Laparoscopic Low Anterior Resection with Diverting Loop Ileostomy for Rectal Cancer with Conversion to Open Approach

CHAPTER 1

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.

CHAPTER 2

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.

CHAPTER 3

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.

CHAPTER 4

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.

CHAPTER 5

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.

CHAPTER 6

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.

CHAPTER 7

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.

CHAPTER 8

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.

CHAPTER 9

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.

CHAPTER 10

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.

CHAPTER 11

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.

CHAPTER 12

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.