Latest / Behind The Knife: The Surgery Podcast / Operative Standards for Cancer Surgery Series: Total Mesorectal Excision for Rectal Cancer
Transcript
- Rectal Resections BTK === [00:00:00] And then we'll just tell the, the people that edit the video if they can just put a little more hair on the top of my head. Yeah. A little more juice in there. And then, uh, Tram just 15% body mass. Just want 15% less, and they can do that. I'll take 20. I mean, ChatGPT, they'll fix it, but all right. Sorry, go ahead, Jason. Hello, my name is Jason Lieselek. I'm currently a second-year surgical oncology fellow at Moffitt Cancer Center in Tampa, Florida. Uh, and tonight I'm joined by, uh, Dr. Sean Langenfeld as well as Dr. Larissa Temple, to discuss the operative standards for cancer surgery regarding tosal-total mesorectal excision for rectal cancer So Dr. Langenfeld, why don't you give us a little background on yourself? Yeah. So, um, I'm a colorectal surgeon in Omaha, Nebraska at the University of Nebraska Medical Center. [00:01:00] I am the chief of colorectal here, and I've been here for about 15 years. I was lucky enough to have Dr. Leiszlek as a trainee in the recent past, who's a wonderful resident. And I have a practice that focuses a lot on colorectal cancer, and I did actually, uh, help write the clinical practice guidelines for colon cancer, rectal cancer for our society, which is the American Society of Colon and Rectal Surgeons as well And then Dr. Temple, you're currently practicing at, practicing at the University of Rochester. Is that correct? That's right. Um, I am, uh, I've been in University of Rochester for 10 years. I'm the chief of the colorectal division. My entire professional career has been focused on oncology and improving patients' outcomes. For the first 10, 15 years of my career, I think we were all focusing on optimizing sphincter preservation for our patients and, uh, looking at how we can, uh, improve long-term functional outcomes. I think we were all really excited when we launched the tonal adjuvant therapy approaches, and I was [00:02:00] certainly involved in that, those pivotal trials to, to move towards a non-operative approach. Now I think we're really focusing on optimizing the value for our patients and identifying the, the way we should be surveilling these patients. But it's been an exciting journey to see where colorectal cancer treatment's go- gone and where it's going to Well, excellent. It's really a privilege, uh, to be here speaking with two experts on this very important topic. Um, so let's get started. As surgical trainees, uh, Dr. Langenfeld would always, always, always impress the importance of a total mesorectal excision, um, for, uh, the management of the surgical management of rectal cancer. So Dr. Langenfeld, uh, will you please, uh, remind me now that I've forgotten why total mesorectal excision is, is so important for the management of this disease? Well, absolutely. So what I would say is that rectal cancer surgery is very technically challenging for [00:03:00] all of us, even people that are high volume surgeons. It's kind of like operating in a glass tube on something that's the exact same size as the glass tube. It's hard to get to. It's hard to get exposure. If you go too far posterior, you get the pre-circo venous plexus, they can bleed to death. Too far lateral, you get nerves and ureters and iliacs. Too far anterior, you get the prostate or maybe a, the vagina end up with a rectovaginal fistula. But those are the small things. The, the, the worst thing you can do is to get too close to the cancer itself and compromise the mesorectum. And when that happens, they have a very high risk of dying of recurrent cancer. And so it's kind of a high stakes area of the body. And thankfully, you know, going back in time a little ways, the way we used to do it was very blind, uh, with a lot of blunt dissection, which led to a lot of specimen disruptions and positive circumferential radial margins. And so with the kind of invention of total mesorectal excision, essentially what we're doing is following the embryologic plane, preserving the entire mesorectal envelope that surrounds the rectum. And that's been shown in multiple studies to [00:04:00] improve long-term survival and reduce the risk of local regional and distant recurrence. And so that's why it's such an important topic, and that's why we pressed into the residents so hard. The other thing to keep in mind is that even though we know all this, when we do assessments of how rectal cancer surgery is done nationally, we unfortunately find that the quality of surgery falls short. Um, and there is a lot of non-TME surgery being done, and they can actually demonstrate that that you know, reduces the quality of care and the long-term survival the patients have. And so that's, that's why it's such an important topic, Jason. And I would add, Jason, one of the things that Sean and I probably have seen more of than you have is the sequelae of you know, local recurrence. It's different than local recurrence after colon cancer. These patients die miserable, d- prolonged. They have-- their quality of life is very poor, and they, they, they succumb of either infection, predominantly infection or sort of ureteric obstruction. And it's [00:05:00] really a devastating way to watch a patient die. And so historically, it was about a fifty percent local recurrence rate with rectal cancer. And it really was in the eighties, we began to see this, this, this, uh, movement of total mesorectal excision and s- began to see improvements. Um, and we, you know, we, the-- it took a lot of, lot of people time to train us. Took us the u- uh, the, the addition of adjuvant therapies to really get to these modern-day outcomes that I think people don't appreciate are only about fifteen, twenty years... They've only been, we've only seen this, this improvement in fifteen, twenty years, twenty years So I, I remember from my training at the University of Nebraska how, um, how the addition of adjuvant radiation and then the migration to neoadjuvant migration and now to the, the concept of total neoadjuvant therapy has changed the management for patients with locally advanced rectal cancer. Dr. Langenfeld for those of us not old enough to remember this antiquated [00:06:00] practice, can you, um, tell us, um, the challenges associated with performing contemporary rectal cancer surgery? Sure. Well, uh, you, you touched on a couple different things that are important. Uh, o-one of them is, you know, we, we learned twenty-five years ago that patients should be getting their chemoradiation before surgery. And then what we were doing is performing surgery, and then we would subsequently give them postoperative chemotherapy, and that adjuvant chemotherapy was the, the big dose, you know, the FOLFOX, uh, chemotherapy. And we know that that adjuvant chemo improved long-term survival. So we know that patients, regardless of the stage, the down stage and the experience, if they got that chemo, they had a better chance at long-term survival. The problem was, outside of the big trials, when they looked at what's actually being done in the community, only about thirty to fifty percent of patients were actually getting the adjuvant chemo because of a million reasons. It's complicated surgery with a lot [00:07:00] of bad outcomes. Uh, uh, there is variation in what the oncologists recommend. And so what people had said, that both you and Dr. Temple had sort of alluded to, is what if we give that chemo pre-op? You know, what if we, we give them their chemoradiation, but then prior to operating, we go ahead and give them their FOLFOX, maybe that will improve the chemo completion rate, and they were absolutely right. And so by doing that, the chemo completion rate went from thirty to fifty percent up to about ninety-five percent. And with that, they saw that there was an, an excellent im- you know, improvement in long-term outcomes. And so now total neoadjuvant therapy, what we call it, is, is the standard of care What was born from that, which is a whole discussion different from what we're talking about to- today, is, is the widespread adoption of non-operative management or watch and wait. But when you talk about the technical implications of this, what it means is that, you know, there's become an increasingly large window between when that patient receives their pre-op radiation and when you decide you're going to do a [00:08:00] surgery to remove their rectum. And with that comes the sequela of radiation, including radiation fibrosis, uh, edema fusion of planes that are otherwise already difficult to get through, and then poor wound healing, uh, including anastomotic healing and, and, and impact on function, including GI function, sexual function, and urinary function. And so, you know, that is something where rectal surgery's gotten progressively hard, if that makes sense. And then kind of related to that, when we do watch and wait, some of these patients do end up with a local recurrence, you know, maybe 20, 30% of them. And so now we're actually doing surgery sometimes one or two years after their radiation, where it's, you know, significantly more technical difficult, technically difficult. And so it just, it's the, the ante's been upped a little bit. Dr. Tep, I'd be interested what you think about this, but the, the way I think about it with watch and wait is that, uh, all the good biology, all the good patients, they're getting selected out from rectal surgery [00:09:00] now, if that makes sense, because they're having good responses. And so the only ones that left are the, the hardest ones with the worst biology. Uh, it's similar to AAAs. So when I was a resident open AAA was my favorite operation. You do this huge incision. You open up, you give proximal distal control, you open up the aneurysm, throw all the jelly out, sew this big graft with a huge prolene. Uh, the patients don't do great, but it's a great operation for a resident. And then stents came out, endovascular stents. And so what happened was over time, not only did the stents come out, but they got better with stents. And now the, the open AAAs were less common, and the only time they would ever do it is when it was the worst one of all time. And so now open AAAs kind of were not fun at all. And I think that s- they're, we're seeing something kind of similar with rectal cancer surgery, if that makes sense. And radiation plays a big part of it, and patient biology plays a big part as well. I, I couldn't agree with you more. So Jason, when I was, um, w- in the era of chemo radiation, surgery, then chemo, we had this mantra that we recommended surgery within 6 to 10 weeks [00:10:00] after, after radiation was completed. We sort of said after we-- if we went before six weeks, things were just too edematous. If we went after 10 weeks, it was just too fibrotic. And so, you know, we've really pushed ourselves into a different, different era where we are operating on people who are, you know, up to t- you know, as, as Sean said, up to d- 12 to 18, 24 months after the radiation. And it is it... And we accept that as our new normal, and we forget... And so the, the operations we do are actually much harder than they were 15 years ago when we were operating on patients six to eight weeks after surgery, after radiation. For me, I do agree with you, Sean. I don't know if we have enough data yet, but I feel to me that the TMEs, the patients who need surgery are different. You know, the, the fibrosis and edema from radiation are real. The other thing to me that's real and challenging is the fibrosis in the area where the tumor used to be and understanding whether that is actually fibrotic tissue just become a des- desmoplastic reaction secondary to the radiation, or if it [00:11:00] actually still represents you know, involvement of those structures. And so thinking through and planning those operations and even finding, and even if it is theoretically just fibrosis, finding a plane without taking that additional, that additional ex- tissue, that, uh, organ, is, is actually more challenging than it's ever been. I do think that they're har- they're, they're not-- it's a harder operation than it was because of these patient and, and, and treatment factors. I don't think we have enough data yet to really understand the, the change in the TME, um, quality yet. And I think we've also, while we... It's harder, I think we as surgeons are getting better, so I suspect we're seeing about the same. I think it's a harder operation though to teach because, um, it's just, it's not as... It's a harder operation to teach, um, given that the operation has gotten harder. That's what I find, Sean. I think it's really hard for... I think we, we as, as tr- as teachers need to give our residents the confidence they can do it, but it is a harder operation than it was. They don't have the opportunity to practice on the easy ones, which we, which we had I totally agree. I, [00:12:00] uh, so I, I don't want to brag, but I have, um, a monopoly on the BMI 50 males with low anterior tumors. They find me from two states away. Oh. And I'm sure they find you, too because that's just the, our burden. And, uh, nobody's having a real good time during those cases. No. And, uh, and so certainly it's gotten much harder. But I agree with you. We're also getting better. But what she talked about there, Dr. Lee is like that you probably already know about, but we probably should at least mention is, you know, data from the Rapido trial. And only because what they found is as they got further away from radiation, um, they did have better complete responses but they had a more difficult operation with more what they called breached mesorectums meaning a, you know, an incomplete mesorectum. And if you look at that, that did result in their long-term data in a higher rate of local regional recurrence. And so there is kind of this trade-off that- Yeah ... you're gonna see that's real. And, and- We're gonna start seeing that. I mean, that, that's in the trial setting. And so when we [00:13:00] think about real world and real life, um, we're gonna see, see those numbers a little bit higher. Um- Right. That's the best-case scenario, right? Yeah. And so it's, it's gonna be really... You know, it's, it's an evolving field and it's gonna be very hard to not continue to pursue non-operative management for those few patients who need surgery and for those few patients that have the positive mesorectal excision. But the, the, the incompletes, but I think that for someone coming in, in, these types of standards about thinking about what a quality TME m- means is still incredibly important. I still think it's the backbone of rectal cancer therapy. Absolutely. So I think with, you know, that robust discussion, uh, really highlighting the importance of the quality of the total mesorectal excision in the contemporary practice of rectal cancer surgery with total neoadjuvant therapy, particularly for those patients that are being offered a watch and wait approach who then have uh, then have a local recurrence. I think this is a great opportunity now to segue into the, the actual steps of performing the operation because that [00:14:00] seems to be seems to be the critically important parts to reduce local regional failure for these patients and then minimize, uh, subsequent complications in postoperative, uh, morbidity. So Dr. Langenfeld, I'll, uh, pivot back to you and, uh, uh, leave it to you to talk about, you know, how you, um, how you set up the case, um, and then how you initiate the operation. Okay. And, uh, Dr. Temt, please uh, you know, your input. You may do this very different than me. Uh- No. I, I, I tend to approach most of the rectal cancers minimally invasive. I do use the robot in the pelvis. I'm a selective robot enthusiast, if that makes sense. I do almost everything else laparoscopic, but I find it to be very helpful in that tight space where you need full control. I think setup is insanely important. Uh, cord management, you've heard me yell at you, anybody about that. But, but essentially what I like to do is, you know, do an assessment of the abdomen for metastatic disease. That's gonna be step one. Localize the tumor, usually with a [00:15:00] finger exam or a bedside proctoscope. I'm gonna start with my left-sided colon mobilization. That's not gonna be any different than what people see for a sigmoid colectomy. I tend to do it in a medial to lateral fashion. So I will elevate the rectosigmoid, identify the inferior mesenteric artery, and then make an incision on the medial side of the mesentery that allows me into the presacral space. You know, once you're in that space, the good thing about the IMA is there's really nothing behind it that you gotta take with you. And so you're gonna elevate the IMA and slowly dissect the retroperitoneum away from the back of the mesentery. You'll see a lot of nervous tissue. If you are too deep, you classically will see a lot of O's, we used to say, uh, which means you're kind of leaving some nerves up. You identify your left ureter Now, when I identify the left ureter you can't just find it once kind of on the left pelvic sidewall and say mission accomplished, 'cause you have a second opportunity to injure it when you're doing your high ligation of the artery. And so I actually dissect. Once I find it, I kind of dissect it both, you know, caudally and cephalad, my gonadal vessels. And [00:16:00] once that's done, I will have dissected down to the root of the inferolateral artery where it comes off of the aorta. Uh, I skeletonize it, and then I take it just with either Ligasure or the vessel sealer. Other people like to staple it. It doesn't matter. What I will say, though, is I leave about a centimeter, and I leave a centimeter for two reasons. One, if it bleeds, I can grab it, um, and, uh, put an endo loop around it or suture it. But the second equally important reason is because there are sympathetic nerves that live at the takeoff of the aorta there that have a lot of function. If you think about point and shoot from from step one and so forth, and so I spare those. Once that's done, you've opened up the space quite a bit. You're gonna continue your kind of anterior retraction of your mesocolon, dissecting the remainder of the retroperitoneal structures off, including the, uh, you know, the Gerota's fascia until you reach the line Tult. Uh, I'm a routine splenic flexure mobilizer, if that makes sense. Uh, I do it every time. I've never said, "Oh, this one's too [00:17:00] mobile." But I guess you could do it selectively. And then because you need to get de- or make- You take your IMV? Yes. So that's what I was gonna say is, like You know, because I need to do a low pelvic anastomosis, every patient is going to get a ligation of the IMV above the ligamentum Teres. I do as well. And that's like three or four centimeters of length at least, I think. Dr. Temple, what do you think? Is that kind of how you approach the, the, the pre-pelvic portion of that operation? Yeah, I, I feel the same way, Sean. I, I am, um, I b- I u- do it robotically. I usually put my ports a little bit more transverse than the classic complete diagonal because I like to have the access of the robot. I find to take the flexure down is easier with those more flat, with a more, more horizontal. Not, not totally horizontal, but not quite as steep. Um, and then I do, um, I, I, I mobilize the splenic flexure 90% of the time, and I, when, and I find that the IM, taking the IMV is really helpful. And when you're doing these super low anastomosis, and Sean, you're total- when you're doing them in these patients with a BMI of 50, you [00:18:00] need ev- every s- every inch ma- every centimeter matters. And so I also like doing it before I get into the pelvis because at the end of the pelvis, I wanna be done. I also find that it's a nice way... I, I know we have, you know, um, uh, ICG now, but it's a nice way to just see the viability of the colon and to see what it looks like at what... Do all that mobilization ahead of time and then go into the pelvis. I do not divi- I'll take the mesentery of the, uh, at the rectosigmoid junction or the sigmoid, you know, just at the distal sigmoid before I go into the pelvis, but I don't divide anything. I leave it all inside you until I, until I, till the end. I just- It's, it's kind of a cool idea. I never thought of it that way. But yeah, you are kind of like letting it sink or swim for that hour that you're down in the pelvis. Um- Yeah ... you can kind of- And that's a remnant from when I did it open. Like- Yeah, you can see the demarcation. I am kind of a selective, you know, into signing guy. I do it when I'm nervous. Yeah. If that makes sense. But, uh, but what, you know, when I am doing that part, the other thing that I forgot to mention with the [00:19:00] flexure is that the deep flexure is often neglected. And, uh, I think the deep flexure attachments probably also hurt mobility quite a bit right at the tail of the pancreas. Mm-hmm. Uh, once that's done, we're moving on to the pelvis. There's a million different ways to approach it from a technical standpoint, but this is when we start to get into the concept of total mesorectal excision. And so anytime you're in the pelvis, you're going to be in the embryologic plane. If you have a low pelvic tumor, total mesorectal excision means you're gonna go down to the pelvic floor If you have a mid-rectal tumor where you can get an adequate distal margin, you can also do what's called a tumor-specific meso-rectal excision and spare a few centimeters of distal rectum to improve function. But you need to have an adequate margin in order for that to happen. And what I will tell you, in the deep pelvis is you're always closer to the tumor than you think. You're not as low as you think, if that makes sense. And so a lot of times, for almost all of these low rectal cancers, and certainly most of the mid-rectal cancers, you're gonna be at the pelvic floor in order to be safe and have a distal [00:20:00] anastomosis June, Julie. The other thing is there's data with the mid-rectal cancer that the if- so for me, I do selective TME for the rectosigmoid tumors, you know, above 12 centimeters. But once you're below 12 centimeters, I think you have to go all the way down. What I find, though, is when you go all the way down the meso-rectum comes up once you've sort of mobilized that sacrococcygeal ligament. And so you do, for the mid-rectal tumors, have a little bit more of a rectal stump that you can divide, divide, versus if it's really low, then you have to go all the way down. But I, I tend, for my mid-rectals, I tend to take the whole meso-rectum. For the upper one, the 12 and up, I'll do that total meso to the s- for those reasons. But it's kind of, I think it's an easier operation when you go down to the pelvic floor I certainly, yeah, no, I think that it... 'cause it- you're just more likely to get a stapler across the way you want it to. Yeah. But for step-by-step component of the pelvis, the way that I conduct it, it's a little bit of a dance. Mm-hmm. But I start posteriorly. I usually bring an arm underneath my mesorectum to elevate for macro retraction. But essentially, you're gonna be in the presacral [00:21:00] space, the holy plane. In that plane, you should not violate the fascia propria of the mesorectum. Uh, you should identify both your left and right hypogastric nerves and make sure that those stay down. The hypogastric nerves will try to rejoin the party periodically as you get deeper into the pelvis. And so if you're just zipping along, you may not identify that you're accidentally putting enough anterior traction where it looks like you're, you know, you're somewhere that you're not, so be very careful with that. Once you kinda get to the point where you have lost tension, that's kinda when I switch gears. But prior to that, I keep a really wide canvas. I have a very wide canvas in the deep pelvis. I'm basically nothing left laterally except that little peritoneum, uh, layer, similar to when you're going lateral on a, you know, on the line of Tolt. But then once that's complete, I'm going to do my lateral dissection, followed by my anterior dissection. And as I do this, essentially, you realize you weren't as low as you thought, so you go back posterior, go back lateral. It's a little bit of a circular [00:22:00] dance. But, um, landmarks that you're gonna run into laterally, I like to actually use one of my retractors to push the pelvic sidewall away so I can create tension, and then, uh, you s- you'll follow that same holy plane. You'll marry it anteriorly. In, in women it's a little bit easier, I would say because the rectovaginal septum's a simpler place to be. Uh, in men, you can get a little bit more confused, especially 'cause it's a little tighter space. But you should be able to incise the anterior peritoneal reflection, identify Denonvi- Denonvillier's fascia, make a choice at that point where you're gonna leave it or take it. Um, for a posterior tumor, I'm gonna leave Denonvillier's fascia and leave all the nerves that are involved with the seminal vesicles and, and, and ta- take yourself all the way down to the pelvic floor till you're basically, you know, you see the puborectalis, you get in the sphincteric space, and that's kinda when, hopefully, you, you... basically, the mesorectum tapers off, and, uh, you, you'll find yourself looking at rectum, and you can... For me, when I staple, I tend to do, uh, Dr. [00:23:00] Temple will tell me what to do here. I, I tend to do an anterior/posterior staple line, 'cause I feel that's the best way to get the angle that I want. Uh, hopefully with one or two staples, sometimes more, I'm not gonna lie. And, uh, kind of visualization of the structures the entire time, 'cause it can be very easy to accidentally incorporate something like the vagina on, on a woman or some of the other, uh, structures on the males if you're not careful, um, because it's such a tight space down there. Um, I, I think we do things very similarly. I- a few other little things that just 'cause I had the privilege of listening to you, is for me, that posterior plane is critical, and it's, it's critical from the... And the best way to get into that posterior plane is when you identify your IMA, and you find that fa- that's it. When, if you, when you do that medial mobilization of that, the, the mobilization of the medial aspect of the of the peritoneum, uh, of, of the mesentery, you really begin to get into that beautiful annular space. So I would really encourage residents, like, that move really defines the beginning of the operation. And so that [00:24:00] posterior plane, it's beautiful when it works, and if it, if you're running into trouble, it's 'cause you're not quite in the right plane, so pull back. I find the robot, you get so close that sometimes you have to pull back to really see the space and understand where you are and where you're, where you need to be. So I think that posterior plane, to me, if when you can get all the way down posteriorly or, you know, quite low down posteriorly before you do the lateral, that's when you really find the lateral piece easier. And you're right, the lateral piece, when, with the mo- posterior mobilization, as you go posterolaterally, it really does become just a, you know, like Saran wrap that you just divide. It's really not, it's really not challenging. And if you set it up right higher up, the hard part in the pelvis gets easier. The only thing, other thing I do is I think, you know, Sean, you talked about how the prostate versus vagina. One of the things I find that, that's nice with the robot is putting that suture into the, into the uterus and using, and lifting that up as well. Because the uterus can be prolapsed, and so if you can pull it [00:25:00] up with that suture, and that, that also helps you get that plane nice- nicer as well. So I, I always put that in. Um, in terms of the stapling, Sean, I am a little, I'm probably a little bit more old school. Um, I don't... Getting those staplers in some of those men, you just, I just sometimes I can't. I don't love the anterior posterior unless I feel like I've got really nice mobilization. So sometimes I'll do a small fanny and put a, put a fo- and put a small stapler down. Yeah. No, I think it's whatever you can do to create the- And then I reinflate to do the rest. Yeah. Whatever it takes to get the angle you need to get a- Yeah what... So w- couple things that, that you said that are very important that I should've said. One is I, first of all, I never get any female patients, I feel like. But when I do that stitch in the fundus or around the fundus of the, of the uterus to pull it out of the pelvis, I'm basically taking this stitch and pulling it through the abdominal wall about two finger breadths above the pubic tubercle, similar to where you put your fanny steal. That is a godsend when it comes to [00:26:00] traction, uh, in that case. The other thing I was thinking of is that, Unfortunately, you can accidentally cone in a little bit as you get into the- Yeah ... deep pelvis. And so it's just very important to recognize that the whole mesorectum's gotta come with you and just be super careful. I think that we, uh, when I was newer in practice, I'll admit it now, like, I don't think I did enough at the pelvic floor. I kinda thought I was done, and I still had some thick tissue there. And so as I learned to dissect down further, get the full release of the posterior attachments the stapling has become a lot less stressful than it used to be. And I would stress... I mean, before we had the robotic stapler, I would do, um, a Phanton steel with a, a green contour, and then that would be 25 minutes right there for me because trying to get the angle. Uh- Yeah ... and things have gotten a lot better as we've dissected further and kind of- Yeah ... pushed it. And you have to, you go down and you have to see the, the levator's, uh, jiggle, and that's when you know you're down. And I, I do think that co- coming [00:27:00] back and forth with the camera to get the different views, I actually think that helps you with the coning, but it also helps you from going too lateral. You know, I think from when I started robotically I was going too lateral, and I was finding women with having some urinary retention that I wasn't... it's not very common, except that you were in that wrong, uh, you were that, a little lateral. So I do think that coning in and c- coming in and coming out helps you s- not cone. So let me ask you this. So tell me what you do or what patient you do and what your process is when you think you have to do a hand-sewn anastomosis instead of a stapled anastomosis. Uh, I still do it pr- robotically, as, you know, I do it robotically. I get down to the pelvic floor, and then I go down perineally. I put a, First of all, the patient, for those patients, I put them in a lithotomy. Now I, now when I do robotics for rectal cancer, I usually am doing split leg. I put those ones in lithotomy. I put them very low on the table before we do the robotic portion. They usually have creeped back up, but they're usually still low enough that you can do it. I use a lone star. I identify the, the intersphincteric groove. [00:28:00] I, I mark that, and then I proceed to sort of work, work, um, just work circumferentially to g- get that, to get that out, and then I will, um, pull that down robotically. You know, because you have the gel port and you can sort of see it, you usually can pull it down and rig- and then you have enough inflation to just double-check your orientation. And then I hand-sew it down. And, uh, you know, I think we're getting... I also don't always, depending on what, what margin I'm looking at, my old boss sometimes would only take part of the internal sphincter, not all of it. Mm-hmm. But, um, usually, you know, if you're n- if you're needing to take internal sphincter to get these, for these hand-sewns, I, I tend now to usually do most of it. Okay. Just do it circumferentially. That sounds pretty similar to me. I, I usually get the rectum to come out, like the colon to come out about two centimeters below because otherwise you're, they're, they're too tense and you get stenosis. Um, and when you, after you do these, even if it's loose, loose, loose, they, they retract a little bit. Like the sutures that look like they're outside and almost like a colostomy, they [00:29:00] go back up and, and you'll find uh, if you guys do these, that there will be a little bit of a stenosis and a little bit of a web at these anastomoses. And so that's why you want it really loose and to sort of almost flop down The hard part for me sometimes is trying to decide if I can deliver the mesorectum through the anus and, and avoid an extraction site. Mm-hmm. It's always kind of a, a, I would say, you know, game time decision, 'cause certainly some of these bigger mesorectums you're having to dilate the anus quite a bit to get it out, but- It's almost like you're doing a Lourdes procedure, right? Right. That's what it feels like. You're absolutely right. And given that you're already t- you know, impacting the sphincter or doing a something else, you know, is, is, it is a challenge. And I don't know, to me, um, it's really important for us to do as much minimally invasively as possible, but at the end of the day, the TME is what really matters, and that's the gold standard. And then, you know, an anastomosis really, you got one shot at these anastomoses. And so if you have to do a little fanny to get the right, right staple to, to do it, you're, it's I consider it good judgment. I agree [00:30:00] 100%. So what I would say then, so now I'm, now I've accomplished my goal. I've, I've gotten my, my, my s- my staple line is done. The mesorectum looks complete to me, uh, but I'm biased, you know? And so what I do, uh, after I've, you know, finished my specimens, I call pathology into the room and I walk over it with them. Now, we already have talked about, you know, on, on an administrative level what we expect from them, but I wanna talk to the individual because sometimes it's a first-year pathology resident. When the pathology assistant comes in, I'm so happy 'cause it's the same person every time. You trust them. But we look at the mesorectum together before we ever leave the room, and then obviously I sort of, uh, coach them on the proper documentation, um, which is obvi- you know, w- this is just part of the, the standards, but, you know, complete means there's no defect in the mesorectum. Near complete means it's almost perfect, but you've got very kinda superficial, um, less than five millimeters of depth, [00:31:00] uh, defects. Uh, but the mesorectum itself, the envelope, uh, you know, it's all included in your specimen. And then incomplete would be you, you probably left some mesorectum behind. And you have to be honest. Y- uh, you can't try to sway the judges, if that makes sense. And then I ask them to take pictures and, and put... They put... For us, they, they load the pictures up into our pathology report, and that's- Right ... you can say, you know, five years later, "Look at this photograph. This is what my mesorectum looks like." But what I would say is that with that, that's been a great teaching tool because you can pull it up later for your residents. It's very reproducible. It's not on your honor. A- and so that's a big part of it. But when I get the path report back, you know, one of the standards that we kinda worked on through ACS is that they have to document the completeness of the mesorectum. And, and so you have to have an agreed upon definition. And for me, I like to have video evidence of it personally. Yeah. And I think that, um, you know, the pathologists work pretty hard to come up with those standards, and they did a lot of training about sort of how to do that. And they, [00:32:00] you know, that when you look at the, um, the reliability of their ability to judge complete excisions, it's quite high now. Mm-hmm. Um, and so they've really owned it. Um, I think that's real... So I think that's really cool that your pathologist comes into the OR to take pictures. I, what I... And I think, Sean, we both do this, and this is something that I think for the trainees it's really important, and I do this with my trainees, is when you take out the specimen, you look at it together and you go over it and say, "This looks good," or, "Oh, this, remember we had this trouble here? This is where, you know, and, and maybe you're a little bit too lateral or maybe whatever." But I think that that's a really important teaching point that I, I think, uh, is really behooves us as colorectal surgeons to be really teaching and reinforcing that. We don't have a pathologist come to the operating room. We're part of the NAPRC, and so all of our specimens will get reviews using the sta- using the, the NAPRC standards. They get photographed and bread loofed, and we review all those images as a group. I love the idea of it actually going into the EHR. I think that that's a really nice way to go back and look at it. But we do a [00:33:00] pretty robust discussion of those, of those TMEs and learn from them. But I think the operative learning is is irreplaceable for the residents, and I think probably the additional conversation that you have with the, with pathologist probably even makes it richer for the residents. Absolutely. Well, you know, I think that it was a very robust discussion that we had regarding, uh, the importance of total mesorectal excision, uh, the operative technique, uh, from, uh, explained from two experts in the field and then the importance of the pathology documentation. Just a couple questions from a trainee perspective that I've garnered along the way. I think it's the easiest for the trainee to see that posterior plane after the division of the IMA and the anterior retraction of the, the mesorectum. However, as that plane's developed, I think it is easy for the [00:34:00] trainee to lose sight of the correct pla- plane laterally, and that can be very dangerous in terms of getting into a, a internal iliac vein or getting into those, uh, other nerves that along the pelvic wall. So how do you keep that plane correctly oriented? And then similarly, as you move anterior, it, it seems as the trainee, it is so obvious when that anterior peritoneal ref- reflection is divided and you can see, you know, Denonvillier's fascia, you can see the seminal vesicles or the re- uh, rectovaginal septum. But as the trainee trying to recreate that, that perfect exposure is i- i- incredibly challenging. So if y- you could both speak to, you know, the kinda tips and tricks for you know, for creating the optimal exposure in those, uh, in those settings. Well, Jason, this is, this is how you remind me that you have to kinda always be aware of how close you are to the iliac vein when you're working laterally. It's just, [00:35:00] the internal iliac's just past you. Even though it's off-screen, it's behind a, you know, some retroperitoneal structures, it is in danger. And so if you just go straight into the pelvic sidewall, you're gonna be very sad. The case changes quite a bit. I've seen videos of it. I've never done it myself. But what I would say is the secret- ... there is that you have to keep a wide canvas when you're working posteriorly. It's very easy when you're in that presacral plane to head straight to the pelvic floor right in the middle. Gotta go- But I take my time, and I go way out lateral then, 'cause that's the easiest time to find that plane. You'll, uh, have a much easier time. You can even walk backwards. You can start kind of posterior and almost work in a distal to proximal manner along the lateral attachments, and that's gonna help you stay in that correct plane. Another thing that helps me is that, like you said, you c- you know, you have, if you, on the rare occasion you get to operate on a, on a woman with a wide pelvis, they could have a mobile pelvic floor, and you can accidentally pull sometimes these pelvic floors in, and you'll get into bleeding. You'll [00:36:00] know pretty quick when there's, you know, brisk arterial bleeding that you're probably in the pelvic floor. But what I would say is that I like to have that kinda lateral or anterolateral retraction. I use tip of penetrator, but basically arm one of the robot- Or your assistant if you're doing it laparoscopically, 'cause that traction on the pelvic sidewall kind of helps you create the angel hairs that you want, 'cause you have that counter traction necessary. When I'm anterior same thing. You have to have that kind of cephalad traction. And then for me, probably something, not everybody agrees with me on this I love a good bedside assistant. And so, uh, even though it's an inglorious role for the resident if it's them, for the urology intern often is who I get for this. But what I would, what I would say is, If I have a, an assistant port in the right upper quadrant in a really obese patient with a narrow pelvis, if they can grab that rectosigmoid, usually just sigmoid, and pull out of the pelvis, that macro retraction really helps me to create the [00:37:00] tension I need. Then my arm one can come in and lift the, uh, seminal vesicles or the vagina anterior, and now I have the ability to do micro retraction with my left hand, uh, with whatever. I use suction, but, you know, whatever to, to kind of create the angel hairs I need to take that plane down. So thank you for, um, bringing that up because there, we, we probably didn't include enough tips and tricks- Yeah ... on that part. But- And I would say my... I remember being told year, time and time again, "Don't get into a hole." And I think that what Sean's talking about, about the posterior plane is lovely, but it is an opportunity to do 90% of your lateral dissection as well. Um, and so don't dig in a hole and just go straight down. When I talked about getting down to the pelvis, I meant going sort of doing the sort of the entire posterolateral up to sort of the perineal t- attachments. And also that coning in, that c- that coming in and out with the camera, that may seem counterintuitive when people are just so focused with the, with, when they're t- when they're starting, but pulling back to get that [00:38:00] panorama is critical. Yeah. I agree. I actually use... We have assists, and I actually will often use a suction to do that assistant, to do that su- assistant on the sidewall. Mm-hmm. I think that that really helps. Um, and, uh, sort of that triangula- like, sort of the trian- u- using your, um, grafters and keeping them open as opposed to closed, just using almost like a V, I find that very helpful. The anterior plane, to me, is the hardest, and it's critical. I will do as much as I can do posteriorly, as much as I can do laterally. And t- and if I can get circumferentially down to the pelvic floor, I'll do that before I start the anterior because the anterior is the hardest. And I think part of it is, is that, that reto-perineal, the perineal fold that you see either with, with the prostate or with the vagina, it's, it, it sort of can trick you. Like, it looks like it's here, but then if you look, it's a little bit further in. So you, you can get tricked. And so when I get into that anterior plane, um, what I love to do is just mark the peritoneum. And often the, es- if it's not an anterior tumor right there, um, [00:39:00] if you mark the plane, you get into that beautiful areolar space that you get posteriorly, and then you just work where it's areolar and then start connecting the dots. Um, and someone once described that anterior plane as kind of like an onion. You know, you're peeling it away as you go down. And so you just have to, you have to just keep following the areolar tissue. Um, and if you retract it well, it gets be- it, it's doable and, and it's quite, it's quite rewarding. I would say that when you're starting out, it is definitely the hardest plane to get finesse at. And I think that... I don't know what you think, Sean. I think it just takes years to get that experience. But it's really about getting that really nice retraction, that macro retraction, the micro retraction, and just really committing yourself. If you don't think you're in the right plane- Um, pulling back, looking at your lateral, where you are laterally, and then in your mind's eye say, "Okay, how do I connect the dots laterally to meet in the middle?" And, and usually that peritoneal reflection will give you, give you that hint. But that's sort of how I approach it. Pull in, pull out, and then just do as much posterolaterally and laterally as you can, and then attack that [00:40:00] anterior plane. I agree. Tunnel vision is the hardest thing. Sometimes you're... I'm, like, sideways and I didn't even know it. I'm like, "Wait." Right, right. That's true, too. And I, you know, this isn't what we were talking about, but it just reminded me, when you were talking about just, you know, reps and experience and years before you get it. I mean, I've been practicing for a while now. I'm still sweating every time I'm doing, like, the anterior, uh, perineal dissection on a guy. Yeah. Every time I'm in the perineal body just freaking out. I'm like, "I'm gonna get his ur- you know, his urethra for sure." Yeah. And, uh, and so I, I don't think I can be friends with somebody that doesn't get nervous, uh, during some of those parts of these tough operations. And we got the tools that we have. You know, we have, You had kind of alluded to the fact that, you know, you don't like that robot stapler and, and, like, I think it's imperfect, too. And so we, you know, we have, you know, the, you know, someday somehow we're gonna have better tools, but not right now. So, you know, f- what I would say is that I've just found that what I like is I have a suction in my left hand. Yeah. Kind of like an arm three. I have [00:41:00] scissors, and then I have these big kinda atraumatic graspers, whether it's a bipolar or a fenestrated, that y- the, the dance of those three tools uh, i- is necessary to kinda get the exposure you need. Yeah. And it's- And I don't use the scissors like scissors, I use them like a Bovie. Sure. Oh, yeah, of course. Yeah. And that, that speaks to me as my time. The other thing I forgot, and Sean you'll agree, is flipping the camera, flipping the camera so it's 30 degrees up. Mm-hmm. When you're, when you're anterior and that plane is really hard, that anterior flip, you have to pull back 'cause you're in, but, but doing that also helps as a, as a young trainee. And don't forget to do that. And also just don't rush it. I, like- Yeah. One case ... you just have to kinda accept that it's gonna take a while sometimes. Yeah. 'Cause when you become impatient and then you do get into the wrong plane, reestablishing the right plane is quite painful. But I hope that's helpful. I, it honestly, when it comes to teaching TMEs, it's not as easy to teach on a podcast as it is when you're right, you know, when you're in the OR and you can show them stuff. [00:42:00] Thankfully they have videos. And this is the other thing- the, you know, for residents, if they listen to this podcast, I don't... I hate to do a plug, but why not? It's really cheap to join the American Society of Colon and Rectal Surgeons as a resident. It's dirt cheap, and it gives you access to all of their online content. And you can find a lot of great videos, especially in the fundamentals of rectal cancer, uh, curriculum just got updated, that walk you through each step, the IMA, the posterior, the lateral, the anterior. And, uh, it really is designed to help that trainee get a better understanding of the anatomy and how to troubleshoot. Well, we've had a really excellent discussion, uh, here today from two rock stars in the field of colorectal surgery. And so I briefly, with the last couple minutes here, I just wanted to summarize the, um, you know, the operative standards for rectal cancer surgery. So, the importance of the total mesorectal excision, uh, is that the quality of the rectal [00:43:00] cancer surgery, uh, keeping that mesorectum intact, uh, both impacts patient survival uh, as well as patient function following rectal cancer surgery. Um, although, uh, this practice is implemented by colorectal surgeons and national societies, uh, on the larger scale rectal cancer surgery is, is not being performed or at that With this with this, um, quality of, um, of surgery. In the contemporary practice of, uh, surgical management for locally advanced rectal cancer are those patients that are receiving total neoadjuvant therapy. A complex, uh, low pelvic operation became more complex with the implementation of uh, full dose, um, neoadjuvant, uh, radiation. There are complications waiting around every corner, whether that's fistulas to the rec-- to the vagina, to the urethra, nerves on the lateral pelvic sidewall, and tempting blood vessels, as well as nerves along the [00:44:00] posterior sacrum. This operation requires, you know, the utmost technical e-expertise as well as a, a tedious steward of, uh, anatomy. The total mesorectal excision involves, uh, mobilization of the left colon, identifying the left ureter and the gonadal vessels, um, ligating both, uh, the IMA high, um, although not too high to make sure that the sympathetic nerves along the aorta are kept intact, uh, as well as dividing the IMV for additional reach into the pelvis. And then selectively mobilizing the splenic flexure, although both of these experts do tend to mobilize that routinely. Then progressing down into performing the TME operation itself starting with the posterior resection, creating that posterior plane and that nice areolar tissue and then, um, and then taking that dissection laterally and dividing the, uh, the middle rectal and lower rectal vessels, uh, and then continuing anteriorly, being sure to identify the vagina, the prostate, seminal vesicles, [00:45:00] um, in, uh, female and male patients. Um, and then transecting the, uh, the rectum in a way that both, uh, you can do so safely with an appropriate oncologic margin is, is key. And then following the excision of the specimen, um, uh, we've highlighted the importance of real-time pathologic review or, uh, review through your system's NAPRC to ensure the adequacy and quality of your total mesorectal, uh, excision. And synoptic reporting on the pathology report, uh, equally important. Dr. Leisek, you've been a wonderful host. I appreciate you doing this. And Dr. Temple I appreciate you too. This has been a lot of fun for me. It's been fun. J-Jason, with people like you, I'm excited about the future of rectal cancer management. Oh, thank you. Thank you for including me today