Fully laparoscopic right colectomy for caecal cancer in an obese patient

Authors

Abstract

This video shows a fully laparoscopic right colectomy with intracorporeal anastomosis for a caecal cancer in an obese female patient with a BMI higher than 34.

Keywords

Fully laparoscopic, right colectomy, caecal cancer, obese patient

Media type

Duration

16'33''

Publication

2011-09

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Audio

E-publication

WeBSurg.com, Sept 2011;11(09).
URL: http://www.websurg.com/doi-vd01en3429.htm

Fully laparoscopic right colectomy for caecal cancer in an obese patient

1. Introduction 00'19''

Our patient is a woman with a BMI of more than 34 with previous surgery, cholecystectomy using a Jalaguier transrectal vertical long incision and freeing the adhesion. This patient had a caecal polyp at the ileocaecal junction. It is a positive polyp, it had adenocarcinoma. This is a 10mm Ligasure™ Atlas device. In obese patients, I think it\'s easier and better to use a 10mm instrument. This patient also had a CT-scan, and we have some dilatation of biliary tract segments 6-7, probably due to the previous surgical history. I\'m freeing the adhesion of the omentum because we will divide the omentum later, and I will explain how I have placed my trocar.

2. Freeing of adhesions 01'31''

The first step in surgery is to expose. Once I have freed the adhesion, I will do the exposure of the vessels to do a primary vascular approach. You see the Ligasure™ Atlas device, it is a very nice and very efficient instrument to divide rapidly the plane with a small decapsulation of the liver. This is the stomach. When you are operating on a patient which has had previous surgery, do you have some rules for going inside the abdomen laparoscopically? Yes, we enter at distance of the abdominal scar and we try to do a mini open, or using a Veress needle. You see this is the right colon, the omentum, I will divide the adhesion of the omentum now, remember this is the ileocaecum, and it will be time to expose the root of the mesocolon and mesentery. Here, you have an outside view: you see the important scar where the adhesion was located. I have first introduced the trocar at this level but look – the umbilicus is very low. The anterior superior iliac spine is at this level so it is unusual to have the umbilicus at this level, except in obese patients. These are the ribs. On the midline, half-way between the umbilicus and the xiphisternum, on the mid-clavicular line just underneath the rib, this is a transrectal in the right iliac fossa, I have a forceps. I will work with two instruments. This is the scope, and in this one, we will introduce the stapler and we will retract the transverse colon with the left sub-costal trocar.

3. Transverse mesocolon exposure 03'38''

We know where the tumor is —it is at the ileocaecal junction. The first step is to expose the root of the transverse mesocolon, you see it\'s very thick, you will see more with Michel Vix. This is the mesentery, we will put the patient head up now to use gravity in order to expose. I\'m pushing to get a left lateral tilt. I\'m using a 0-degree scope. I think to have better traction, we will grasp approximately at the level of the anastomosis or the resection.

4. Identification of landmarks 04'30''

As you can see, I am dividing a very fragile fat meso, this is the root of the ileocolic vessels, this is the duodenum coming, this is a landmark, the ileocolic artery.

5. Ileocolic vessels division 04'52''

This is the artery, and the vein, we can do a division using a separate section. This is the vein and the artery above. I\'m dividing the artery first. I\'m reducing the traction. This is the head of the pancreas, we will go towards the landmark, the forceps we have introduced at the beginning, dividing the entire vascular branch, accessory right colic branch, right colic vein, right branch of the mid-colic artery, these are branches of the gastrocolic trunk of Henle. During this division, we don\'t use traction that much, we will come back later. I\\\\'m going straight, there is always a trend to go laterally, always divide the peritoneum first. I\'m dividing the transverse mesocolon. This is the duodenum; behind we have the stomach, the transverse mesocolon just finished to be divided. We now have to divide the transverse colon.

6. Transverse colon division 06'21''

I\\'m now dividing the transverse colon. I still haven\\'t touched the caecum as you can see. A straight division of the omentum. It is here because I have already freed the adhesion of this omentum to the anterior abdominal wall. The advantage of this technique is that nobody is moving, the surgical field is always exposed and we respect the oncologic principles of Turnbull. You see the duodenum, the pancreas is behind it, and we have to free all the attachments. The danger is to possibly injure the duodenum. This is the stomach, we divide the attachment of the omentum to the stomach. These are the attachments to the great curvature. I think particularly with the 10mm instrument, it\\'s fantastic because it does a larger sealing and it\\'s dangerous too because you can see everything, which facilitates the standardization of the surgical procedure.

7. Ileum division 07'43''

Now I have to finish the distal division, this is the ileum, there is some adhesion due to appendectomy, it is better not to divide the ileum too close because you will have more mobility to perform the anastomosis. I\\'m dividing the ileum using a white cartridge and the meso along with it. Now I have a mesenteric bridge to divide. If I lock the Ligasure™ device like this, there is a problem because there are staples. Don\\'t lock it, use it as it is, electricity will pass between the two jaws to coagulate. If you touch the staples, you will not have that possibility. This is where I have begun my dissection, I have now finished dividing the mesenteric bridge.

8. Peritoneum division 08'41''

I\\'m dividing the peritoneum, and that is where there is a danger for the ureter, and try to find the posterior plane, the attachment of the caecum, stay close to the colon, and because we are using traction, we will open the plane. Sometimes, we don\\'t try to dissect the ureter, sometimes we will see it, where we have to go, it is not too deep because you will be in the Gerota\\'s fascia, we have to stay anterior to it, and that is why we have to stay close to the mesocolon. This is, I hope, the right plane. How to make sure it is the same plane we have outside and inside, medially and laterally. Medially, we have the duodenum there, and we continue the dissection. This is back to the fascia. This is the duodenum.

9. Ileocolic anastomosis 10'02''

Now I have to prepare my anastomosis. This is the right colon, now we have the transverse colon, you can see it there. We have to verify that there is no twist. We are sure that there is no twist because we follow the limit of the division. We will dispose the 2 stumps like this; so at a 2cm distance from the stapling line, we put a stitch; here’s the segment of bowel. And we will do an extracorporeal knot. On the other side, the same. Why do it inside? Because you see that it’s not necessary to mobilize too much; if we do it outside, we are obliged to mobilize more and in obese patients, there is more danger to break the meso. I’m keeping too long a thread to have a difference between the side to avoid twisting if we do the anastomosis outside. Other advantage: we can do the incision everywhere. It’s a blue cartridge. Move back. Because we have to close with two half-running sutures. We pull. The idea is to be close to the suture you have to catch. You come around like this, you do a loop, you open, you catch and you do an angulation like this to avoid to slide. Monofilament is interesting because it is sliding very well and you will have a regular tension on each stitch. It’s not necessary to pull always. The advantage of monofilament is at this moment: we pull as you see, we pass several stitches. You can see we have finished the anastomosis. We now have to limit the risk of internal hernia.

10. Mesenteric defect closure 14'10''

We have to close the mesenteric gap, which is at this level. We will close. We can use running sutures or Endo-Hernia so we have a short or long one. In this case, we can use green that is long. We can angulate and rotate in all directions. This is the right transverse. We will put a loop on one of the extremities. I will keep these sutures outside the bag to find one of the extremities. SPECIMEN EXTRACTION Now through the peri-umbilical trocar, I will enlarge the incision so the size of the incision is 3 to 4cm. This is the plastic wound protector, very cheap, it’s a drape with a hole in the centre. We pull the trocar around the forceps and introduce the wound protector. We deploy the ring inside the abdomen. Now we introduce the Endo-catch II through this new flexible port. We come back inside the abdomen, and I’m deploying the bag and we will push the caecum. See the suture is outside and now I’ll close the bag like this. I’m pulling on the bag outside.

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