Laparoscopic Pelvic Autonomic Nerve-Preserving Surgery for Patients with Lower Rectal Cancer after Chemoradiation Therap
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DOI: 10.1245/s10434-006-9052-6
Laparoscopic Pelvic Autonomic Nerve-Preserving Surgery for Patients with Lower Rectal Cancer after Chemoradiation Therapy Jin-Tung Liang, MD, PhD, Hong-Shiee Lai, MD, PhD, and Po-Huang Lee, MD, PhD
Division of Colorectal Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan
Objective: This is a phase II study, the aim of which is to determine if a laparoscopic approach can be used in pelvic autonomic nerve-preserving surgery for patients with lower rectal cancer following chemoradiation therapy. Methods: Patients with T3 lower rectal cancer treated by preoperative chemoradiation were recruited and subjected to laparoscopic pelvic autonomic nerve-preserving surgery with total mesorectal excision and a sphincter-saving procedure. This study was performed with the approval of the ethics committee of National Taiwan University Hospital. Because the quality of a surgical trial is highly dependent on the skill of the surgeon with respect to the technique under study, it is imperative that a surgical trial only be implemented after the surgical technique has been judged to be mature. Before the start of this clinical trial, we gained a sound knowledge of surgical anatomy through conventional open surgery for rectal cancer and mastered the related laparoscopic skills from other sound and proven laparoscopic approaches, including right hemicolectomy, left hemicolectomy, among others. We determined that the learning curve for this surgical technique necessitated that colorectal surgeons carry out at least 20 such procedures. At this point we conducted this clinical trial. The details of the surgical procedures have been shown in the attached video. Briefly, the dissection commences at the pelvic promontory with exposure and preservation of the superior hypogastric plexus. The pre-aortic plexus and inferior mesenteric plexus are preserved by sparing the pre-aortic connective tissue and leaving a 1– to 2-cm-long stump of the inferior mesenteric artery in situ. Subsequently, the ‘‘holy plane’’ at the transition of the mesosigmoid to the mesorectum is meticulously dissected to progressively displace the hypogastric nerves dorsally and laterally and, therefore, preserving them. Following adequate dorsal and lateral dissection down to the floor of the pelvis, the so-called lateral ligament is reached at which the mesorectum appears to be adherent, anteriorly and laterally, to the inferior hypogastric plexus (at roughly 10:00–2:00 OÕclock or within an angle of 60° about symphysis on both sides). The ligaments are divided immediately at the endopelvic fascia of the mesorectum to avoid damage to the inferior hypogastric plexus (pelvic plexus). Finally, great care was taken to dissect the lateral border of DenonvilliersÕ fascia where the inferior hypogastric plexus joins the neurovascular bundle described by Walsh. Postoperatively, only patients successfully operated on by total pelvic autonomic nervepreserving surgery we
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