Laparoscopic TME: principles and technique

WeBSurg est une université virtuelle accessible mondialement sur Internet. Notre objectif est de fournir aux chirurgiens, aux sociétés savantes et au secteur médical un enseignement médico-chirurgical de pointe en ligne en chirurgie mini-invasive et toute information concernant les dernières avancées en chirurgie laparoscopique, dont notamment la Chirurgie Endoscopique Transluminale par les Voies Naturelles (NOTES) et la chirurgie assistée par robot.

Naviguez dans
l'Université Virtuelle

Laparoscopic   TME:   principles   and   technique

Authors
Mots-clés
Type de vidéo
Durée
11'00''
Publication
2004-11
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Nov 2004;4(11).
URL: http://www.websurg.com/doi-vd01en1280e.htm

Laparoscopic   TME:   principles   and   technique

1. Vascular approach 00'13''
For this operation, we will use a standard 6 trocar technique. The dissection of the peritoneum will be started at the site of the promontory and we will continue along the right border of the aorta until we reach the 3rd part of the duodenum. The inferior mesenteric artery will be cut between clips and the inferior mesenteric vein will be clipped. You can start the first dissection, which is at the site of the promontory and we will prolonged to the right border of the aorta. In this case, the coagulating scissors are used in the same way as ultrasonic dissection or Ligasure can be used for this dissection. When we reach the inferior mesenteric artery, it will be dissected and freed outside of its bifurcation with the aorta. At this level, we make sure not to damage the inferior mesenteric plexus. When this dissection is completed, we can choose to clip and divide the artery directly or to use other devices as Ligasure, which is performed in this case. Always make sure that you don’t damage the nerves, and therefore the cut-off point is about 1cm from the aorta. Further dissection after this point of the operation will be done along the Toldt’s line and the Toldt’s fascia. This will typically leave behind a very fine tissue layer that covers the ureter and the vessels. This is an embryological plane, which is avascular and is the perfect place to go in this type of operation. You can see the use of the Ligasure to find ourselves exactly in this plane. It is not always very easy to find this plane as you can see. However, once we find it, it’s going to be easy to continue this dissection along this avascular plane.
4. Mobilization of splenic flexure 06'55''
Further dissection for mobilization of the splenic flexure is in this case done by a medial approach on the lateral edge of the inferior mesenteric vein going over the pancreas reaching the lesser sac. It will be finished by dividing the attachment on the omentum and the splenocolic ligaments. Here we can see very nicely the entering of the spleen. We go on the medial edge of the inferior mesenteric vein and we will find ourselves on the pancreas. Make sure not to enter the plane posterior of the pancreas, which can be disastrous in this type of surgery. At this level, we will soon enter the lesser sac by following the plane. If as we can see in this image, we clearly have a view on the anatomy, the risk of damaging the pancreas is small. However, the dissection at this level may be very difficult. You can see a very nice view on the lesser sac and on the pancreas and subsequent dissection along the different planes. This dissection will be continued until we reach nearly the lateral edge of our dissection we performed earlier as you can see in the following images. As I said, we will continue the lateral dissection by dividing the omental attachments and by dividing the splenocolic ligaments, as you can see in this video. It’s always important to ask your assistant to be actively involved in this part of the operation to make a continuous traction and counter-traction to open up the planes. Here we divide the omental colic attachments and we see very nicely that we find the plane that we dissected medially as you can see we can see the stomach at this level. We take down the bowel to make absolutely sure that we had enough dissection and that we don’t have to mobilize any further and this is the case, we don’t have to. We will put the specimen in a retrieval bag and we will use as well a wound protector to make sure there is no diffusion of malignant cells.