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Laparoscopic left colectomy for carcinoma using three trocars

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Laparoscopic left colectomy for carcinoma using three trocars

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colectomy,operation,left colon resection,ports,trocars

媒體類型

手術影片

期間

09'00''

刊物

2002-12

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最愛

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數位出版

WeBSurg.com, Dec 2002;2(12).
URL: http://www.websurg.com/doi-vd01en1379e.htm

Laparoscopic left colectomy for carcinoma using three trocars

1. Trocar placement 00'14''

We place our 1st trocar here above the umbilicus half-way between the xiphoid and the midline. We make a triangle in this fashion so that the 2 operating trocars are located as shown here and here and the reason we start with this incision is because of the falciform ligament posterior to the fascia, this makes an open entry safer and easier. This patient has a splenic flexure carcinoma and we will be doing a resection of the splenic flexure and descending colon.

2. Colonic mobilization 00'46''

We start here at the greater omentum; this is the stomach at the upper part of the field. We open into the lesser sac as shown here. Once I get inside the lesser sac, I’ll continue to go distally in this direction as shown here to the splenic flexure and come around the corner so to speak. This is accomplished with using the ultrasonic shears. Here we are at the lateral attachments of the splenic flexure near the phrenocolic ligament. We continue to free these adhesions here until the lateral and superior aspect of the splenic flexure is completely freed. We open the peritoneal sheath here just near as the pancreas and we go just inferior to the edge of the pancreas and open only the peritoneal sheath. The stomach is to the left side of the screen; the pancreas is just beneath it and we will be opening the fascial layer here. What I’m looking for now is the area between Toldt’s fascia and Treitz’s fascia. We continue this dissection towards the distal aspect of the pancreas. This is the correct plane to be in; now we’re between Toldt’s fascia and the Treitz’s fascia. This is an avascular plane from embryonic origin. Toldt’s fascia is to the right. This is the tail of the pancreas; this is the ligament of Treitz here, the origin of the inferior mesenteric vein is here and I will isolate this vein now as shown here. We use a Ligasure device to divide the inferior mesenteric vein at its origin. We continue our dissection below the mesentery and anterior to Toldt’s fascia. We have the area of the splenic flexure dissected free and we will continue inferiorly. This is the inferior mesenteric artery. I will stay anterior to this vessel. This is probably a branch to the left colic artery; again we can divide this with a Ligasure device. It seals and cuts the vessel and we continue to sweep in a clockwise fashion anterior to Toldt’s fascia. This is the ureter back here, we can see it. The only thing I don’t like about this particular technique is the manipulation of the mesentery. However, that’s better than manipulation of the bowel itself, especially since this case is carcinoma. Now we will take down some of the lateral attachments of the sigmoid colon and the intention here is because our cancer is located at the splenic flexure to spare part of the sigmoid colon and make our anastomosis on the distal sigmoid colon rather than at the rectosigmoid junction. We can see now that we’re continuing to free up the lateral adhesions of the sigmoid colon to give us full mobilization of the colon. It is mandatory to stay in the correct plane here anterior to Toldt’s fascia. This is another of the sigmoid vessel coming off the inferior mesenteric artery. We can divide this. The inferior mesenteric artery is below the grasper; you can see it tented up right in this region. We will take another of the sigmoid vessels, which is branching off the inferior mesenteric artery. We’re preserving the inferior mesenteric artery with the intention as I said previously to preserve the distal sigmoid. We have the colon completely mobilized now. We will divide our specimen.

3. Colonic resection 06'56''

Distal sigmoid again and the Endo-GIA device, and you can see it’s freely mobile here. We can do an exteriorization of the specimen at this point. We’re identifying and preserving the middle colic vessels and the colic vessels here. They are intact. We will now expand the lower trocar site in order to adequately exteriorize the specimen through a wound protector. This is the distal aspect of the specimen. You can see it’s easily exteriorized. This is the transverse colon here with the greater omentum attached as you see. This is the splenic flexure. The tumor is just in this region here and may likely represent a T3 lesion as we see some abnormalities on the serosa. This is the descending colon here with its full mesentery. We have the full origin of the vessels. This is the left colic vessel here, 2 sigmoid arteries and one left colic artery were found. We then divide our specimen using a purse-string device first and the anvil is placed in our mid-transverse colon. The purse-string is tightened and then reintroduced into the abdomen and we can complete our anastomosis.

4. Anastomosis 09'03''

The pneumoperitoneum is re-established by decreasing the size of the trocar site. We can see here we are deploying the circular stapling device through the distal segment, which is done trans-anally. We then meet the anvil, fire the device and remove it. The anastomosis is now complete and you can see this is a tension-free situation.