LAUSR

We used the CURVE navigation system (BrainLab, Feldkirchen, Germany) as a navigation platform, which includes a stereoscopic infrared camera for tracking the three-dimensional position. Preoperative computed tomography scan data were used as a “map” to allow for image-guided realtime stereotactic navigation. A laparoscopic procedure was performed with five trocars with the patient in extended lithotomy under general anesthesia. Using the stereotactic navigation system, the precise position of the tip of the electrocautery device could be tracked in real-time and correlated with the actual location as seen on the optical image from the laparoscopic camera. After the location of the recurrent tumor was identified by this system, laparoscopic lateral lymph node dissection was initiated bilaterally. After isolation of the ureter, dissection was performed along the external vessels, psoas major muscle, and internal obturator muscle. The obturator nerve was identified and preserved, while the obturator vessels were divided. The roots of the inferior vesical vessels were divided, while the superior vesical vessels were preserved. A dissectible layer between the internal iliac vein and the sciatic plexus/piriformis muscle was extended from the lateral side. After sufficient mobilization of the internal iliac vein, the pelvic splanchnic nerve (S3, S4), coccygeus muscle, and sacrospinous ligament were divided. Using the stereotactic navigation system, the sacrum was divided, to some extent, at the level of S2–3 with a soft coagulation method. Next, the patient was repositioned to jackknife position. The gluteus maximus muscle and sacrotuberous ligament were divided along the sacrum, and sacrectomy was performed at the transected level of S2–3. The rectum was divided just above the levator ani muscle using a linear stapler, and the specimen was extracted. The skin defect was reconstructed using a pedicle flap. Local cancer recurrence following rectal surgery is a major problem that threatens the prognosis and quality of life of individual patients. Surgery for locally recurrent rectal cancer is technically challenging due to postoperative adhesions and altered anatomy around the tumor. In addition, the surgical procedure can vary greatly, depending on the site of local recurrence and its anatomical relationship to the adjacent structures. Frameless stereotactic navigation is a technique that can provide surgeons with real-time image-guided anatomical information in neurological and orthopedic surgery [1–4]. However, in pelvic surgery, only a few reports originating from one group have assessed the usefulness of stereotactic navigation [5–7]. In this video, real-time navigation is applied to a laparoscopic Hartmann operation with distal sacrectomy. The patient was an 80-year-old male diagnosed with a locally recurrent rectal cancer. He had undergone laparoscopic low anterior resection 3.5 years earlier for primary rectal cancer. The recurrent tumor was located at the posterior space of the anastomotic site and directly invaded the sacrum (S3/4/5).