WebSurg中文版尚未完成，翻譯工作進行中！

Laparoscopic oncologic sigmoidectomy for Tis (tumor in situ) with transanal specimen extraction

This is the case of a patient presenting with a big polyp located 20cm away from the anal margin. It is a degenerated polyp, and a submucosal and lymphatic invasion can be noted. An oncologic resection of the sigmoid colon has been decided upon after the polyp was removed and localized by a clip.

建立帳號

瀏覽全世界

繁體中文 ▼

Google translate

總結
章節
您的意見
詢問專家群

欲觀看此影片請先登入！

於WEBSURG-HD購買此高畫質影片

Laparoscopic oncologic sigmoidectomy for Tis (tumor in situ) with transanal specimen extraction

作者群

J Leroy, J Marescaux

摘要

This is the case of a patient presenting with a big polyp located 20cm away from the anal margin. It is a degenerated polyp, and a submucosal and lymphatic invasion can be noted. An oncologic resection of the sigmoid colon has been decided upon after the polyp was removed and localized by a clip.

關鍵字

Laparoscopic oncologic sigmoidectomy, Tis, tumor in situ, transanal specimen extraction

媒體類型

手術影片

期間

23'46''

刊物

2011-07

普通的

最愛

Favorites Media

音訊

數位出版

WeBSurg.com, Jul 2011;11(07).
URL: http://www.websurg.com/doi-vd01en3370.htm

Laparoscopic oncologic sigmoidectomy for Tis (tumor in situ) with transanal specimen extraction

1. Introduction 00'20''

This is the case of a patient presenting with a big polyp located 20cm away from the anal margin. It is a degenerated polyp and a submucosal and lymphatic invasion can be noted. In this patient with a BMI of 22, an oncologic resection of the sigmoid colon has been decided upon after the polyp was removed and localized by a clip. The preoperative imaging studies, and particularly the CT-scan, did not demonstrate any suspicious adenopathy or any distant lesion. As pointed out, there is a case of adenocarcinoma here. It is rare to find it on a polyp. A segmental sigmoid resection will be done, using an oncologic approach. In this case, the surgeon will be sitting down during the operation to ensure good ergonomics. The surgeon does not use a robot but he is well-seated. The patient is in a supine, Lloyd-Davis position, both arms alongside the body, not too much Trendelenburg, and using a right lateral tilt. The patient’s BMI is interesting for a live demonstration. The endolumenal clip is not visible and/or palpable. There are different ways to find it. The easiest way to do so is to use peroperative colonoscopy. For polyps of the distal colon, sigmoid colon, and rectum, tattoos can sometimes be used, but tattooing the peritoneal cavity could cause problems. Laparoscopic ultrasonography can also be used. In this case a colonoscopy will be used.

2. Trocar position 02'05''

The procedure begins with the introduction of four trocars, three 5mm ones, and a 12mm one. The optical trocar is introduced just above the umbilicus. For working purposes I use 2 trocars, one at the level of the umbilicus on the right mid-clavicular line, and the other in the right iliac fossa in the middle of a McBurney’s incision as this patient has also had appendectomy operated on through a conventional McBurney’s.

3. Intraoperative colonoscopy 02'32''

We begin with the colonoscopy. First, the bowel is clamped, the bowel is then turned around the clamp in order to make sure that there will be no insufflation. Then, the clip has to be found. After the clip has been localized endoluminally, a seromuscular suture is fixed right in front as an external landmark. The advantage of the clip is the possibility to fix it several days before the surgical procedure. Therefore, patients can be operated months after the placement of clips, as they stay in place. In some countries, particularly in Asia, this lesion is considered to be a rectal one, whereas in Western countries it is considered to be a sigmoid one. That explains why there are so many sigmoid resections as compared to rectal TMEs.

4. Sigmoid mesocolon exposure and peritoneum opening 03'17''

The sigmoidectomy begins with a perfect exposure of the root of the sigmoid mesocolon, and by opening the peritoneum anterior to the promontory while placing traction on the meso. This results in a pneumodissection of the retroperitoneal space, as can be seen in these pictures. The objective is to find the plane of either the inferior mesenteric artery or the superior rectal artery. The pneumodissection and the anterior traction of the sigmoid mesocolon allow for an easy identification of that plane.

5. IMA identification and skeletonization 04'04''

The inferior mesenteric artery can be easily found, by following the posterior border of the artery from the promontory until the origin of the inferior mesenteric artery. The artery will be skeletonized proximal to the aorta, but not too proximal though, as it is unnecessary in this patient with T1 or Tis carcinoma oncologically speaking. The skeletonization and division of the artery are undertaken while maintaining contact with the artery and preserving a proximal stump of about 2cm from the aorta.

6. IMA division 05'03''

The division is safely carried out by means of the 5mm Blunt-tip Ligasure® vessel-sealing device. The vascular sheath still has to be divided medially while avoiding too deep a division, in order to respect the plexuses in contact with the inferior mesenteric artery. Here the plexus in contact with the aorta is clearly visible and the skeletonization of the aorta —although not necessary here— would bring about the injury of all these nerve branches as well as a risk of retrograde ejaculation in this male patient.

7. Dissection to IMV 05'53''

The procedure is then carried out laterally external to the duodenojejunal flexure staying in a fairly anterior position in order to get closer to the inferior mesenteric vein.

8. Ureter identification 06'10''

Here, the ureter can be seen lying deep. For the moment, it lies rigidly but it will soon contract and reptate, which makes its identification easier. The ureter is usually situated between the genital vessels and the aorta.

9. IMV division 06'38''

Here, the division of the inferior mesenteric vein using the 5mm Blunt-tip Ligasure® is clearly visible. The ligature is secured by a loop positioned in such a way as to avoid the risk of secondary bleeding. The dissection of the posterior surface of the mesosigmoid and of the mesocolon is carried on by progressing laterally. Here the ureter is identified. It is located between the genital vessels and the aorta.

10. Complete mesosigmoid mobilization 07'25''

The posterior surface of the mesosigmoid still has to be mobilized completely, staying at a distance from the posterior Toldt’s or Gerota’s fascia, and staying in contact with the posterior surface of the mesosigmoid proximal to the vascular sheath. Once the lateral attachments of the sigmoid colon have been freed using monopolar scissors –as can be seen in these pictures—, the sigmoid colon is further mobilized proximally through an incision. This sigmoid incision is performed cranially enough to allow for a tension-free anastomosis of the lowered colon. In order to avoid the risk of hemorrhage during the different handling maneuvers, a Vicryl® loop has been placed on the vascular package of the mesosigmoid as well as on the proximal part. The best way to do this is to perform the maneuver quickly during the division. Once the sigmoid colon has been totally freed and once the vascular pedicle has been divided in an oncologic fashion, dissection is continued caudally, always by staying lateral to the fascia and using the landmark thread previously placed.

11. Rectosigmoid dissection 09'35''

Division of the mesosigmoid and of the upper portion of the mesorectum or of the colorectal junction in this case is performed transversely in order to obtain a cylindrical division of the meso at least 5cm underneath the region that has been previously identified —namely the inferior limit of the tumor. The 5mm Ligasure Blunt Tip® device proves efficient to perform the dissection without causing an hemorrhage to the meso. Division is continued on the posterior surface of the rectum, then laterally to the left, and finally anteriorly. The objective is to obtain sufficient skeletonization of the rectosigmoid so as to carry out a ligation allowing for the perfect exclusion of the distal end of the rectum and of the colon. The exclusion will be done by means of a ligation, a clamp, or an Endo TA™ stapler. Although the latter is unavailable on the European market, it has been used by authors such as Michael Li from Hong Kong, in order to obtain a perfect exclusion of the distal end of the colon.

12. Distal colon ligation 11'16''

A ligation with extracorporeal knots is used here. It allows for a high-quality, inexpensive exclusion. The vascular package should now be resected oncologically. To do so, the mesosigmoid is removed, and the vascularization of the descending colon is preserved. That is why it is useful to identify the division area, which should be free of diverticula and located at least 10cm above the upper pole of the tumor. Once again, the 5mm Ligasure Blunt Tip® device proves to be efficient. The 10mm Ligasure Atlas® is more powerful with obese patients.

13. Rectum washing and opening 12'25''

Once the distal stump and the rectum have been washed by means of a betadine solution — at least 500 cc are used to properly wash the rectum—, the rectum is opened at its upper portion, at the level of the colorectal junction, using the Ligasure® device so as to obtain a perfect hemostasis of the division area, which will be resected again.

14. Complete division 13'03''

The division is now complete.

15. Rectum suspension 13'08''

The rectum is suspended in order to partially maintain it above the exteriorized portion of the pelvis. The previous ligation is completed using a Vicryl® loop in order to have a landmark allowing to obtain traction through the thread, which will be brought through the rectum, as can be seen here.

16. Transanal forceps introduction and specimen extraction 13'47''

After introducing a forceps transanally, the colon should be correctly positioned inside the rectal lumen, and traction should be exerted on the thread so as to exteriorize the colon. The exteriorized portion should include the suspicious area, particularly the area containing the landmark thread, to make sure the procedure is carried out at least 10cm above that area. The landmark thread is exteriorized, as can be seen here. The clip is found through palpation. The polyp had been previously resected. A colotomy is carried out about 10cm above the suspected area in order to wash the proximal colon using a betadine solution.

17. Anvil introduction and proximal colon division 15'03''

The colon will then be divided under laparoscopic control. However, prior to that, the anvil of a 28 PCEEA circular stapler is introduced and pushed into the lumen of the colon, and then into the abdominal cavity. Division is carried out below the anvil, the thread is fixed to it using the Endo-GIA plus™ linear stapler. This device allows to dissect thicker tissues and to close the staples. Purple cartridges —half-way between blue staples and green staples— are used for that purpose.

18. Anvil exteriorization 16'23''

A small colotomy is carried out on the antimesenteric border of the stapling using the fisherman’s technique so as to search for the thread attached to the anvil. The exteriorization is secured by means of a Vicryl® loop. The anvil and the thread are then removed through the rectum.

19. Rectal stump re-cutting 17'03''

The rectal stump should now be re-cut. This will be performed in a larger area, thus allowing for a standard stapling. The rectal stump is dissected again. The procedure is continued while remaining in contact with the rectal stump in order to carry out the stapling in a healthy, well-vascularized area. This area will not be damaged by the extraction. The rectal stump, the lower distal portion of the sigmoid to be more precise, was slightly torn. It was not as large as the upper rectum.

20. Side-to-side anastomosis 18'25''

Once the stapling has been completed, the side-to-side colorectal anastomosis is carried out, almost laterally on the colon. The stapler is removed. The thickness and completeness of the cuffs should now be checked. They are in good condition in this patient. Further mobilization may be needed at this stage. The phrenocolic ligament is divided so as to decrease tension at the level of the colon. In this case, tension is moderate both at the level of the colon and of the vascular pedicle, which is of great importance. The defects should now be closed as performed in most procedures, and especially so in this case where the defect is quite large.

21. Anastomosis air test 18'51''

The anastomosis is checked through an air test control.

22. Defect closure 19'55''

The defect is closed using a running suture, as can be seen here. An absorbable Maxon 3/0 thread, or Endo-Hernia™ staples can be used for that purpose. The latter are used in this case, thus allowing to rapidly close the defect and to respect vascular structures.