Clinical Analysis Of Laparoscopic Transanal Total Mesorectal Excision

Transanal total mesorectal excision(TaTME)is a new surgical method for rectal cancer.But there is no doubt that the emergence of the new operation will always bring questions about its safety,feasibility and clinical efficacy.What,s more,at present,the clinical research of this operation is still lack of large center and large sample verification;however,the tumor free operation technology of this operation and the anatomical understanding of the transanal approach operation are insufficient;surgeons need to learn and train structural chemistrv to master it.All of the above factors affect the surgeons' acceptance of tatme and its further expansion,which promotes us to carry out various researches on tatme,including feasibility and radical,R0 resection,learning curve and transanal endoscopic application of anatomy and surgery technology,and also provides clinical reference for the dissemination and use of the operation.Part one:Comparison of Transanal total mesorectal excision and Laparoscopic Total Mesorectal ResectionObjective:To evaluate the feasibility,safety,radical and short-term clinical efficacy of TaTME in the treatment of rectal cancer.Clinical data and methods:the patients with middle and low rectal cancer who were admitted to our hospital from December 2018 to December 2019 at the same time were included in the operation group of TaTME after evaluating the operation method suitable for TaTME and fully communicating with the patients for consent,and then the operation method,operation index,oncology index and short-term effect were analyzed.Results:there were 28 cases in TaTME group and 30 cases in laparoscopy group,and the clinical data of the two groups were comparable(P>0.05).Results:the operation time was(187.82±38.99)min in the TaTME group and(113.00±21.84)min in the laparoscopic group,with significant difference between the two groups(P<0.001);The amount of intraoperative bleeding in the two groups was(75.00 ± 18.40)ml and(73.16 ± 17.88)ml respectively;the time of postoperative analgesia,intestinal function recovery and hospitalization in the two groups were respectively(1.93± 0.71)days and(1.83± 0.64)days,(1.76 ± 0.58)days and(1.75 ± 0.58)days,(8.43±3.51)days and(8.07 ± 3.29)days;there was no significant difference between the two groups(P>0.05);there was no significant difference in postoperative complications between the TaTME group and the latme group Difference(P>0.05).Radical results of oncology:there was no difference between the two groups in the length of specimen resection and the distance of the distal margin of the intestine;the pathological examination of the distal margin of the two groups was negative.Prognosis:the follow-up time of the two groups up to now,the selected group is less than T3 stage,the patients reexamined tumor-free survival.Conclusion:TaTME is safe and feasible,and it is safe and feasible in the near-term curative effect in the complications and mortality of operation After understanding and mastering the corresponding anatomical knowledge of transanal operation,it can be popularized to some extent.Compared with traditional laparoscopic TME,TaTME can also strictly abide by the principle of radical oncology.The tumor evaluation,recurrence rate and survival rate of the samples in the TaTME group showed that the transanal laparoscopic group brought a certain degree of minimally invasive without sacrificing the radical nature of the tumor;at the same time,it further reduced the human trauma and further reflected the advantages of minimally invasive surgery.The second part:To observe the surgical anatomic plane of total mesorectal excision through anusObjective:To explore the anatomic points of the surgical plane in the treatment of middle and low rectal cancer with tatme,and to summarize the anatomic position of the middle space of the transanal approach and the anatomic marks of the surgical plane in each stage under the technology of single hole and multi-channel endoscopy.Clinical data and methods:From December.2018 to December,2019,the anatomic position of the middle space through anal approach was observed and recorded during the TaTME operation in the patients with middle and low rectal cancer who were admitted in our hospital at the same time.The anterior,posterior.and lateral walls of the rectum were separated and recorded by the sequential operation of the same operator.The successful cases are analyzed by comparing with the image records.Results:In the transabdominal part:the physiological adhesive zone between the visceral peritoneum and the parietal peritoneum of the left paracolon is the anatomical starting point of the left toldt's space.The left toldt's space is the potential space between the mesocolon and the prerenal fascia,and then the prerenal fascia.The fascia extends to the front of the dorsal midline as the anterior aortic fascia,to the lower left as the presacral fascia,and to the front of the rectum as the anterior denonvillies fascia,forming a middle line The whole structure of left lateral,left lower and front rectum fascia;toldt's space also forms a complete avascular space behind the left colon and rectum along the fascia structure,and the left colon and rectum radical operation is carried out along the space until the pelvic floor level is cut off.The end line of TME is located a the level of anorectal ring,about 3.0-3.5cm from the anal margin,which is the so-called surgical anal canal,which is 1.8-2.0cm higher than the anatomic anal canal.So in the middle and lower rectal cancer,the distal margin should be long enough.Experts agree that:the distal isolation end of the lower rectal cancer is 1-2cm from the lower end of the tumor,but when the]ower rectal cancer(less than 4-5cm from the anal margin)is removed through the anus,the initial place for the bag suture is from the lower edge of the dentate line to the transverse rectum or the internal sphincter and rectum ring(this is different from the consensus of 2017 version),which can meet the THE standard;the rectal wall is divided into mucosa layer,The four parts of submucosa,muscular layer(inner ring,outer longitudinal)and plasma(outer)membrane are different under microscope.Correct identification plays an important role in the smooth operation.It is more convenient and intuitive to separate the anterior wall of rectum through anus than through abdomen.The rectourethral muscle is the earliest important anatomical sign of the anterior wall.After blunt separation,the posterior wall of prostate covered by membrane can be seen to be further separated,and then the seminal vesicle can be seen to be connected with the operation field of abdominal cavity group;the primary anatomical sign of the posterior wall of rectum is hiatal ligament(rectococcidial muscle),which continues to be separated to the head and meets Waldeyer Fascia(rectosacral fascia),which is the inflection point of L-type pelvic cavity,will turn to a relatively dense place;the rectum side wall should correctly understand the relationship between the rectum proper fascia and the pelvic nerve from the space between them,while the rectum side ligament is the connection between the two,and the operation should be close to the proper fascia side as the resection line,which can give consideration to both radical treatment and nerve protection;conclusion:the toldt's line is the left paracolon sulcus The anatomical starting point of the physiological adhesive zone between the lamellar peritoneum and the parietal peritoneum is the correct surgical plane mark.Toldt's space is a complete avascular space formed at the back of the left colon and rectum following the fascia structure.The radical operation of the left colon and rectum follows the space until the end of the pelvic floor level,which is the correct surgical plane of total mesorectal resection.The anterior wall of tatme is easy to recognize,and the posterior wall should pay attention to the rectosacral space rather than go deep into the anterior sacral fascial space.The lateral wall should pay attention to the internal stroke,avoid damaging the distribution area of the vascular and nerve bundles in front of both sides,as well as the branches of the middle rectum artery from the internal iliac artery in the lateral ligaments of both sides,and avoid damaging the pelvic plexus by excessively leaning on the outside.