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Exposure in laparoscopic left colonic and rectal surgery

This video demonstrates the technique of medial approach to mesenteric mobilization and vascular dissection during a left hemicolectomy. The surgeon demonstrates the principles of trocar placement and internal retraction without the use of Trendelenburg. This video is intended to provide basic review of medial mesenteric mobilization of the left colon.

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Exposure   in   laparoscopic   left   colonic   and   rectal   surgery

作者群
J Leroy, D Fölscher
摘要
This video demonstrates the technique of medial approach to mesenteric mobilization and vascular dissection during a left hemicolectomy. The surgeon demonstrates the principles of trocar placement and internal retraction without the use of Trendelenburg.
This video is intended to provide basic review of medial mesenteric mobilization of the left colon.
分類
basic techniques
關鍵字
medial mesenteric mobilization, technique, vascular dissection, left colon
媒體類型
期間
13'00''
刊物
2004-09
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1111e.htm

Exposure   in   laparoscopic   left   colonic   and   rectal   surgery

1. Case presentation 00'12''
Proper exposure in laparoscopic surgery is probably the most important step. This starts with placing ports. In this case, 6 are used: one optical trocar, 2 to operate with, 2 to retract, and one that will be used as a third arm by the assistant. The 1st step in exposing the left colon and rectum area is to take the omentum and push it on to the liver below the diaphragm; this not only pulls the omentum out of the way but also the transverse colon. This step of exposure is greatly aided by having the patient in a steep head down position. Next the small bowel is grasped but not proximally in the mid-part and pushed towards the right paracolic gutter. This is helped by having the patient in a right lateral tilt position. A retractor will be used to keep the small bowel in this position. Next, attention turns to the right iliac fossa where there will always be small bowel protruding into the operative field. Once again, a steep head down position helps to keep it out of the way but also a retractor will need to be introduced through a port in the right subcostal area. It’s safe to grasp the peritoneum like this and then swing the small bowel around it. This obviates the need for the use of fan retractors or other mobile small bowel retractors that have a significant chance of injuring the bowel. This exposes both the right and the left iliac vessels. See that the patient is quite steeply tilted and this helps. Alternatively, the bowel itself can be grasped. It is easier to grasp a little fat attachment like at the juncture of the hilum and the cecum here and this is pulled upwards and so the bowel forms its own bulwark against invasion of the operative field. Witness now the extent view of the pelvis and also of the aorta and the bifurcation where our dissection will commence. The inferior vena cava is visible on top and this is the inferior mesenteric artery, which in this thin patient is clearly visible. The duodenum as well as the angle of Treitz are well seen. This is the transverse colon. At this stage, it’s not invading the operative field but if needs be, the 3rd arm of the assistant can take hold of the appendicis epiploica and pull it up and this brings the transverse mesocolon and the middle colic vessels into view as can be clearly illustrated here. This 3rd arm is very useful and should be used actively. In this case, the patient had a previous hysterectomy and there is no uterus to bother the vision. However, if there is and it’s a problem, it is an easy matter just to suspend the uterus to the anterior abdominal wall using a suture. As dissection now starts, there is nothing obstructing the view. Notice how the tissue is lifted with the left hand; in other words, it’s an active bimanual dissection and not only a dissection with the scissors. This is demonstrated here and it is actually more difficult to lift the tissue to be dissected away with only one hand. If a second hand is now used, this opens up an inviting plane for further dissection. In this case, our scissors with variable angulation also makes this exposure much easier. The grasper held by the assistant is actively used to lift up tissue and show the thin fascia that holds it together. This illustrates an important principle in laparoscopic surgery. As far as possible, one should try to dissect with triangulation. In other words, the assistant in this case holds the tissue up, the left hand will grasp the bottom of the tissue and all dissection can then be performed under tension with diathermy scissors in this case. Notice that in this case as in most cases of surgery to the left colon, the sigmoid colon is not a problem as it usually has some adhesions laterally. One takes care not to divide these adhesions as they will allow this colon to flop down into the operative field. Once again, notice how the third hand retractor held by the assistant opens up thin and easy to divide tissues. The left hand aids greatly in this exposure. Once again, we’re dissecting the inferior mesenteric artery as here traction and counter-traction is the secret of adequate exposure. The tissue held up opens up the whole operative field to the surgeon and allows triangulation and vision as well as dissecting tissues away, which are held under an amount of tension. This is different from open surgery and needs a specific mindset and specific application of the 3rd hand of the assistant. The plane is now being opened up on the fascia of Toldt and using the ascending left colic artery as a retractor, further dissection now continues along the vascular plane to identify the inferior mesenteric vein. As vascular surgeons know, the safest plane to dissect near the vasculature is right on the vessels and that is clearly illustrated here with tissues just stripped away with a combination of blunt and sharp dissection. The left colon is now liberated while simply dividing on the fascia of Toldt. Again using upward traction and downwards pushing motion with the scissors allows the tissues to sweep away easily with minimal application of diathermy and minimal bleeding. In this case, it is not necessary but one should always keep in mind that the angle of the camera can be changed by simply putting it in another port or by putting in another port specifically for that purpose. In this case, it is well shown that the best angle to dissect at is at 90 degrees to the straight axis of the camera. The lateral adhesions of the left colon, which had been holding the colon up out of the operative field is now divided. One should use all the resources available; in this case, gravity now aids in pulling the colon down towards the right as the table is still tilted towards the right of the patient. This now allows the colon to fall away progressively out of the operative field as it is mobilized further. It is hardly ever necessary to put retractors directly on friable tissues or on organs. In this case, the left hand of the surgeon grasps the colon under direct vision but retractors can also be put on the appendix’s epiploica, on the ligaments or on connective tissue. In this case, it would have been a mistake to take down adhesions from the abdominal wall as this serves a purpose of retracting tissues and allowing one to dissect the colon away from these tissues. Notice once again how the 3rd hand is used on this safe ligamentous tissue to hold back and try to angulate the area of dissection. Here’s the spleen visible. Witness how proper retraction on the third hand opens up the space to be dissected and minimizes any chance of damaging either the spleen superiorly or the colon inferiorly. It perfectly illustrates the principle of triangulation and dissecting under vision, which is so important in laparoscopic surgery. Therefore, to recap with exposure, one needs small bowel out of the way and time taken to do this properly, one needs the 3rd hand to be used actively to triangulate tissue and dissection should always be done under vision and under a certain amount of tension. This coupled to good ergonomics and proper port placement will ensure good results and a surgeon that is not fatigued.