Multimedia article. Autonomic nerve-preserving total mesorectal excision in the laparoscopic era.

PURPOSE: Although technically demanding, laparoscopy may be advantageous in magnifying the anatomy of the pelvic autonomic nervous system when performing total mesorectal excision for rectal cancer. We present our method for laparoscopic total mesorectal excision for men.

METHODS: We performed laparoscopic total mesorectal excision for 36 men with middle or low rectal cancer. The rectum was mobilized through a medial approach down to the pelvic floor without minilaparotomy or hand assist. Anteriorly, the dissection plane was in front of Denonvilliers fascia. Anterolaterally, to preserve the pelvic plexus and neurovascular bundle, Denonvilliers fascia must be cut at its lateral continuity. We found that the most important factor in obtaining a good surgical view is keeping adequate tension in the dissection plane by coordination between the surgeon and assistant. Dissection was performed by using only electrocautery without an ultrasonic dissector or vessel sealing device.

RESULTS: No case was converted to open surgery. The short-term feasibility was acceptable.

CONCLUSIONS: Our method of laparoscopic total mesorectal excision is a feasible approach and may be beneficial for the standardization and popularization of laparoscopic total mesorectal excision. Long-term results, including survival data and urogenital function, are needed to evaluate the true efficacy of this procedure.