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Laparoscopic left colectomy for cancer

The laparoscopic approach for colonic cancer has been shown to be feasible, safe and respects oncologic criteria for cancer surgery. In this video demonstration at the IRCAD Advanced Course in Laparoscopic Colorectal Surgery in November 2009, Prof. Francesco Corcione shows a laparoscopic left colectomy strictly respecting oncological principles.

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Laparoscopic   left   colectomy   for   cancer

作者群
F Corcione, J Marescaux
摘要
The laparoscopic approach for colonic cancer has been shown to be feasible, safe and respects oncologic criteria for cancer surgery. In this video demonstration at the IRCAD Advanced Course in Laparoscopic Colorectal Surgery in November 2009, Prof. Francesco Corcione shows a laparoscopic left colectomy strictly respecting oncological principles.
分類
basic techniques
關鍵字
Laparoscopic left colectomy, cancer
媒體類型
期間
24'33''
刊物
2009-12
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Dec 2009;9(12).
URL: http://www.websurg.com/doi-vd01en2821.htm

Laparoscopic   left   colectomy   for   cancer

7. Dissection of inferior mesenteric artery 05'39''
Now we are approaching the artery that is, I repeat, always under this cord, always surrounded by lymphatic tissue. So my strategy is that we have flat tissue, lymphatic tissue. So my strategy is always to design this cord as you have seen before, and then I go from a superficial to a deep layer to identify the artery. But because you do a lateral approach. Now as you have seen here, I think you have the bifurcation from the left colic artery and sigmoid artery and all the tissue here is completely covered by the mesenteric artery. It’s very difficult in this tissue to identify the artery. You haven’t an unusual amount of fat there but you’re taking your time and I think in a minute you’ll know what’s happening. Now you see. To be sure that you have a good hemostasis of the artery, you have to prepare the artery without the lymphatic tissue. Now I am able to put a clip safely. We see the nerve very well. With this dissection, you avoid to injure it. Now I clip the mesenteric artery. Why don’t you keep the left colic in this old man? 30cm with the endoscope doesn’t mean anything, it’s less than 30 for sure, we don’t see the tumor, we would like to see where it is positioned because there is a randomized study in France that showed that there is no difference if you keep it or not and this man is old and has a cardiac disease. Do you see the tumor Francesco? Yes, I do. Just fix that and show us later. It’s a big tumor. Where is it? In the middle of the sigmoid? No I think in the high part of the sigmoid. I’ll show you in a few minutes. We could understand the hemorrhage problem, it was because the second clip was coming over the first one. Now we are going to continue our dissection. I think that for oncological problems we have to remove all the lymphatic tissues that you can see here. There are a lot of nodes so it depends. I think that it is not a matter of centimetres for in true left hemi-colectomy, we are sure that oncologically you perform the right operation. So you make a true oncological left colectomy and this answers everything, so we have to remove the left colonic artery very clearly. We have not really seen that there are no lymph nodes around the root of the inferior mesenteric vessels. So in general cancer principle, I think one should be as radical as you can be without significant extra sacrifice. Now I try to join the intraperitoneal space here with the extraperitoneal space of the artery and to have a good dissection, I think it’s better to mobilize these 2 layers as much as I can in this medial to lateral dissection until the posterior peritoneum. Here the dissection is very hard, I think, because of the lymphatic tissue that we dissected before. If you see now, we have this very strong adhesion perhaps oncological between the spermatic vessels and the tumor, which is there. I try to dissect laterally and I leave this adhesion here. But now due to this adhesion, you have to look for the ureter soon. Now I stop here and I go to the vein. Maybe it’s not an optimal choice for the patient but it’s an optimal choice to learn laparoscopic surgery because to preserve the left colonic artery, it is more difficult. In how many cases, is the ligation of the mesenteric artery responsible for complications in your experience? I don’t know. Well, this is the problem. I agree with you, I don’t know but if I take the inferior mesenteric artery proximal to the aorta, I always mobilize the splenic flexure. The problem could be if you remove the left colonic artery without mobilization, so this depends on the overall strategy not only the artery. Or again you put clips and I think that typically at this level the Ultracision® or Ligasure® is working very well, much better than for the artery. We never had hemorrhage at this level by using modern instruments. So we never put clips. You would agree that in benign surgery, that is mostly diverticulitis, there is no one reason to cut it so you learn on that. In 90% of case, we can keep the left colonic artery and we go on the descending colon. We agree that is another question. In benign disease, we never cut the artery. This is a different strategy. This is the lateral dissection first, and not a medial one; we never cut neither the inferior neither the left colonic artery. We are only going through the mesentery that is the 2nd option for a left colectomy. But you now open the meso here. So in front of the pancreas. The vein was clipped. The mesocolon is attached to the inferior pancreas. It’s a very nice demonstration, which shows to the audience as well how quickly you can come in the back of the pancreas, so you have to be very cautious at this point. You are now removing, as I presume, for cancer reasons, the peritoneum of the posterior wall of the lesser sac of the front of the pancreas, which you are doing very neatly and nicely, I must admit. That is another oncologic addition, I’m not sure how important it is but he’s doing it very well. The goal of this dissection is only to have a good mobilization. I don’t think it is an oncological reason to have this kind of dissection. Absolutely you have taken very nicely the posterior peritoneal wall of the lesser sac of the front of the pancreas and that is not something we see routinely but it does look, I think, very elegant and very radical to me. I like it as a cancer surgeon. This is the reason why I perform this dissection under visual control and as said before, we have some opportunities to dissect the mesocolon from the lower edge of the pancreas but this way, I think, this is safer and it’s a little bit easier to understand and to learn. Now I finish this dissection. I put this gauze under the pancreas to avoid injuring the pancreas in the next mobilization. And I go to the parietocolic gutter to complete this dissection. Is it really essential to take the peritoneum off the surface of the pancreas? Can the peritoneum not be preserved, I mean, I’m just wondering, well, if you routinely do this, is there a risk?… It can be preserved also. If you have a lesion of the pancreas, but if you look very clearly and if you have no bleeding, I think it’s impossible to have a complication. It’s a very high splenic flexure as you can see. A tricky one. I think you’re doing it very nicely Francesco. If you are able to know and understand where you are, there is no question about stenting. This question could only appear for recurrent diseases, when you have fixation; if you see at the CT-scan that the tumor is going close to the ureter and maybe the question for you is to remove or not the ureter, if you know that you will need to dissect all the ureter. But if you are sure that the tumor is not close to the ureter, there is no reason for that. I am waiting for you because I have finished my dissection. We have the blunt dissection posterior, the spermatic vessels are there and the ureter is covered by this fatty tissue and then we finish this very difficult mobilization of the splenic flexure because it was very attached to the spleen here. As you can see, I left all the omentum here, the pancreas is there, the greater curvature of the stomach is there and I mobilize all the splenic flexure to have a good tension-free anastomosis. We go under the sacral promontory to prepare the mesorectum for the anastomosis. I have finished my dissection.
9. Pfannenstiel incision, colon exteriorization and anastomosis 20'47''
We now perform the mini-laparotomy as a Pfannenstiel. I take the last part of the rectum with this grasper to recognize when I perform the mini-laparotomy. I would like to show you the specimen: this is the hard part of the sigma, the dissection of the rectum, the colon that we have mobilized before, the color is very good, the lymphatic tissue of the vein, the artery is there and now we prepare the colon here for the anastomosis. I think that even Professor Hohenberger would approve of that as a very good lymphatic clearance for a left-sided colon cancer. At the time of finding that arterial route, we weren’t quite so sure, but I think it looks quite good, very nice and radical. The panel here agrees with the extent of your dissection, because it was discussed here. Eric Rullier made a very interesting point about the bad results of some, not enough oncological point and all the panel agrees that the dissection should be good as you have done. I would like to show you the final aspect of this operation. The colon is lying down without tension as you can see here, the anastomosis is good, the rings are perfect and the colon here has normal aspect as well as the splenic flexure. The last thing I would like to show you is that I will close this space with glue because of potential occlusion of the bowel that is lying down behind the mesocolon. I have had one complication of this kind of postoperative occlusion. To avoid this complication, you can put a stitch here, sometimes it is difficult because of the dilatation of the bowel. I think it is much easier and safer to put the glue. I think the audience is very impressed and we will give you a round of applause.