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Asian J Endosc Surg ISSN 1758-5902

SHORT REPORT

Hybrid approach using laparoscopy and transanal minimally

invasive surgery to treat rectal cancer with invasion to the seminal
vesicles
Takuya Yamaguchi,1 Minoru Imai1 & Dai Uematsu2
1 Department of Digestive Surgery, Mimihara General Hospital, Osaka, Japan
2 Department of Colorectal Surgery, Saku Medical Center, Nagano, Japan

Keywords:
Rectal cancer; seminal vesicles; TAMIS
Correspondence
Takuya Yamaguchi, Department of
Digestive Surgery, Mimihara Central
Hospital, 4-465 Kyouwa-chou, Sakai-ku,
Sakai, Osaka, 590-8505, Japan.
Telephone: +81 72 241 0501
Fax: +81 72 243 1946
E-mail: yamachanfeynman@yahoo.co.jp
Received 9 September 2016; accepted 19
September 2016
DOI: 10.1111/ases.12343
Abstract
We treated a 64-year-old man for rectal cancer with direct invasion to the
seminal vesicles and no distant metastases by complete resection with laparos-
copy and transanal minimally invasive surgery (TAMIS). We inserted the TAMIS
device into the anal canal to above the anorectal ring and dissected to prostate
level. High ligation of the inferior mesenteric artery and vein was performed by
standard medial laparoscopy. The sigmoid and descending colon were mobilized,
and in the postrectal space, we dissected to the space made by TAMIS. The
membranous peritoneum was dissected on both sides of the rectum to the cul
de sac. The peritoneum was dissected anterolaterally to reveal the seminal ducts,
which were ligated and dissected on both sides. The seminal vesicles were
dissected from the posterior wall of the bladder to the prostate level. The rectal
specimen was now fully mobilized. Lower rectal resection with combined lapa-
roscopy and TAMIS provided a better surgical plane than standard laparoscopy.

Introduction and endoscopic and pathological findings confirmed the

Complete en-bloc local resection with a negative surgical
margin is used to treat lower rectal cancer and yields a rad-
ical cure with a low risk of local recurrence (1,2). Laparos-
copy usually provides sufficient space and information to
allow for rectal surgery with an abdominal approach. How-
ever, closer to the pelvic floor, it is difficult to dissect the
“holy plane,” especially in patients with a narrow pelvis.
Recently, transanal minimally invasive surgery (TAMIS)
for total mesorectal excision (TAMIS-TME) has been used
to improve visualization of the anatomy near the anus
(3–6). The combination of a perineal and an abdominal
approach may be helpful in patients with a narrow pelvis,
patients with bulky tumors in the pelvic space, or obese
patients (6). In the case presented here, we used this hybrid
approach to treat rectal cancer that had invaded the
seminal vesicles.
Case Presentation
A 64-year-old man was referred to our hospital (Mimihara
General Hospital) because of a positive fecal occult blood
test. Colonoscopy revealed a type 2 lesion on the anterior
side of the middle third of the rectum. A biopsy was taken,
lesion was rectal adenocarcinoma (Figure 1). MRI showed
the tumor had invaded the seminal vesicles (Figure 2). CT
revealed no lymph node or distant metastases. The rectal
cancer was clinically diagnosed as T4bN0M0, stage IIc.
Because of the location and invasion of the tumor into the
seminal vesicles, we planned a hybrid TAMIS and laparo-
scopic total mesorectal excision approach.
The patient provided written informed consent for his
case to be described in this report.
TAMIS-TME
The TAMIS-TME procedure that we used was described in
detail by Atallah et al. and Lacy et al. (3,6). Briefly, while
the abdominal field was kept sterile, the patient’s legs were
brought into a high dorsal lithotomy position. To perform
the proctectomy using a reverse approach, we introduced
the sleeve portion of the GelPOINT Path (Applied Medical,
Inc. Rancho Santa Margarita, CA, USA) Transanal Access
Platform port into the anal canal, seated it immediately
above the anorectal ring, and sutured it to the skin. A
purse-string suture was placed distal to the tumor, ensuring
a negative distal margin.

Asian J Endosc Surg 10 (2017) 219–222

© 2017 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd 219
Laparoscopy and TAMIS for rectal cancer Yamaguchi T et al.

Figure 1 Preoperative colonoscopy revealed a 50 × 50-mm type 2 lesion in

the middle third of the rectum.

We created a full-thickness circumlinear incision through

the rectal wall just above the inner rim of the plastic sleeve.
Next, the GelPOINT Path’s lid was placed onto the sleeve,
and the device was connected to CO2 insufflation
(15 mmHg). We used a 30° 10-mm lens to visualize the sur-
gical field. We used a laparoscopic grasper to hold the tail of
the purse-string suture and connected a spatulated laparo-
scopic cautery device (Opti4®, Medtronic, Minneapolis,
MN, USA) to a suction device.
We performed TAMIS-TME, beginning at the point of
division of the rectal lumen and proceeding in the anterior
direction. As with the standard laparoscopic abdominal
approach from above, the posterior and then the lateral
planes along the pelvis were established first. We
established the plane between the presacral fascia (parietal
endopelvic fascia) and the rectal fascia of the mesorectal Figure 2 (a,b)MRI revealing tumor invasion into the seminal vesicle.
envelope by sharp dissection from the posterior. We then
laterally extended the dissection to where the lateral stalks the surgeon, who was standing on the patient’s right. As
divide near the mesorectum to prevent injury to the pelvic in the standard medial approach, we performed high
splanchnic nerves and other laterally coursing parasympa- ligation of the inferior mesenteric artery and vein.
thetic branches. We mobilized the sigmoid colon and descending colon. In
We approached the anterior plane last and dissected the retrorectal space, the dissection reached the space that
between Denonvilliers’ fascia and the prostate below the had already been created by the TAMIS approach.
level of the seminal vesicle. We achieved a completely We dissected the membranous peritoneum on both sides
intact mesorectal envelope of the subperitoneal rectum. of the rectum to the cul de sac and dissected the peritoneum
Once the dissection had progressed anterior to the level of and adipose tissue anteriorlaterally. The seminal ducts were
the prostate, we moved on to the abdominal phase of the ligated and dissected on both sides, while care was taken
operation. with the ureters (Figure 3a,b). After anterior dissection of
the connecting tissue, we cautiously dissected the seminal
vesicles from the posterior wall of the bladder and prostate,
ABDOMINAL PHASE which had already been removed from the anterior side of
We introduced five ports and tilted the operative table lower rectum during TAMIS. At this point, the rectal
downward toward the patient’s head and laterally toward specimen was fully mobilized (Figure 3c).

Asian J Endosc Surg 10 (2017) 219–222

220 © 2017 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd
Yamaguchi T et al. Laparoscopy and TAMIS for rectal cancer

resection margin did not reveal tumor tissue (Figure 4).

TNM staging for the tumor was T4bN1M0, stage IIIc.

Discussion
We combined TAMIS and a laparoscopic approach to
successfully treat a patient with rectal adenocarcinoma.
This hybrid approach has certain advantages in the excision
of difficult rectal cancers that have invaded the seminal
vesicles. It facilitated a multidirectional approach that
decreased the likelihood of inadequate dissection, which
could leave cancerous tissue at the dissection margin.

Figure 3 (a–c)Intraoperative laparoscopic images. X, bladder; Y, seminal

ducts; Z, seminal vesicle.

After mobilizing the splenic flexure, we identified an

early colon cancer in the transverse colon adjacent to the
splenic flexure, which we resected. The remaining length
of colon was too short to reach the pelvic floor, requiring
us to create a colonic stoma.

Results
The operation time was 570 min, and blood loss was
270 mL. There were no postoperative morbidities, such as
wound complications or urinary retention. Figure 4 Pathological findings for the excised tumor. (a,b) Macroscopic
The main tumor was an advanced rectal cancer 5 cm in images of the excised tumor. (c) Area shaded in red denotes
diameter. Microscopic examination of the circumferential adenocarcinoma. Black arrowheads indicate seminal vesicle.

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© 2017 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd 221
Laparoscopy and TAMIS for rectal cancer
In minimally invasive surgery to remove rectal cancer
that has invaded the seminal vesicle, it is difficult to
determine the optimal plane from which to create a
sufficient tumor margin. For en-bloc resection, total pelvic
exenteration is often a prudent choice because the surgical
margin is very wide. However, this procedure results in
functional damage that necessitates the creation of a
urostomy.
In our patient, MRI revealed possible invasion to the
seminal vesicles. Previous studies have shown that MRI
findings accurately correspond to operative specimen
findings (7).
It is known from classical surgery that when it is difficult
to dissect from one direction, clinicians may have to
approach from other directions. TAMIS accomplishes this
by enabling a transanal approach to rectal dissection.
Laparoscopic low anterior resections are usually performed
by the standard abdominal approach. However, in low
anterior resections with adjacent organs such as the vagina,
prostate, and bladder, it is often difficult to find the plane
from which the surgeon should go from one side to the
other. Therefore, with the standard approach, before
dissecting at critical points such as the area adjacent to
where the tumor has invaded, the surgeon must move to
the other side to obtain additional information.
In the present case, we first dissected the rectum to the
prostate level by TAMIS. We then moved on to the
abdominal phase of the operation; during this phase, we
dissected the seminal vesicles with confidence because we
had already identified the correct plane from which to
approach the vesicles with free space on the dorsal side.
Based on our experience and the experience of other
surgeons, we believe that a multidirectional approach may
decrease the likelihood of inadequate dissection, which
can leave cancer tissue at the dissection margin; this is one
of the most critical aspects of rectal cancer surgery (1,2).
In conclusion, in this case, combined laparoscopic and
transanal approaches yielded a more precise dissection than
222 © 2017 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd
Yamaguchi T et al.
either procedure alone. TAMIS-TME can be used to
facilitate a multidirectional approach to rectal cancer
complicated by invasion to the seminal vesicles.
Disclosures
The authors have no conflicts of interest to disclose.
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