Laparoscopic right colectomy for cancer: vascular problem during the anastomosis

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摘要

This video presents the case of a right colectomy, with an intraoperative complication of the anastomosis, requiring a redo of the ileocolic isoperistaltic anastomosis.

分類

routine cases

關鍵字

laparoscopy, right colectomy, cancer, vascular supply, anastomosis

媒體類型

期間

27'50''

刊物

2008-09

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, Sept 2008;8(09).
URL: http://www.websurg.com/doi-vd01en2405.htm

Laparoscopic right colectomy for cancer: vascular problem during the anastomosis

1. Trocar placement 00'10''

This is the head of the patient and the feet here and this is the umbilicus. There is a big scar from the umbilicus to here, which is what I had troubles with. So we initially go in over here on the patient’s left and it was free except the omentum was plastered to the abdominal wall so we had to get that whole off. So I have the 12mm port here, this is a 12 as well and I have a 5 over here on the left upper quadrant but ordinarily it’s in the midline. I usually put it here in this case because I needed a better angle to divide the scar tissue with the scissors.

2. Exploratory laparoscopy 00'51''

The first operation she had produced a lot of scar tissue so we spent one hour dividing scar tissue just so you get exposure. I’m not sure what it is here on the right ovary. But I’m thinking that 74 years old, this should come out the ovary. So the tumor is in the caecum. Let’s show the abdominal wall. I think the tumor is invading the abdominal wall here because I feel the tumor here. You see how it sort of puckered and going in so I’ll take this with the specimen after we do the mobilization. There’s a lot of scar tissue. Here’s the terminal ileum here. We’re lifting up the caecum, ileocaecal valve, which of course exposes the ileocolic vessel and she’s pretty thin and so you can see the duodenum down here. So I do a medial to lateral and that’s all we’re going to do. There’s no signs of any cancer anywhere else that I can see. The patient is supine and by the side.

3. Medial approach 02'22''

So first I like to divide the peritoneum over the vessels before I use any energy device. The energy should be applied directly to the vessels and not to the fat. Now we have to decide where we want to go here. Here’s the Terminal ileum (terminal ileum), some adhesions too. If I go here, I think it’s adequate for resection. I like to mark where I’m going first.

4. Ileocolic vessel ligation and mesocolon division 03'33''

I use the bipolar LigaSure. The thing that amazes me is that the plane is always a little bit higher than you think. It’s the ileocolic here. Some people would take this way down here. I never do that because I’m always afraid that if I lose the vessel down here, I’m going to have big trouble in terms of controlling so I take it a little bit higher so at least it is a centimetre of distance to be safe if I have a problem, I can control. And here you can see the ileocolic so I’m going to follow the cut line here. This is the proper plane you can see back here. The only reason I do that is because I like the way it dissects. Because I do an intracorporeal anastomosis and that needs a 12 trocar so if I bring a 5mm instrument to a 12 trocar, it’s like not stable, so it makes it harder. We stay in the proper plane. This is the colon. It’s very easy to go too posterior. The most important thing is to keep it dry. No blood and it’s always higher than you think. Here’s the duodenum and the colon here. The plane is right high here. It’s on the mesentery. It’s not down here. If you go in here, you get trouble. You bring the ureter and everything else in the play. I think there’s a little trouble with the adhesions from the tumor. It seems to me that it’s stuck. I’ve switched to an intracorporeal anastomosis so I don’t have to mobilize as much colon either. We’re going to move my assistant back to the ileocolic. By marking this thing to begin with, for me it helps. I went through the mesentery posteriorly; this is behind it. You have to be very careful and be in the right tissue plane. This is the plane here. I want to do the small bowel because I take this all the way to the end of the bowel right now. Once again, every energy device whether or not it’s a bipolar, I don’t want to talk about the ultrasonic, but either of the energy devices work better when they’re directly applied to the vessels. I take great care in dividing the peritoneum so that I can put the energy device where I want it. And so it has the effect that I want it to have. The other thing I do is I relax my hand very gently. I’m not pulling that, there’s no traction whatsoever. It’s very important to make sure you do exactly what you want. This is a good demonstration. I’m through a 12 trocar and it doesn’t stay stable. I can transect this now. That’s done.

5. Terminal ileum resection 09'53''

What I look for is not the ureter. I look for the fascial plane above the ureter. If I see the fascial plane above the ureter, then I know the ureter is underneath. There’s no anatomical anomaly that puts the ureter above the fascia. The answer is that I look for the ureter but I don’t specifically go looking for the ureter. I can show you the ureter if you want. It has got a floppy colon. The duodenum again is over here. This is actually a good demonstration of why you need to be able to do a medial to lateral. Sometimes it just doesn’t come the right way so when I find that I have trouble getting the plane over here either I switch to a lateral approach-you can see the small bowel once we go in there. Let’s decide where we’re going to transect the colon. I have a redundancy in this colon.

6. Hepatic flexure dissection 11'50''

You can see the omentum had a lot of scar tissue. I had trouble getting it up. Here’s the right transverse colon here. The tumor is over here and I have already lost its blood supply. The principle here is to get exposure. That’s all I’m doing. I think I’ll do the hepatic flexure. Very little distance between the duodenum and the colon you can see.

7. Distal colon resection 14'15''

I’m going to divide the bowel right now. I’m looking right at it. I think it’s very important to pre-plan what you’re going to do and the mark where you’re going to go because sometimes in a very fat person, it can be difficult. So I’m going to excise abdominal wall with this. The bowel is divided. This is it. I have to make the anastomosis. I’m going to do it inside intracorporeally. You have to divide an adequate amount of the meso, the mesentery and the small bowel and that determines how much mesentery, how much bowel’s gone. It looked pretty good. This is what I’d do in open surgery, same thing. Then you can do this laparoscopically. If you’d have to change what you’d ordinarily do, then you shouldn’t do this laparoscopically. I give in that you can technically do the same thing. I don’t see any difference whatsoever. I didn’t see an appendix. I approach every cancer with a laparoscope and then I decide, I look, decide what I can and what I can’t do. I have left, I’d say, about 1cm-1.5cm of the vessel, I’d say the superior mesenteric a little bit further. The truth is that in a small percentage of cases, we put the small bowel at risk and you have to put on a risk benefit scale and for me I think the risk far outweighs the benefits of going 1 or 2cm more because you’re talking about a very small group of patients who you would potentially cure as opposed to the potential risk of getting into the vascular issues by the head of the pancreas. He’s asking for a problem so for me I’m not going to do that. It’s a personal philosophy but I think it’s pretty good.

8. Ileocolic anastomosis and intraoperative complication 18'15''

The real advantage of doing it intracorporeally is that I’m going to identify the mesentery here. This is the edge of the mesentery here. You can see that the days of twisting an anastomosis are over because I can see that it is the absolute layer. Here’s the bowel. We put the bowel where it’s supposed to be in an isoperistaltic fashion and we can flatten the patient and you can see that it’s not going to happen anymore, no more twisting. I’ll get it lined up. This is how I do my anastomosis, isoperistaltic. Here you can see the ileum coming this direction. Here’s the cutting of the colon where I stapled and it’s normal direction; good blood supply here and I think one of the real advantages is that the blood supply is so good, we don’t mobilize the colon. Now we’re going to open up, put a staple in to do a 60mm. I use electrocautery on the cut. Make sure we do it at a right angle. This is the colon. You grab the colon. Ligatures. It looks nice. I need the suture Vicryl now. I use Prolene. Full-thickness. It gets very easy in one second. We use stapler, GIA.

9. Redo anastomosis 24'21''

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