Laparoscopic ileocecal resection for tumor

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Laparoscopic   ileocecal   resection   for   tumor

Authors
J Leroy
Keywords
colon,operation,ileum,cecum,caecum,resection
Media type
Duration
14'00''
Publication
2004-09
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1265e.htm

Laparoscopic   ileocecal   resection   for   tumor

1. Case presentation 00'32''
The patient is positioned with both arms along the body, legs apart with knees slightly flexed. These are the right and left anterior superior iliac spines, the pubic bone, the umbilicus, and the xiphoid. A roll has been placed beneath the patient’s right hip, which results in a left side rotation. The small bowel loops thus fall to the left of the abdominal cavity. The target is here. The 2 operating trocars are on the left side. The adhesions of the greater omentum to the previous appendectomies are freed. We then free the ileocecal adhesions. The planes are exposed one after the other by traction, counter-traction movements allowing for progressive dissection of the right planes. The adhesions between the transverse and right colon are then divided. The transverse colon is retracted cephalad as well as the greater omentum, which is placed superior to the colon. This is the duodenum, the small bowel is positioned in the left lower quadrant and in the pelvis. This is greatly facilitated by the positioning of the patient. The vascular access is here. The mesentery is on the lower side of the screen and the mesocolon is here. This is the vascular access, the appendix, the small bowel mesentery; the assistant grasps the mesocolon with an instrument introduced through the suprapubic port. The ileocolic vessels can be seen here. These vessels are then well exposed and we can see that we are on the inferior side of the junction of the 2nd and 3rd part of the duodenum. The duodenum is dissected free from the area of dissection and the dissection is carried on towards the caecum. We try to dissect anterior to the fascia of Toldt leaving the ureter and the retroperitoneal structures behind. If the ureter can be seen too well, it is because Toldt’s fascia has been opened and that dissection is performed in the wrong plane. The ileocolic vessels are cut. In this case, there is no need to divide them at their origin. A linear stapler of the vascular type is used to perform division of these vessels. The dissection is carried on in the same plane. We can easily the plane between Toldt’s fascia and the mesentery. Extensive mobilization of the colon will facilitate the creation of the anastomosis. Thus the dissection is carried on on the posterior surface of the right colon, always anterior to Toldt’s fascia. We have now reached the right phrenico-colic ligament, which will be opened. We have now reached the hepatic flexure of the colon. We will proceed to lateral mobilization of the colon. Lateral mobilization is started and will continue towards the ileocecal junction. All the line of Toldt is freed using sharp dissection and diathermy. Extensive mobilization of the colon is done to facilitate ulterior creation of the anastomosis. The mesocolon is divided going down towards the terminal ileum. We have seen the ureter pass and the structures should be carefully avoided. Dissection is carried on and the terminal ileum is divided using a linear stapler. The division of the colon is performed at the level of the right transverse colon. Mobilization of the transverse colon is continued. An ultrasonic dissector is used for this mobilization. This instrument allows for a good hemostasis. The transverse colon is finally divided. Two successive linear staplers are used. A retrieval sac is introduced and the specimen is placed into it. The bag should be made of a strong material that will not burst if a vigorous traction is exerted on it. This is important to avoid any tumoral dissemination. The advantage of this sac is that it can be left into the abdomen while performing irrigation. We see here the area of dissection, the duodenum, the gallbladder, the right liver, and the head of the pancreas. Thorough irrigation is made before performance of the anastomosis. This is the terminal ileum. It must be mobilized to ensure that it can easily be brought up towards the wound for anastomosis. Further mobilization is performed. The next step is the performance of the extracorporeal anastomosis. A wound protector is placed on the incision. The colonic and small bowel extremities are brought up to the skin. Two small incisions have been made on the colon and ileum and the linear stapler is fired. We make sure that there is no tension on the bowel before firing the linear stapler. The anastomosis is completed by firing a second linear stapler. A side-to-side anastomosis is thus performed. A running suture may be performed or not on the linear stapler line. The sac containing the tumor and the specimen is extracted without difficulty. The anastomosis is verified and the bridge into the mesentery is closed with staples. The procedure is ended after checking for trocar site bleeding and deflating pneumoperitoneum. The nasogastric tube is left in place until the operative night.