Identification of hiatal ligament for laparoscopic total mesorectal excision

Total mesorectal excision (TME) based operation is now established as a standard procedure for patients with lower or middle third rectal cancer. Laparoscopic surgery has a great advantage in colorectal surgery, with good operative views, as well as benefit to the patients owing to less invasiveness, early recovery and shorter hospitalization. From April 2001 through March 2002, we assessed the laparoscopic TME for eight consecutive patients with rectal cancer in Kobe University Hospital (median age: 65.3). The procedure included sharp mesorectal dissection with high vascular ligation and preservation of autonomic pelvic nerves. During the laparoscopic TME, the hiatal ligament that is the sequence of anococcygeal raphe body can be identified with the traction of the rectum upward, and this fixes the posterior wall of the rectum to the levator hiatus. Resection of the hiatal ligament enables us to isolate the recto-anal canal up to the level of the internal anal sphincter. We conclude that identification of the hiatus ligament is essential to achieve the appropriate laparoscopic TME.