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Laparoscopic resection of sigmoid colon for a large dysplastic polyp

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Laparoscopic resection of sigmoid colon for a large dysplastic polyp

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J Leroy, J Marescaux

媒體類型

手術影片

期間

28'00''

刊物

2005-08

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最愛

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數位出版

WeBSurg.com, Aug 2005;5(08).
URL: http://www.websurg.com/doi-vd01en1819.htm

Laparoscopic resection of sigmoid colon for a large dysplastic polyp

1. 3D reconstruction and polyp localization 00'09''

First of all, as opposed to virtual colonoscopy, you can see the CT-scan of the patient in a volume. It allows us to see the patient into different slices and then we can superimpose the 3D reconstruction of the patient onto the CT-scan. For instance, here we have the aorta extracted from the CT-scan and around all the structures that can provide useful information for the surgeon, and especially today, the colon is most important. Here you can see the patient in 3D. I can also add some skin; from this image we can perform virtual colonoscopy. I’m adding a 2nd window that gives me a 2nd view of my patient. I will now try to locate the pathology and to do so, I’ll perform a virtual navigation inside the patient. So I go inside the colonic lumen. And in order to know where I am, I can add a 2nd view, for instance here I’ll move around this structure and focus on the colon. I place the colon in transparency. You see in red here the location of my camera. Thanks to this 2nd view, I know where I am during the virtual colonoscopy. Here we see the polyp and I discover the external shape of the polyp. In 3D, you can see the colonic lumen. You can benefit from external and internal views. We can see this polyp in all directions.

2. Beginning of the procedure 02'33''

We will perform a sigmoidectomy for cancer since we consider the patient presents with a potential cancer.

3. Trocar placement 02'55''

The vascular approach will be carried out at the origin of the artery, the IMA, respecting probably the left colic artery. We will not perform a large resection of the sigmoid colon because there is no diverticulum as you will see.

4. Cavity exploration 03'07''

It is not necessary to resect too much. It is a segmental resection of a big polyp with a risk of cancer but 10cm above the polyp and 5cm underneath, it’s sufficient if we remove the mesosigmoid widely. The patient is placed in a supine position and the whole team will work on the right side of the patient with one assistant between the patient’s legs. The laparoscopic unit is located on the left so we will use only one monitor. This way, the team will benefit of the view provided by the same monitor. The patient’s right arm is placed alongside the body. The left arm is free for the anesthesia since nobody will stay on the left. The surgeon stands to the right of the patient’s body and the 1st assistant stands on the lateral side of the right shoulder. The 2nd assistant stands between the patient’s legs in order to expose and do the anastomosis. We will use 5 trocars. We can reduce and you will see different procedures. I use trocars to get a good exposure, which offers certain advantages, and especially when we have to do difficult dissections in obese patients and fine dissections in the pelvis too. I have drawn a few landmarks on the patient’s abdomen: the pubis, the left and right anterior superior iliac spine, ribs, vertical midline, right and left mid-clavicular line, left and right anterior axillary line, and horizontal line through the umbilicus. Using a mini-open technique, I have introduced the optical trocar just above the umbilicus. Then I have introduced 2 other trocars as you see, approximately at the level of the umbilicus or a little more. It depends on the distance between the anterior superior iliac spine and the ribs. We have enough distance. We can increase and place this trocar more cephalad. This is trocar B. It’s a working trocar for my left hand. Trocar C in the right iliac fossa, at a minimum of 8-10cm underneath the previous one. Then there’s trocar D. This one is the mirror of trocar B on the left. It will be used for exposure to maintain the small bowel proximally cephalad if necessary and if we have to mobilize the splenic flexure, but this will not be the case. And the last trocar is trocar E for exposure because I’ll do the extraction of the specimen through this suprapubic incision that I’ll enlarge later on and protect with a drape. I have placed this and it is not usual but it’s because the umbilical ligament is falling in the field and I maintain it close to the abdominal wall to have a better view inside. We have placed the patient in Trendelenburg with a 20-30 degree tilt. We then push the omentum above the transverse colon cephalad and because of the patient’s position, the omentum is staying up.

5. Small bowel placement 07'20''

We push the small bowel cephalad on the right. I put one loop after the other and place them above the previous one to have a good and easy exposure. We can place all of the small bowel on the left. We can maintain a part of the small bowel on the left. My objective is to find the duodenojejunal junction, the angle of Treitz here. We slide on the back this way but not on the duodenum and we maintain this instrument this way using orthostatic retraction of the proximal bowel maintained cephalad. This is the polyp. It’s more difficult to see on imaging studies. As you’ve seen on virtual colonoscopy, the polyp is posterior. There’s the Douglas’ pouch and here’s the polyp. I will proceed as for cancer but as you can see, we have a very long, flexible, and compliant colon 10cm above the polyp and we’ll do the anastomosis in this area. It’s not necessary to resect all the sigmoid loops. I ask my assistant standing between the patient’s legs to lift the mesosigmoid anteriorly.

6. Opening of sigmoid mesocolon 09'16''

And I’ll begin to open the peritoneum anterior to the promontory. I use traction and counter-traction to lift the mesentery as you see the assistant performing it. I use monopolar diathermy dissection. By using this technique, you can show us how clear and precise you can see the anatomical layers. It’s a 2D retraction so far. I change traction in order to open the plane. It’s mainly my left hand that is important. We have to remember that we have to keep the nerves also. We have the feeling that the artery is here. We have the vascular sheath. How can we find the right plane laterally on the left of the artery? The key is to dissect posterior to the vascular sheath of the IMA. You’re really finding the plane between the visceral tissue and the pre-aortic tissue, aren’t you? Normally the IMA is what you have on the virtual colonoscopy you saw before. The artery is close to the aorta. It’s because I’m lifting it that this artery is far. I’ve the artery at this level and I have to stay close to the vascular sheath here. We don’t open it because you’ll see the artery better. I’ll not divide at the origin of the IMA that you have here just under the duodenum. This is the origin of the IMA. It is possible to keep the left colic artery probably at this level so I’ll divide. The danger is mainly for the nerve. These are sigmoid branches or perhaps the left colic artery.

Do you deal with the artery before you have seen the ureter? It’s impossible to have the ureter in my forceps because I did not a complete skeletonization and I don’t want to do more. Division is performed using the Ligasure device. I will now complete the dissection. The nerves are really posterior and we don’t see them because we’re far from them and the objective is to discover Toldt’s fascia. This is the trunk of the artery. We twist on the left. Dissection is continued posterior to the vascular sheath. I will complete the division. I have the superior rectal vein just divided. And we enter anterior to Toldt’s fascia right now. This is a medial approach. These are the genital vessels probably and this plane is a good one completely avascular and we slide back to the mesentery. The ureter is not far from here. Here it is.

8. Left ureter 14'54''

I continue the dissection staying posterior. It is the same dissection than for TME, I’m dissecting anterior to Toldt’s fascia. It is the key to find the presacral space. The vascular sheath is here. This is the fascia propria of the rectum. I have to free laterally now to be sure that I’ll have the right segment of the sigmoid. I ask my assistant to retract medially.

9. Lateral dissection 16'00''

And I’ll continue my retraction to expose this way using scissors. The danger is to be behind Toldt’s fascia because we’ll be closer to retroperitoneal structures this way. Now we’re in the same plane that we discovered medially and posteriorly. We have to stay anterior to Toldt’s fascia and not too lateral. This should be sufficient for the proximal dissection in this case. We have more mobility on the sigmoid. Perhaps I’ll continue laterally. I’m staying at distance but also close to the medial zone of the pelvic fascia. It’s a danger particular in inflammatory disease. This is the opening of the presacral space. I come back medially and maintain the rectum and retract it. Most of the time, when you do that before cutting the artery, you will be able to see the ureter behind Toldt’s fascia and I think this is safe. We have the example of the 3D retraction described by Bill Heald. We’re pulling the rectum cephalad with this forceps maintaining the sigmoid and rectum above the promontory. We use another traction on this side. The ureter is here and I’m sure that I am distal. We retract with atraumatic peanuts for example. I have to do a cylindrical dissection and resection of the sigmoid mesocolon. I don’t put the jaws of the blade laterally. This is the left branch. I think open surgery or laparoscopic, the Ligasure is a good device for essentially rather than unsatisfactory step in the operation rather than imprecisely through a thick mesentery. Once you’re committed to doing a bowel resection, I think you might as well do it with an oncologically correct manner.

10. Resection of rectosigmoid 19'49''

Now I’ll divide the colorectal junction using the linear stapler. Always watch the tip of your stapler to be sure you’re not touching other structures and the bowel. We’ll do the anastomosis approximately at this level. I’ll ask my assistant to catch this area with a forceps on the left. This is the origin of the IMA, the aorta. I don’t dissect close because I’ve got nerves and plexuses. This is the trunk of the IMA. This is the superior rectal artery and I preserve either the left colic artery or the superior sigmoid branch, very big, with the left colic artery probably but I don’t want to dissect more. You see that I’ve introduced my instrument in the right iliac fossa. This landmark is the forceps. I’ll divide the colon probably here. My target now is to divide the mesentery. I’ve changed the orientation, I‘ve a straight direction for the Ligasure device. I’m now dividing the mesocolon. I’ll not resect the sigmoid inside but I’m dividing the mesocolon. Because during the extraction, particularly if it’s a fatty patient, I’ll have to divide this, either inside or outside. If I divide inside, and not at the limit of the resection I’ll perform but just under the limit, and I’ll not break the mesentery outside, particularly if I use a small incision. I have now freed. I’ll complete this freeing. It’s not the mobilization of the splenic flexure, it’s a lateral freeing of the descending colon and this is sufficient in my opinion. You see Toldt’s fascia and there is danger if we’re behind it. If I have to complete the mobilization, I’ll do it later. I do a resection of the mesentery but it’s not a tronconical dissection, I remove, as you see, a cylindrical part of the mesorectum and sigmoid. We’ll do the extraction so we’ll put a drape. We introduce it around the forceps this way, 7cm in size for the diameter of the ring and I have caught the segment of colon. I have incised the aponeurosis but not the muscle. I pull and introduce my finger round the forceps and I do a dissection and opening, and I introduce the ring, sliding along the forceps pushing cephalad.

11. Specimen extraction 23'46''

And I pull this and the ring is now well positioned. You can see the bowel. The ring is used as a protection. I’m pulling. The polyp is here. I’m 5cm underneath the polyp. Now I know where I have divided the mesentery since the division is at this level. I can complete the division of the mesocolon along the colon now. If I’m pulling too much, there is a risk of rupture of the mesentery. My assistant is placing a Babcock forceps to maintain the colon when I’ll cut it to prevent it from falling into the abdomen. This is very compliant. We reintroduce through this small incision. We’ll use this to lift the ring and put it in contact with the posterior aspect of the abdominal wall. I do closure and aerostasis of this. The anvil is in the pelvis.

12. Anastomosis 26'26''

This demonstrates that there is no traction and we have freed the colon sufficiently. We’ll do the anastomosis. We control that there is no twist. Now we’re done. The ring is perfect. We’ll do an air test pushing air into the rectum. I’m closing the rectum and there are no bubbles.