Laparoscopic left colectomy

This video demonstrates a formal left hemicolectomy using the three trocar technique. The surgeon uses a superior approach to mobilization of the left colon. The patient is thin and there is an outstanding demonstration of anatomy of the structures encountered during left colon mobilization. Splenic flexure is completely mobilized and the anastamosis is made between transverse colon and the rectum. This video is good for demonstration of anatomical landmarks and surgical approach to splenic flexure mobilization and resection of left colon for cancer.

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Laparoscopic left colectomy

Authors

Abstract

This video demonstrates a formal left hemicolectomy using the three trocar technique. The surgeon uses a superior approach to mobilization of the left colon. The patient is thin and there is an outstanding demonstration of anatomy of the structures encountered during left colon mobilization. Splenic flexure is completely mobilized and the anastamosis is made between transverse colon and the rectum.
This video is good for demonstration of anatomical landmarks and surgical approach to splenic flexure mobilization and resection of left colon for cancer.

Classification

basic techniques

Keywords

left colectomy,three port technique, superior approach,colectomie gauche,laparoscopic approach

Media type

Surgical video

Duration

17'00''

Publication

2005-11

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E-publication

WeBSurg.com, Nov 2005;5(11).
URL: http://www.websurg.com/doi-vd01en1875.htm

Laparoscopic left colectomy

1. Trocar position 00'15''

As usual, I put my first trocar between the xiphoid process and the umbilicus. The 2nd port is this one situated in the umbilical line and the last one is situated in the lower right quadrant.

2. Exploration 00'34''

This is the laparoscopic view: the anterior aspect of the stomach, the Latarget nerve, the gastro-hepatic ligament, the coronary vein, the left gastric artery, again the crow’s foot and the gastrocolic ligament with the Winslow arcade; this is the vangoetehen point where the left gastroepiploic artery joins the right one.

3. Lateral colonic mobilization 01'17''

You need only few instruments and few tasks inside. I think that for diverticular disease as in the present case it is much better to mobilize the splenic flexure because my anastomosis becomes soft and easy to do. But as you know, many American surgeons are doing only segmental resection, I try to open the gastrocolic ligament now. It is now opened. I open the lesser sac and twist the stomach and so I an expose the pancreatic tail and you can see the mesogastric fascia covering the pancreatic tail. We can reduce the number of complications. The ligament is completely opened. Now I change instrument position. The gastric tube must be retracted. I have the transverse colon mesentery in front of me. I can show you the splenic vein nicely, the bifurcation of the splenic artery. This approach is very convenient. In order to better expose the splenocolic ligament with my right hand to the right I pull down the colon and with the LigaSure I cut the ligament. Reverse Trendelenburg position allows the colon to fall down. The stomach is in the field again and here are the transverse colon mesentery, and the mesogastric fascia which I try to open. The patient is rotated to the right side. The mesogastric fascia is so thin. All of the transverse mesocolon must be opened. This is the Drummond’s arcade so I cut the ligament. You can observe the splenic flexure falling down, the pancreatic tail, the mesogastric fascia, and Gerota’s fascia.

4. Mesocolon dissection/Medial approach 06'58''

Now we have to push up the transverse colon. We have a small space inside because the patient is small. The right side rotation helps to put the small bowel on the right side. The inferior mesenteric vein lies in front of me. You can see the left colic vein, gonadal vein behind, the aorta, inferior mesenteric artery, the jejunum, Treitz’s muscle and ligament, the inferior mesenteric vein, the colic artery and vein, Treitz’s arcade. Here this is the mesenteric vein going into the splenic vein. So I lift up the splenic vein and I seal it. It is convenient for me to cut the vein before the artery. It is my right plane and the splenic flexure is down. The scope position is the 2nd port on the umbilical line and the patient has to be placed in Trendelenburg position. Treitz’s arcade is the left colic artery and vein, artery coming from IMA, and vein coming into IMV. It is close to Treitz’s ligament. This is the right iliac artery, and Gruber’s ligament. This ligament is the key to some of Prof. Huscher’s dissection techniques. Avoid any blind maneuver. You can see Toldt’s fascia and Gerota’s fascia. Now the whole colon has been freed.

5. Complete colonic mobilization 12'47''

The junction is in front of me. The stricture is here. We are under the promontory.

6. Colonic resection 14'10''

Membrane of gonadal vessels and ureter and genitofemoral nerve and hypogastric right iliac, right ureter can be seen. The specimen is ready to be removed. The transverse colon is falling down and the greater omentum covers the anastomosis.

7. Extraction 15'19''

You can see the IMV, the posterior aspect of the pancreas, the Treitz’s fascia, and the gonadal vessels coming into the left renal vein.

8. Preparation of anastomosis 15'42''

Now the specimen is extracted and shows fibrosis.

9. Anastomosis 16'47''