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Laparoscopic Intersphincteric Resection
intersphincteric resection and colon shaping for low rectal cancer and then put 01 18F surgical drain in the abdominal/pelvic area
treatment in adults. through the 5-mm hole in the left side. Then, we removed the gas
and closed the trocar hole.
MAterIAls And Methods Variables and Data Collection
Study Design and Patients Patients were examined for functional symptoms, physical
A case series was conducted on 43 patients diagnosed with symptoms, and some subclinical indicators and imaging diagnoses
low rectal cancer and underwent laparoscopic intersphincteric (e.g., ultrasound, chest X-ray, and computed tomography). Patients
resection at Thanh Nhan Hospital, Hanoi, Vietnam. Criteria for underwent a colonoscopy of the entire colon and rectum to evaluate
selection included: (1) primary low rectal cancer diagnosed by the tumor location, the shape of the tumor, degree of invasion,
biopsy; (2) tumor-anal margin distance ≤6 cm; (3) cancer stage from circumference of the rectum, number of tumors, tumor in the colon,
T3 or less as classified by Union for International Cancer Control polyp status, and biopsy. Endoscopic ultrasound was performed
(UICC); (4) having laparoscopic intersphincteric resection; (5) with to assess the degree of invasiveness, degree of serosal invasion,
or without colon shaping, and (6) accepting to participate in the and degree of sphincter invasion and lymph node metastasis. The
study. Exclusion criteria included: (1) tumor-anal margin distance postoperative disease stage was divided according to tumor-node-
more than 6 cm; (2) tumor-anal margin distance less than 6 cm but metastasis (TNM) standards of the UICC. Functional assessment was
switching from laparoscopic surgery to open surgery; (3) tumor-anal performed according to Kirwan classification with five grades: 10
margin distance less than 6 cm but the tumor recurs. The research
was approved by the Institutional Review Board at Thanh Nhan • Grade I: Perfect
Hospital, Hanoi (Code: 02/BVTN-HDDD). • Grade II: Incontinent to gas
• Grade III: Occasional minor leak
Surgical Technique • Grade IV: frequent major soiling
The patient was placed in a supine position. The patient’s head was • Grade V: colostomy
set low and tilted to the right. A 10-mm trocar was placed above or Wexner score was used to evaluate three components of fecal
below the navel; then, gas was pumped into the peritoneal cavity. A incontinence (solid, liquid stools, and flatus). 11
5-mm trocar was placed in the left pelvic fossa, a 10–12-mm trocar After surgery, patients were scheduled to reexamine
was placed in the right pelvic fossa and 2–3 cm from the upper periodically 6, 12, 18, 24, 36, and 48 months or any time if the
anterior pelvic spine, and finally, a 5-mm trocar was placed on the patient had abnormal symptoms. For patients who did not go to
outer margin of the abdominal straight muscle on the right, with the hospital, information was obtained through short, easy-to-
a distance of about 10 cm to the first trocar. understand questionnaires that were sent to patients and families,
First, we dissected the lateral and medial surface area of the or calling to patients and their families. We also monitored patients
sigmoid colon and rectum, along with the left colonic adhesion. We by phone and regularly inquired to note any abnormal signs (if any).
continued to identify the sigmoid artery, and the lower mesenteric Low rectal cancer-related fatalities were recorded.
artery, from which we dissected with forceps to reveal the lower
mesenteric artery. After that, we used clips, Hemolock, or sutures Data Analysis
to control and cut this artery. At the cut site of the blood vessel, we Research indicators were directly recorded through examination,
cut the mesenteric sigmoid and descending colon to the left to free monitoring, and evaluation of treatment results. Data were recorded
this part of the colon. The rectum was dissected that the organs in medical records. Information from medical records was coded,
from the rectum to the lifting muscles moved completely according cleaned, and verified. The SPSS 20.0 (Statistical Package for Social
to the principle of total mesorectal excision. In the posterior side Science) software was used to analyze data. Kaplan–Meier estimates
of the rectum, we dissected the nonvascular area in front of the were conducted to measure the overall and disease-free survival
sacrum and behind the rectum, closely following the curvature of rates. A log-rank test was used to compare the characteristics of
the mesorectum, to avoid tearing the mesorectum, when also not fatal and nonfatal patients. p <0.05 was statistically significant.
damaging the anterior sacrum. On both sides of the lower rectum,
we used a harmonic scalpel or a LigaSure knife to stop bleeding
and avoid damage to the pelvic plexus located outside of the results
lateral ligament. In the anterior rectum, we dissected the surface In 43 patients with low rectal cancer, the mean age was
between the mesorectum and genital organs, helping to release 68.7 ± 13.3 years. The proportion of male patients was 62.8%.
the entire rectum. Most patients had an anal margin of 4 to less than 5 cm (53.5%).
Next, we performed surgery to reveal the entire anus and The invasion degree was mainly at T2 (60.5%). According to the
episiotomy. We used the Lone Star Valve (Lone Star Medical TNM classification, the cancer was mainly in stage III (39.5%) and II
Products Inc., Houston, Texas) to expose the anal area and dissect (37.2%). Subtotal intersphincteric resection was the primary surgical
the anal canal 5 mm under the dentate line. We removed the method at 37.2%. The colon was mainly J-shaped with 51.2% of the
entire internal sphincter or the deep muscle bundle of the external patients (Table 1).
sphincter with the entire mesorectum, going upward until we met Table 2 shows that, according to Kirwan classification, there
the laparoscopic dissection plane. Through the anus, we pull out were 83.7% of the patients at grade I. This rate decreased to 62.9%
the sigmoid colon and rectum with the mesorectum and then cut after surgery. There were 13.9% of the postoperative patients
and connect these bowel segments. We shaped the colon into the reaching grade III. The difference was statistically significant.
ileal pouch and performed one layer of end-to-end anastomosis. We According to Wexner score, before surgery, 62.8% of the patients
put a surgical drain that connects the rectum to the anus and ends had a score <5. This rate after surgery was 48.8%. There were
in the epis. Then, we pumped gas into the peritoneum, rechecked, four patients with Wexner scores between 10 and 20 points. The

World Journal of Laparoscopic Surgery, Volume 14 Issue 3 (September–December 2021) 163