I want you to take that harmonic right there, like that, go ahead. Squeeze it. Hit the, yeah. Keep, whoa, whoa, don't stop. You don't stop until it's done. Okay. Okay, take that. Okay, again. Again. Okay. All right, take a bite, right... Yeah, no, no, no. You've gotta come into the bowel, otherwise, you devascularize it. No, it's gotta... Right? So if you're gonna do it. Like this? Yeah. All right, Contour 4.5, please. And then this up here. Don't angle down, otherwise, you're devascularizing the remnant bowel, right? Okay, yeah. Okay. Keep going. Yep. Okay, there's one little band right here, done. All right, Contour, please. Deaver now, please. Okay, get your Contour.
Sigmoid colon - or rectosigmoid, sorry. Rectosigmoid. Yep, take it. It's gonna be rectosigmoid. Yep. It's gonna be rectosigmoid. Okay. Okay. Thank you. Yep. Heavy. Yep. All right. When you put your scope in, was the aperture big? Was it easy to pass the scope? Oh, yeah. Yes? Oh, yeah. All right, 31, please. Would you like a powered? Yeah, I'll use the power one if we have... Do we have a 31? Yeah. Okay.
All right. You can relax. Okay, come through that. Okay, that's beautiful right there, right? Yep. Yep. All right, give him a stitch, please. Thank you. You're very welcome. Snap. Mm-hmm, wipe it down. Mm-hmm. Yep. Good. Good. All right, anvil, please. Make sure you're in. Okay. Thanks. These are dirty. Thank you. I'll hold this for one sec just to help this. Yep. Dirty. Thank you. All right, go below. All right, wiggle on in. Handle up. Mm-hmm, slowly I'm right there. Okay I can feel it. Yeah, okay, handle down slowly. Hold on. Yeah, okay, hold on. Yep, spike out. Spike out? Yep, little gentle pressure forward. Okay. It's coming out, it takes awhile on this one. Yep, okay. Now that is way to hell down there too, man. Okay, bring it in. Okay, coming in. Thank you. You're welcome. You should just seen us until 30 years ago trying to hand sew these. Down there, yeah, that'd be tough. So hard, we used to parachute them. All right, we're like right at half. All right, I want you to go - yeah, half is fine for this. Okay. Yeah, that's plenty. Because he's got a thick bowel. Yeah, okay, take it. Okay. So safety off, and firing. I do like the uniformity of it, but I still had a bleed. Green check. All right, so gonna open it now. So now you have to do two, but there's no click, remember? Right, so the hobble button's up towards me. So that's one. Yep, and then that oscillating motion out. Wriggle, wriggle, wriggle, wriggle. I think it does that much nicer as well. Yeah. There we go. Okay.
All right, reverse-T coming your way. Tell me when Keep going, keep going, stop. Okay, Travis, go ahead. Put the... Evacuating it. Yeah. There you go, all right. Put some air in, move up a little bit. Uh- huh, now center it. You're on the side of the 'mose Pull back just a little. Yeah, there's the 'mose. Good, I have no bubbles, great. Suck it out. So it's bleeding on the side, you see that? Yeah. You need me to look again? No, no, no, we're gonna - there's nothing to do. You say, so what do you do for that? Nothing, you let it stop bleeding.
All right, the donuts are intact. Yeah. All right, you're still paralyzed, right? Yep, I just checked him like two minutes ago, but lemme check again. Yeah. Yep. Okay, kockers, please. Yes, we will. Okay. Oh, could we go from 35/35 to 40/40, please? Yes. Can I have a pick up, please? Mm-hmm. Either. You're gonna have to take some fat out. It's long, sorry. Yeah, I really want teeth. Right over here. I only have one rat tooth. Use your other hand. Good. Yep. Just you have to cut that little piece of flab off. You see the cruciate, here? Yeah, up and down to start. Can I get a babcock, please? Sure, yeah. So we now need to find the cecum. I think that this, yeah, there's the ileocecal valve, and so this is the proximal. I think we got to loosen the... Go high, stay high. Keep going, stay high. So look - look where the ileocecal valve is. Remember, I have to put 'em back together, so you gotta give me enough. Okay. Right? Yeah. Otherwise I'm gonna be... Well, otherwise I'm just not gonna have room to get it... Now that is something else, okay. There it is. All right, there might be something bleeding there. Can we have the pickups and a Schnidt, please. This way. Good, that's right. Can I have a tie, please. Yeah.
All right, number one Proline. Can I have a snap? All right, we're gonna do clips, and local, and then we're gonna mature the stoma. So how much local do we got? 30, do you want more? Yeah, can we dilute that? How much kilos? What do we got in kilos here? A lot, I got a lot of kilos. 100 kilos, you can give ... what do you got, quarter percent? Yeah, we'll make it quarter percent. So can I do? You can do, quarter percent, you can do 120 cc. Okay, so open another 30. Okay. Pour it in and dilute it one to one. Okay. And we'll just use like 100 of it. So we're gonna give 100 of quarter, okay?
All right, cautery please. Pickups with teeth. Thank you. You're welcome. Can I have a pickup, too? Yeah, are you okay with a lefty? Yeah, 'cause I'm probably not gonna use it. I just feel weird without having something in my hand. And I'll steal one more small Teggy, I'm sorry. And a little bit more this way. Stitch please to each of us. So you only pop the first four. We used all 120. Or the first two. The first four. Each of us will do two. Yeah, mm-hmm. Six total stitches. Okay. Thanks. It's if you do it the other way, you can't move forward with four stitches at the same time. Gotcha. Which is why I pop off the first four because once it's set in with the first four in, then you don't have to do anything, right? You just go. Yeah, it's not going anywhere. Yeah.
So we've just completed the operation, and the operation began by placing our trocars in the abdomen. We then elevated the omentum and lifted the omentum up, pulled the transverse colon down, which allowed us to get into the lesser sac. We used that to free the splenic flexure and then I freed the descending colon. I identified the left colic artery and divided that between clips. I then mobilized down towards the pelvis and elevated the rectum off of the retroperitoneum, being careful to preserve the nerves. I divided the IMA with clips and freed the bowel down. I began with the mesorectal excision down into the pelvis, taking the posterior and lateral stalks, and I also divided Waldeyer's fascia. However, due to the narrowness of the pelvis and the size of the patient, I could not complete the dissection down below the tumor. Consequently, I made a midline laparotomy, entered the abdomen, and completed the dissection. I then divided the distal bowel With a contour 4.5-mm stapler, divided the proximal bowel after tying off the marginal artery with a GIA 100 stapler. I then proceeded with an anastomosis using a Covidien 31-mm powered EEA stapler with a side-to-end anastomosis. I checked that with a colonoscope underwater, making sure there were no bubbles. I then brought an ileostomy out at a previously marked site, closed the abdomen, and matured the ileostomy.