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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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媒體類型
期間
09'00''
刊物
2002-12
普通的
最愛
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音訊
en
副標題
en
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

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.