Laparoscopic oncologic proctosigmoidectomy with low colorectal anastomosis in a cadaver model

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Abstract
The purpose of this study was to demonstrate that a standardized approach to laparoscopic proctosigmoidectomy in a cadaver model with (1) initial proximal ligation of the inferior mesenteric (IM) vascular pedicle, (2) complete mobilization of the splenic flexure, and (3) intraperitoneal stapled colorectal anastomosis can be accomplished in complete accordance with oncologic surgical principles. Using nine cadavers in the fresh state, six abdominal wall cannulas were placed so as to allow good access to the left colon and rectum. After identifying the left ureter and gonadal vessel, the IM pedicle was divided close to the aorta and the left mesocolon was separated from the retroperitoneal structures. The sigmoid colon was transected at the proximal resection line with an endoscopic stapler; then the splenic flexure and descending colon were completely mobilized. The rectum was freed circumferentially, dissected first posteriorly, laterally, and anteriorly, and then transected in its middle portion with an endoscopic stapler. The specimen was removed through a widened left-lower-quadrant trocar incision and the anvil of a circular endoscopic stapler was placed into the proximal colon extraperitoneally. An intraperitoneal laparoscopic colorectal anastomosis was performed using a double-stapled technique. The median length of specimen was 53 cm (range 45–80 cm) and the median number of removed lymph nodes was 15 (range 11–20). A careful abdominal autopsy was carried out in all cadavers. Length of remaining inferior mesenteric artery was smaller than 1.5 cm in all cases and only one remaining lymph node (3 mm in diameter) was found adjacent to the IMA in one subject. No damage to either ureter occurred. All colorectal anastomoses were patent without signs of air leakage or defects on air insufflation and gross inspection. Using this standardized laparoscopic technique, it is possible to perform a proctosigmoidectomy with stapled intraperitoneal anastomosis according to oncologic surgical principles.

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