Adenocarcinoma of colorectal junction: laparoscopic anterior rectal resection. Advantage of the Ligasure Advance® device

The purpose of this video is to show an anterior rectal resection technique for an adenocarcinoma of the rectosigmoid junction using the Ligasure Advance® device (Valleylab, Covidien, Boulder, CO).This video shows how this device can optimize efficiency and safety in the operating room and potentially reduce overall operating time.

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Adenocarcinoma of colorectal junction: laparoscopic anterior rectal resection. Advantage of the Ligasure Advance® device

Authors

J Leroy, J Marescaux

Abstract

The purpose of this video is to show an anterior rectal resection technique for an adenocarcinoma of the rectosigmoid junction using the Ligasure Advance® device (Valleylab, Covidien, Boulder, CO).This video shows how this device can optimize efficiency and safety in the operating room and potentially reduce overall operating time.

Catégorie

clinical cases

Mots-clés

Adenocarcinoma, colorectal junction, laparoscopic anterior rectal resection, advantage Ligasure Advance® device

Type de vidéo

Vidéo chirurgicale

Durée

19'24''

Publication

2009-07

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2709.htm

Adenocarcinoma of colorectal junction: laparoscopic anterior rectal resection. Advantage of the Ligasure Advance® device

1. Introduction 00'10''

The purpose of this video is to show an anterior rectal resection technique for an adenocarcinoma of the rectosigmoid junction that is well identified by the MRI, especially in the sagittal sections. The first operative time is the introduction of the 12mm optical trocar along with the additional trocars used for exposure and dissection.

2. Medial to lateral dissection 00'52''

The principle is to perform a medial approach while preserving the lateral colonic attachments. Once the root of the sigmoid mesocolon has been exposed, we open the peritoneum from the anterior surface of the sacral promontory up to the lateral edge of the duodenojejunal flexure along the aorta. This incision will be extended towards the pelvis, and more specifically, towards the posterior surface of the mesorectum. Thanks to tension placed on the tissues using a grasper introduced suprapubically and maintained by the assistant, we continue a plane by plane dissection using monopolar scissors, then with the Ligasure Advance® using the 2mm monopolar electrode tip that uses computer- and generator-controlled monopolar Valleylab® current and adapting in this way to the tissues dissected. At this point in the dissection, we do not use more than 5 Watts. We can also use the Ligasure device function that allows to grasp tissues before they are sealed and divided with the system-integrated knife.

3. IMA dissection and division with Ligasure device 02'53''

The dissection of the inferior mesenteric artery is performed until the artery is perfectly skeletonized. Once the artery is isolated, we use the Ligasure Advance® to seal in a more extended fashion 2cm distal from the aorta. We continue to place tension on the tissues and use the Ligasure Advance®’s tip with monopolar current to complete the division of the fibrous tracts. We use the Ligasure® function to divide or seal the more important vessels, here the inferior mesenteric vein. Caudally, the dissection continues on the posterior surface of the sigmoid mesocolon, and on the mesorectum while keeping in contact to the vascular sheath as this will allow to identify the upper rectum’s fascia propria. It is thanks to traction and counter-traction on the tissues and the application of minimal monopolar current using the Ligasure Advance® that the division of the tissues is performed.

4. Lateral sigmoid colon and rectal dissection 04'52''

Once the vascular approach has been performed at the level of the origin of the inferior mesenteric artery and once the posterior attachments of the sigmoid mesocolon have been freed, we continue the freeing of the sigmoid colon by dividing its lateral attachments. This division is performed in a stepwise fashion until we find the posterior dissection plane performed by medial approach. The dissection will continue caudally using either the monopolar tip and Valleylab current, or the Ligasure Advance® that allows a division with a wider hemostasis of the tissues. We have now finished freeing the sigmoid colon, freeing that will allow us to place better traction of the upper rectum and the colorectal junction. Thanks to this perfect exposure of the colorectal junction’s posterior surface and the tension placed on the tissues, here we can see the right superior hypogastric nerve plexus that can be divided if we are not careful enough as the traction can modify its trajectory. The counter-traction is performed here using a mounted peanut swab, which allows to be completely atraumatic, especially on the nerve branches, but also to avoid the diffusion of current should contact to a metallic instrument occur. The dissection is continued caudally with accentuated traction on the fibrous tracts with the mounted peanut swab, which allows to push on the fascia propria without any risks of perforation, contrarily to a more traumatic instrument or laparoscopic fenestrated grasper. The use of moderated current associated with traction allows to gradually divide the fibrous tracts while avoiding the current’s diffusion or hyperthermia thanks to the instrument’s plastic jaws that allow not to diffuse any over-heating. We continue the dissection to the right and we notice that thanks to the instrument’s shape that allows to increase the pressure applied on the tissues and to use monopolar current, we gradually open the perirectal planes, here on the posterior surface of the rectum, up to its medial part. As it is a lesion of the colorectal junction, we will continue the dissection up to the Douglas’ pouch. Without lesion manipulating, we can see here the traction, counter-traction applied by the surgeon and his assistant, while the dissecting instrument is used to divide the tissues in the correct plane with the monopolar electrode for the fibrous tracts, or the Ligasure Advance® for the longer and deeper divisions. This dissection is performed gradually and slowly with perfect hemostasis. The multimodal function of the instrument enables to adjust the dissection to the tissues. The decision is made to divide the colon at the level of the Douglas’ pouch. To do so, a cylindrical division of the mesorectum is performed at the mid-portion of the rectum. The inferior pole of the lesion is situated 7 to 8cm more cephalad. Dissection is started first on the posterior surface using the principles of triangulation and especially 3-directional retraction as named by Prof. Bill Heald. This means that the rectum is retracted cranially; counter-traction is then carried out with a forceps in order to place tension on tissues, and finally the dissecting instrument completes the retraction, hence facilitating the dissection.

5. Colon ligation 11'45''

In order to respect oncological principles, the colon is ligated underneath the tumoral area and slightly above the rectal area that will be divided later. Preparation of the area to be divided is continued using the Ligasure Atlas® device; this is done in order to apply the linear cutting stapler later on. Before doing so, the rectal stump will be washed using a Betadine® solution, which will help to clean it of potential tumoral cells that might have migrated during dissection and handling of the upper rectum.

6. Rectal stapling 12'49''

The stapling can then be carried out using either a 45mm or 60mm long Endo-GIA® linear stapler, blue cartridge (since we are not at the level of the lower rectum). Here we can see that two applications of the 45mm long stapling device crossing each other at the mid-portion of the rectum are not sufficient. Indeed, there is a small bridge remaining to be divided by another last application of a 30mm long Endo-GIA® linear stapler. The proximal colon then needs to be divided as soon as the vascular package has been isolated. The vein that had been simply sealed at the beginning of the procedure is divided at this moment.

7. Splenic flexure and descending colon mobilization 14'16''

Then the splenic flexure and the descending colon are freed of their lateral attachments. Here there are a few adhesions originating from sequelae or inflammatory bouts that are unrelated to the adenocarcinoma of the colorectal junction. Once the descending colon has been freed and the vascular package has been isolated, the sigmoid mesocolon is divided until we reach the zone in which the colonic anastomosis will be performed and that we had previously identified. The meso is divided while making sure to preserve the vascularization of the descending colon, and especially the marginal vascular network that will then be used to supply the lowered colon. We therefore divide the meso along the axis of the mesentery slightly underneath the zone that will be anastomosed in order to preserve a good vascular supply.

8. Proximal colon division 15'55''

Once the sigmoid mesocolon has been divided, the colon is divided slightly underneath the zone of the final division where the anastomosis will be achieved.

9. Specimen extraction 16'05''

The colorectal segment can then be extracted through a plastic wound protector introduced through a small suprapubic incision. The specimen is placed in a plastic bag that allows for its double isolation. Indeed, the colon’s manipulation via the thread used for its identification and located on its extremity, is fairly safe and straightforward thanks to this double protection. This avoids the risk of cancer spillage during the squeezing of the specimen.

10. Anvil introduction 17'05''

The left colon is then brought through the suprapubic incision while still protected by the plastic drape. The anvil of a 28mm DST EEA® circular stapler is introduced once a purse-string has been applied on the colonic extremity. This purse-string is tightened around the shaft of the anvil. Once reintroduced into the abdominal cavity, any tension at the level of the zone that will be anastomosed is ruled out. We make sure that the anvil does come into contact with the rectal stump.

11. Transanal colorectal anastomosis 18'08''

The rectal stump is perforated with the circular stapler. Then the anvil is introduced into the tip of the stapler in order to achieve a trans-sutural end-to-end colorectal anastomosis thanks to the 28mm DST EEA® circular stapler introduced transanally. The integrity and thickness of the donuts are controlled.

12. Air test 18'51''

An air test is performed and, should there be any remaining doubts, an endoscopy is also carried out. Here, the air test proves negative. The colon is clamped before injecting air into the rectum.

13. Mesocolic defect closure 19'04''

The mesocolic defect then needs to be closed in order to prevent any occlusive syndrome induced by an internal hernia. This closure can be carried out either by staples as in the present case, or by performing a running suture. The defect must be perfectly closed laterally at the duodenojejunal flexure.