Usefulness of intraoperative endoscopy in laparoscopic rectal resection

Abstract

Introduction

The use of intraoperative endoscopy in laparoscopic colorectal surgery is usually limited by the need of mechanical bowel preparation and colonic insuflation. Besides, most of the tumors can be easily identified, even with preoperative ink staining.

Description

We present 3 cases of laparoscopic rectal resection that required an intraoperative endoscopy for different reasons.

Case 1: 66 year-old male with an upper rectal invasive cT3 N0 adenocarcinoma (10 cm from anal verge) and a mid-rectal sessile polyp (7 cm from anal verge, biopsy: high-grade villous adenoma) not amenable to endoscopic polypectomy. Alternative approaches are discussed (TAMIS local excision first and subsequent conventional high/low anterior resection versus initial low anterior resection), choosing the las one, with a 1 cm distal margin. Pathology revealed a pT3, N1 upper adenocarcinoma and a pT0 tumor (limited to the mucosa) for the mid-rectal polyp.

Case 2:  75 year-old male with an upper rectal villous tumor comprising ¾ of circumference, arising 10 cm from the anal verge. Preoperative MRI suggested a cT2, N0 intraperitoneal tumor, although biopsy did not show invasion. in abscense of  neoajuvant therapy criteria, the patient was set for a laparoscopic low anterior resection. The soft nature of the villous tumor did not allow its identification, then performing an intraoperative endoscopy to assess the distal margin of transection.

Case 3: 75 year-old female, with a small (1/4 circumference) ulcerated invasive adenocarcinoma arising 15 from the anal verge (rectosigmoid junction), not identified in the preoperative CT scan, set for elective rectosigmoid anterior resection previously tattoed with Chinese ink. After access to the peritoneum, diffuse staining of the whole abdomino-pelvic cavity was found. Intraoperative endoscopy confirmed tumor location. Specimen pathology confirmed the presence of the small tumor, and postoperative stage was pT4, N2 (21 nodes harvested, 12 metastatic)

Conclusions

Intraoperative endoscopy during laparoscopic rectal resection might be specially useful in selected cases: small, non-palpable tumors, diffuse ink staining and assessment of distal margin.