A case of a 63 y/o Filipino lady, k/c of Metastatic Rectal AdenoCa 4cm FAV cT2N0M1 (liver- potentially resectablfe) few months ago. Decision made for upfront chemo in view of metastatic dse with asymptomatic primary. After 3 cycles of FOLFOX, the patient was planned for Laparoscopic TME, Intersphincteric Resection (partial), CAA, DI + intra-op Liver USG kiv metastasectomy.
Highlights: 1. Again, there are 4 critical points where nerve injury could occur during TME. We almost transected the SHP in this particular case which was somehow tented even after IMA ligation. 2. A standard approach to TME is quite helpful ( read:choreography) 2. I would tend to agree that female pelvis’ are kinda forgiving plus given the fact that this lady has a small mesorectal fat area. We did manage to demonstrate clearly some key structures in the pelvic floor such as the anococygeal raphe and the levator ani muscles. Essentially, the majority of the intersphincteric dissection was done trans-abdominally. 3. Finally, the medial to lateral approach (demonstrating the ‘Delta wing of Melani’) to the splenic flexure was utilized in this particular case.
