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Complete laparoscopic splenic flexure mobilization as the first step in anterior resection (medial to lateral approach)

This video shows a complete laparoscopic splenic flexure mobilization as the first step in anterior resection (medial to lateral approach). The advantage of routine specific flexure mobilization in an anterior resection is that sufficient length for a tension-free anastomosis is always assured and its completion early in the operation minimizes table adjustment and prevents its deliberation at the end of the procedure when the operator may be fatigued.

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Complete laparoscopic splenic flexure mobilization as the first step in anterior resection (medial to lateral approach)

作者群

R Cahill, I Lindsey, C Cunningham

摘要

This video shows a complete laparoscopic splenic flexure mobilization as the first step in anterior resection (medial to lateral approach). The advantage of routine specific flexure mobilization in an anterior resection is that sufficient length for a tension-free anastomosis is always assured and its completion early in the operation minimizes table adjustment and prevents its deliberation at the end of the procedure when the operator may be fatigued.

分類

contribution

關鍵字

laparoscopic splenic flexure mobilization first step anterior resection medial to lateral approach

媒體類型

手術影片

期間

14'30''

刊物

2010-06

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Jun 2010;10(06).
URL: http://www.websurg.com/doi-vd01en2987.htm

Complete laparoscopic splenic flexure mobilization as the first step in anterior resection (medial to lateral approach)

1. Clinical case presentation 00'18''

A 28-year-old thin female patient presents with lower abdominal pain on a background of increasing constipation over the previous two months. A CT-scan of her abdomen has shown a stricturing lesion of her mid-sigmoid that has been proven malignant by colonoscopic biopsies. She therefore requires a laparoscopic high anterior resection. Our preference in this operation is to routinely complete the splenic flexure mobilization in conjunction with a medial to lateral approach to the inferior mesenteric artery. The advantages of routine splenic flexure mobilization in an anterior resection are that sufficient length for a tension-free anastomosis is always assured and that its completion early in the operation minimizes table adjustment and prevents its deliberation at procedure-end when the operator may be fatigued. Its routine performance also assures familiarity and expertise for difficult cases and allows standardization of the operating protocol for all left-sided resections. Its disadvantages are that it is only absolutely required for length purposes in 20-30% of rectal resections. Furthermore, it adds operative time and it may be challenging. Further it can risk damage to the blood supply of the colonic remnant. However, these latter points can be offset by its expert performance.

2. Patient position 01'50''

For the splenic flexure first approach, our preferred operative set-up is to have the patient in a modified Lloyd-Davis position.

3. Trocar position 01'57''

The 30-degree camera port is placed subumbilically with a second 12mm port located in the right iliac fossa. Two working ports are placed at the level of the umbilicus in the mid-clavicular lines- one left and one right- and a third is placed in the epigastric region. To begin the operation, the surgeon stands on the patient’s right with the camera man to his left. The inferior mesenteric vein identification, dissection and division are performed from this position, as well as the entry into the lesser sac and the lifting of the mesocolon from the body of the pancreas. These positions are switched when the supracolic dissection of the omentum from the transverse colon is performed. With the ports in place, the procedure is begun with full laparoscopy including confirmation of the location of the tumor. Thereafter we turn our attention to the mobilization of the splenic flexure. In this case, the patient was found to have an aberrant omental attachment to the descending colon, which required division to allow us access to the root of the mesocolon at the origin of the inferior mesenteric vein.

4. Operative field preparation 03'26''

Once this is performed, the omentum is placed cephalad to the transverse colon. Thereafter, the displacement of the small bowel to the patient’s right-hand side is performed. It is aided by some head up tilt of the patient and it allows access to the root of mesocolon and the inferior mesenteric vein. This can be clearly seen coursing towards the inferior border of the pancreas. To allow access to the vein above all its tributaries, it is usually required to perform sharp dissection of the attachments of the fourth part of duodenum. The plane here is close to the duodenum and caution is recommended if cautery is used to avoid injury to the duodenum and to the small bowel lying just below the visual field.

5. IMV retraction 04'21''

The inferior mesenteric vein is then retracted upwards and, further, a sharp dissection is performed on its inferior border. As the dissection proceeds, the vein should be regarded as the ceiling of the dissection plane. All structures on its underneath as belonging to the retroperitoneum are therefore dissected downwards. The line of traction and counter-traction is in the vertical plane. For efficient progress, the distracting left instrument should be constantly re-adjusted to ensure that adequate tension is imposed on the tissues being dissected. Although the dissection can be continued caudad, it is important that the cephalad extent is limited to the inferior border of the pancreas and that this organ is not undermined. In this way, dissection proceeds over Gerota’s fascia (which is barely present in this thin patient) and towards the patient’s descending colon. The extent of the lateral dissection is determined primarily by the instrument\'s length. Once this limit is reached, attention should turn to the division of the IMV.

6. IMV division 05'49''

To do this, a window is opened in the mesocolon just lateral to the vein. Here we use overlapping Ligasure® seals to secure closure before the division, although equally Hem-o-lok® clips could be applied. Thereafter the vein is divided and the stumps checked for security. A mastoid swab is then placed laterally under the mesocolon and attention is turned to entering the lesser sac.

7. Transverse colon retraction 07'08''

This is best done by retracting the transverse colon vertically upwards and by determining the anterior border of the body of the pancreas. With this groove clearly identified, a window is made directly through the mesocolon by a combination of sharp and blunt dissection.

8. Lesser sac entering 07'27''

Once the lesser sac is entered, the stomach should be seen below the colon. The dissection can be continued back along the mesocolon towards the left branch of the middle colic artery. Very well seen here is an accessory left colic artery, which is a branch arising directly from the middle colic artery. This accessory artery is present in 10% of patients. It will be divided later in the procedure.

9. Mesocolon dissection 07'59''

Next the mesocolon should be dissected off the pancreas. Any vessels crossing this plane should be divided. Further, the blunt dissection is facilitated by effecting sufficient retraction on the mesocolon to allow it to be cleanly lifted off the pancreas. This also allows for the opening of a contiguous space connecting the lesser sac with the initial dissection space obtained under the descending mesocolon. This is evidenced by the earlier placed swab now coming into view.

10. Left colic artery division 08'55''

Once the mesocolic attachments have been dissected, the accessory left colic artery is skeletonized and can now be divided again by the Ligasure®. Thereafter, dissection continues out along the upper border of the pancreas. It is important to limit the dissection to freeing the tail of the pancreas. Actually, ingress into the mesocolon may induce damage to the marginal vessels and may compromise the vascularity of the colonic segment to be used ultimately in the anastomosis.

11. Splenic flexure freeing 10'15''

The next step then is to clear the omentum from the top of the transverse colon. At this point, the operator should switch positions with the camera assistant. The omentum is lifted towards the abdominal wall, and the colon itself is distracted downwards in the opposite direction. An appropriate site is identified and the dissection is begun in a plane close to the transverse colon. Both anterior and posterior sheaths of the omentum need division. For this part to proceed efficiently, is it important to maintain orientation and to continuously readjust the retracting tension on the tissues. While cautery scissors were very effective for this dissection in this patient, often the Ligasure® or other energy device may be better in ensuring hemostasis during this part of the operation. Regardless, the crucial factor is the combined traction and counter-traction being applied by the surgeon and his assistant. Frequently, the last part of the flexure is best approached by switching to a lateral approach in heavier patients. However, in this case, the splenic flexure could be almost entirely freed solely from the transverse colon’s side, allowing to cleanly bring the flexure down. Next, the lateral and posterior attachments of the colon are dissected off the lateral abdominal wall and the retroperitoneum respectively. We normally continue this dissection up to the level of the umbilicus and then proceed to complete the operation by beginning with the medial address of the inferior mesenteric artery after the patient has been moved into a reverse Trendelenburg position.