V14 - Dynamic Grasper Assisted Laparoscopic Total Pelvic Exenteration With Mucosa-Removed Colonic Flap

Purpose/Background: Total pelvic exenteration (TPE) is essential for achieving an R0 resection in patients with locally advanced rectal cancer. Minimally invasive approaches provide superior visualization and faster recovery but remain technically demanding in the narrow pelvis. When TPE is performed via a minimally invasive approach, the procedure becomes even more challenging. The addition of a dynamic grasper-a simple modification of a standard laparoscopic grasper using an elastic rubber band and silk suture-provides better exposure and stable, self-adjusting traction controlled solely by the operating surgeon.

This video demonstrates the application of dynamic-grasper-assisted laparoscopic TPE, including left lateral pelvic lymph node dissection and dissection through the arcus tendineus to achieve an R0 resection, followed by mucosa-removed colonic flap reconstruction of the pelvic floor.

Methods/Interventions: A 60-year-old man was diagnosed with low rectal adenocarcinoma presenting with features of colonic obstruction. He underwent a diverting sigmoid colostomy to relieve the obstruction, followed by total neoadjuvant treatment. MRI demonstrated invasion of the prostate and left pelvic floor, with lateral pelvic lymph node involvement.

The planned operation consisted of dynamic grasper assisted laparoscopic total pelvic exenteration, beginning with dissection along the left ureterohypogastric fascia, harvesting the left lateral pelvic lymph nodes, and continuing through this plane to dissect along the left arcus tendineus to ensure clear margins. Reconstruction was achieved using a mucosa-removed colonic flap created by stripping the sigmoid colon mucosa and suturing the preserved colonic wall to the pelvic floor defect, thereby obliterating the pelvic dead space.

Results/Outcomes: The operation was performed successfully with minimal blood loss and no intraoperative complications. The dynamic graspers provided stable, ergonomic traction throughout the deep pelvic dissection without the need for additional assistants. The patient recovered uneventfully and was discharged on postoperative day seven. Final pathology revealed a well-differentiated adenocarcinoma with clear resection margins (R0), with no metastatic carcinoma seen in 12 perirectal lymph nodes (0/12) or 4 left lateral pelvic lymph nodes (0/4), corresponding to a final pathological stage of ypT4 ypN0.

Conclusion/Discussion: Laparoscopic total pelvic exenteration is safe and feasible in selected patients when performed by experienced surgeons. The procedure's technical limitations are effectively addressed by the dynamic graspers, which provide stable, self-adjusting traction and enhance precision in deep pelvic dissection. Combined with the mucosa-removed colonic flap, this approach offers a cost-effective, reproducible technique for complex minimally invasive pelvic oncologic surgery worldwide.