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Laparoscopic left colectomy for cancer in a male patient after failure of endoscopic approach

Laparoscopic colon resection is a complex endeavour since it involves a good knowledge of the anatomy, surgical skills and many times a wide specimen extraction. This video demonstrates the technique of laparoscopic left colectomy for treatment of malignant tumor with takedown of the splenic flexure using a laparoscopic approach.

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Laparoscopic left colectomy for cancer in a male patient after failure of endoscopic approach

作者群

J Leroy, F Costantino, J Marescaux

摘要

Laparoscopic colon resection is a complex endeavour since it involves a good knowledge of the anatomy, surgical skills and many times a wide specimen extraction.
This video demonstrates the technique of laparoscopic left colectomy for treatment of malignant tumor with takedown of the splenic flexure using a laparoscopic approach.

分類

complex cases

關鍵字

Laparoscopic left colectomy, cancer, failure of endoscopic approach

媒體類型

手術影片

期間

28'20''

刊物

2009-01

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Jan 2009;9(01).
URL: http://www.websurg.com/doi-vd01en2528.htm

Laparoscopic left colectomy for cancer in a male patient after failure of endoscopic approach

1. Clinical case presentation 00'18''

This is the case of a male patient with a BMI of 27. The patient is in a supine position with his right arm alongside the body; the legs are retracted with the second assistant between the legs. The first assistant is on the right side of the patient, lateral to the right shoulder. I am lateral to the patient on the right flank, and we have placed a small pillow behind the patient’s left flank to have a small right lateral tilt. We have a limited right lateral tilt of the operating table.

2. Trocar placement 01'13''

You see we have different landmarks, the midline, the right and left mid-clavicular line, the horizontal line going through the umbilicus. The first trocar is the optical one, the second one is a working one lateral to the right mid-clavicular line and is for my left hand; the third trocar is a 12mm in the right iliac fossa and is for my right hand. The 4th trocar is suprapubic on the midline to retract and expose the sigmoid, mesosigmoid and colon. We have the 5th trocar to retract and complete the mobilization of the splenic flexure to do a tension-free anastomosis.

3. Exploratory laparoscopy 02'20''

You see that it is an obese male patient. He has a more visceral obesity than subcutaneous obesity. We see some adhesions on the left side and a tattoo on the abdominal wall, probably due to a perforation during the tattooing, you see a micro-perforation that occurred probably during the tattooing or resection of the polyp. This is also the site of the surgical approach. It is not a sigmoid loop. We have a panoramic exploration.

4. Exposure 03'03''

First step is the exposure. I put the patient head-down. We push the omentum above the transverse colon to use a maximum of space that is not useful. We retract the proximal bowel. What is interesting to see is that the length of the meso is not too short, you see on the left side the instrument and above I will push a maximum of bowel. This is to expose the aorta and to be able to do a radical resection. I am pushing the small bowel in the right hypochondrium. I now have to retract the ileal part. The duodenojejunal junction is there. We can see the limit of the perforation there, this is a sigmoid loop, this is the perforation, the Douglas’ pouch. We begin the vascular approach.

5. Medial approach 04'54''

First, we have to use scissors as you see to open the peritoneum. Where is the sacral promontory, could you show them that? It is not far from this area. So it is at the base of the sigmoid mesocolon going along the aorta. This is the medial to lateral approach, right? Yes, it is a medial to lateral posterior approach. The danger is to be too anterior for the dissection of the IMA because it will be more difficult to find the right plane. To avoid this, I will change my traction. The best landmark is to be back to the vascular sheet and we will find it lower, more anterior to the promontory. This is the right plane we have to find but we will complete later. You see we are very lateral, it is not the right position. We have to see the aorta but not dissect too close. I see the artery coming here and I need to be close to it. I must slide on the back of the vessels. It is a clear vascular approach, you see the origin of the IMA coming, this is it. It is important to skeletonize the vessels, to dissect the vessels away from the aorta in order to better respect the plexus trunks, which are there. We use the Ligasure device. We need to keep enough length, 2cm in order to be able to grasp. We have to seal between the two marks, we reduce the traction on the vessels and we seal like this, you don’t need to double as there is a retraction and we will complete with a loop. We can put a clip or the best is to keep enough to be sure, particularly in elderly patients with arteriosclerosis, that we have closed completely the vessels with surrounding tissue. We have the plexus trunk running back and these are branches of the plexus. I will divide close to the artery and you will see the plexus that will fall, we will do the parietalization of the plexus trunk. We see the vein and the fascia coming, we have to skeletonize. This is the artery, a branch, perhaps the left colic, I will seal with the Ligasure device. Same for the vein. This is the IMV. See the vessels are retracted, the best is to do a very large ligation. We are lateral to the duodenojejunal junction. We have begun the primary vascular approach of the left colectomy, I would say it is a key to open the door, which we are opening now. I am using the Ligasure device like a finger. This is a good plane. I would say it is a little more fixed perhaps due to the postoperative inflammatory reaction after the postoperative polypectomy and tattoo. I am now at the lateral limit, you see this is the limit of the parietal lateral fixation. I continue to slide back to the vascular sheath at this level. I will try to keep the lower part of the sigmoid. The problem when we do that is that the vascularization is sometimes bad except if there is good anastomosis between the superior rectal vessels and the sigmoid vessels. We have to see the ureter. I haven’t said so but I saw it, the ureter is medial to the genital/spermatic vessels, and they are there. The ureter is just behind this.

6. Lateral dissection 12'41''

I have to free laterally now and I have to remove more descending colon. I now want to find the medial plane I had found before. I have finally finished the lateral dissection. I want to mobilize the colon more at this level. The main problem when we do the anastomosis very high is to be sure that the stapler can be pushed easily inside the bowel. Could you say something about the postoperative management of this patient? Normally, we will not put a drain if there are no problems, no gastric tube, the patient can drink a little on the day of the procedure, and the next day, the patient may resume liquids such as tea, coffee… The Ligasure device is very good with this thicker tissue. Yes, we don’t lose time to do what is not an interesting step of the procedure, that is hemostasis, particularly in fatty patients with the 10mm Ligasure. The 5mm one is more for fine dissection. If you want to remove the colon through the rectum, you have to clean it. I am happy to see the development of NOTES procedures because everybody now does good bowel preparation to avoid contamination because we have to open the colon during the procedure.

7. Distal colonic division 16'33''

What antibiotic regime do you use? A flush that the anesthesiologist does anterior to the procedure and no postoperative antibiotics, unless there is an abscess; but for a procedure like this, we don’t use antibiotics. I think we won’t have trouble pushing the stapler because this is a 60mm lens and I suppose I did a perpendicular section. We have finished the distal division. We are 20cm away from the inferior limit. We will now complete the freeing. I will begin laterally. I’ll use a 10mm Ligasure. Is it necessary to mobilize the splenic flexure? Yes, because it is the descending colon. I will try to do a lateral mobilization only, when we do this type or resection, we have to do it at least 10cm above the superior limit. We don’t know exactly where it is but I suppose it is where there was a tattoo of the abdominal wall. I introduce the instrument in the right side via trocar three, right iliac fossa, but I will change now. Personally, I always use the 2 working trocars, I have done the posterior freeing, this facilitates the opening. This is a tool to use to dissect the right plane as a finger. This is a lateral approach. There are other possibilities such as the medial approach. How close are you to the spleen? The spleen is above the adhesion, this is the omentum fixed to the diaphragm. Normally I try to stay under the sustentaculum tali, the phrenicocolic ligament. I will go medial to have better mobility. Staying anterior to Toldt’s fascia and the pancreas, the key is to open the lesser sac by doing a small incision of the lesser sac. The lesser sac is now open. This is the superior layer. We now have the root of the transverse mesocolon free from the pancreas. Can you show us again where you think that the pancreas is? It is behind. I don’t want to dissect the pancreas, I’m dividing the root, placing anterior traction for that. I will try to complete now the lateral freeing. You have to remember that the freeing is mainly to do a tension-free anastomosis. I suppose this is the limit for the mobilization. We check that now it comes better, the problem we have is that the omentum is fixed now, but it will come. During an open or laparoscopic procedure, you have to consider what takes time, in laparoscopy the longer time is mostly the opening and closure and sometimes the dissection. People usually just consider the dissecting time. Can you show us again the site of the marking? The perforation and the superior tattoo were located around this level. We marked out the area where we will divide, around here but we will do more probably later; it is only the limit we have for the landmark. Dividing now the meso, marginal vessels, close to the bowel. See where the forceps are? We will remove more. I have divided the meso because when I do the extraction, I will see the inferior limit.

8. Proximal colonic division 24'14''

I am changing the incision, 6-7cm and I will introduce a plastic wound protector. I introduce it around the forceps, it is self-introduced inside the suprapubic trocar. I slide the ring of the plastic wound protector along the forceps that is a guide. I push it inside the abdominal cavity. Normally I put a loop around, it is easier and less traumatic. I will do the exteriorization. It is important to use a wound protector though; yes it is and it also facilitates the extraction. It is coming now, it is well-vascularized, well-colored. We are at least 20cm above the superior limit. I push the purse-string.

9. Intracorporeal anastomosis 26'22''

We twist the plastic drape, re-use the purse-string without staples after it is cleaned with Betadine. It is a temporary incision, we can re-open and if we want to complete the dissection, we can come back. This is a one hand loop. We will now check the doughnuts. We will do an air-test now and close the gap. Here’s the tumor, marked with the clip.