Full medial laparoscopic right colectomy for cancer of the ascending colon

Authors

J Leroy, C Callari, J Marescaux

Abstract

This video shows a live right laparoscopic colectomy for the management of cancer of the ascending colon.

Classification

live recorded

Keywords

Full medial laparoscopic right colectomy, cancer, ascending colon

Media type

Duration

14'00''

Publication

2011-05

Popular

Favorites

Audio

Subtitles

E-publication

WeBSurg.com, May 2011;11(05).
URL: http://www.websurg.com/doi-vd01en3289.htm

Full medial laparoscopic right colectomy for cancer of the ascending colon

1. Exposure of operative field 00'27''

So the first step is the exposure. First, put the patient head up. And at the same time, I’m retracting the omentum above the transverse colon as you can see. I’m using the forceps on the left hypochondrium to maintain the root of the mesosigmoid retracted. We will now put the patient in a left lateral tilt to maintain the small bowel retracted in the pelvis and on the left side of the abdomen. And I can see the caecum. The tumor is located here. We can feel the tumor; we will not touch more. And the first step is to do a vascular approach. To do so, it is necessary to find where the ileocaecum is. This is the ileum. We have the duodenojejunal junction. This is the line where we will have the root of the mesentery.

2. Peritoneal opening 01'23''

Now we have to stretch anteriorly and I’m beginning to open the peritoneum —see the meso is a little fragile, and only the peritoneum. I can continue to dissect, and using traction and counter-traction to rapidly find the duodenum we will see there just behind the ileocolic vessels. See this is the duodenum. We will now continue the dissection not far from the SMV (superior mesenteric vein), so slowly we divide the fatty tissue.

3. Division of ileocolic vessels 02'10''

See the ileocolic artery beating there and the vein is probably in front. I will seal separately the vein and now the artery. We can increase the patient’s head up to have a better exposure down, and the colon will fall more in the pelvis. So we put the forceps where we will do the division. As you see, I’m not far from the transverse colon and I’ll do the division approximately at this level. Oncologically speaking, it’s necessary to be at a minimum of 10cm distal to the tumor if we remove all the mesocolon. At this level, we have the right colic vessels, the right branch of the mid-colic vessels just divided. This is the duodenum, the attachment of the transverse mesocolon to the duodenum, this is the genu superius – there are other approaches but I love this one, so I have just divided the attachment to the stomach and I’m just above to open the submesocolic space.

4. Division of transverse mesocolon 03'54''

Now we will do the division of the transverse mesocolon and the omentum. We will continue to dissect the meso. See the right colic branch of the middle colic artery.

5. Division of colon 04'10''

So we’ll now do the division of the colon. We remove the grasper and introduce it through the supraumbilical trocar and I have to position it perpendicular to the bowel to keep a good vascularization. So I’m now dividing the omentum. It is not working. Why? Because there are staples. So when you have staples, don’t close completely. You’ll use bipolar coagulation like this. So I’m continuing the division of the omentum straight. The anastomosis I’ll do will be a side-to-side isoperistaltic one intra-abdominally. But if you are a beginner, you can do it through a small incision, that’s why I’ll simulate the incision later. So the first step was to divide the transverse mesocolon.

6. Division of ileum 05'18''

So we stop at this moment and we’ll continue the procedure distally. With a forceps introduced in the left hypochondrium, we will now do a division of the ileum. So oncologically speaking, we’ll have completely excluded the 2 extremities of the right colon. I’m using a white cartridge to have a better hemostasis – it’s routinely used in bariatric surgery. Now I have to divide the mesenteric bridge. We have the duodenum at this level; this is the attachment of the appendix. I’m doing an appendectomy. If we stay close to the caecum, we’ll see the embryological plane anterior to the Treitz’s and the Gerota’s fascias, this is the right plane where we are sure that we will not be in contact with the retroperitoneal structures. We can work alone. When we are in the right plane, you can see that it’s coming easily. We will be on the duodenum. So we have finished to free the attachment of the hepatic flexure and the right colectomy is done. Now we will push the specimen above the liver. OK, so now we have the transverse colon and easily we can go and do the anastomosis outside just in front of the epigastric trocar.

7. Anastomosis 06'59''

We can do an incision in front to do the anastomosis outside but we’ll do differently. We’ll maintain this. Now I have to find the ileum. How? I follow the limit of the section probably there. That’s it. We’ll fix together the 2 segments with a suture. I’m using the 5mm trocar, fixing together the 2 stumps on the antimesenteric side not too close (2cm), not too far. This is a landmark, as I said, to do a pulley. We will do an extracorporeal knot. On one side we will cut one thread. On the other side, both together. Because if we want to do the anastomosis outside, we will identify proximally and distally. We’ll introduce the anvil, like this. It’s an isoperistaltic anastomosis. We have to verify when we do the anastomosis that there is no twist particularly at the small bowel. We always carry out a bacterial examination at the end of the procedure when we have cleaned. We will do our main sutures now. First, I want to put the gauze in a plastic bag and I will push this inside. There is a valve, particularly interesting in the gallbladder because we have a valve inside trapping everything. So we lose nothing. If you want to use a lateral approach, well, it is not what I do or what it’s recommended to do. We do primary vascular approach in oncology. The advantage of monofilament, as you see, is to pass several stitches before pulling. I’m using Maxon 3/0. Now I pull the monofilament. It’s sliding. To prevent the suture from sliding, you do this: you twist and you have an eye friction. I will do now the second suture to finish medially. To make a knot, you stay close, you come around, you catch, and you have a flat knot. And the last one. We have to do a pulley to slide better. Now we will cut this. We have to close the mesenteric gap. We will remove the last suture later. We have two possibilities: using a lateral approach or a medial approach. It looks good to close like this. You can use running sutures or, as you will see, I use the titanium Endo-Hernia™ stapler. You can modify the angulation. You can rotate too, like this. And you can change the cartridge too. This a 10-staple cartridge. To change, you put like this and you push. And you have two sizes: a short size (blue cartridge) and a deep one (green cartridge). I would like to show the shape of the staples. When it’s close, it is like this. It\'s not new, it has existed for 20 years. It’s a 10mm device. You pre-fire. I’m not touching now. The staples are out so you can anchor this and you can complete like this.

8. Specimen extraction 12'24''

Now we have to put the specimen into a plastic bag. First, I complete the incision, as I said using monopolar. You can keep the trocar, but I will remove it. I’m putting a plastic wound protector. It is a drape with a ring. I’m pushing this drape and we’ll use it as a big trocar. We will introduce the big Endo Catch II™ bag inside the abdomen and will put the specimen in it. I put a loop on the transverse extremity of the colon to rapidly find the specimen outside the abdomen. I’m closing more and more, and we have the suture outside. We pull on the plastic bag. As you see, we can open more the plastic drape. The advantage is not to pull first the omentum, but to have a stitch on the specimen to have one of the extremities of the colon. We will slowly remove. When I know people doing removal of the specimen and doping ileocolic anastomosis outside, I don’t know how they do in right colectomy. Because it’s always a huge specimen. It’s coming easier, as you see. And we can pull the specimen to reduce the volume inside the bag. No drainage at the end. Perfect. The tumor is there. I cannot open, but this is a tumor.

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