Laparoscopic right colectomy for cancer

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Laparoscopic   right   colectomy   for   cancer

Authors
J Leroy, M Smith-Savu
Keywords
colon,operation,resection,cancer,laparoscopy
Media type
Duration
07'00''
Publication
2002-09
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Subtitles
en
E-publication
WeBSurg.com, Sept 2002;2(09).
URL: http://www.websurg.com/doi-vd01en1225e.htm

Laparoscopic   right   colectomy   for   cancer

1. Case presentation 00'09''
We present here a right colectomy performed laparoscopically for cancer. As you can see here, the placement of our trocars, we use 5 trocars for the endoscope placed in the umbilical port. We perform a vascular approach from a medial to a lateral dissection for the right colon. We start at the lateral edge of the mesenteric vessels as our landmark using a peritoneal incision on the anterior lateral aspect of the superior mesenteric vein. We then identify our ileocolic vessels, which are clipped and divided, and our right colic vessels superiorly, which are then also clipped and divided. As you can see here, we use sharp and blunt dissection to clearly isolate our ileocolic vessels. Once isolated, clips can be placed and the vessels are sharply divided. We use as our landmark the superior mesenteric vein and the lateral aspect of this to find our right colic vessels. Here you can see that the right colic vessels are being clipped and will be divided between the clips. It’s very important throughout the procedure to elevate the mesocolon in the area of the transverse colon. We have now transected our medial vessels. The dissection will now continue cephalad by the incision of the peritoneum over the greater omentum, and we will then divide the greater omentum inferior to the transverse colon. The transverse colon is elevated and retracted using grasping instruments and the dissection is continued inferior to this area. The greater omentum is being divided away from the mesentery. This continues the dissection to create a window in the area of the hepatic flexure. As you can clearly see here, a window has been created. Harmonic scalpel can also be used in the division of the omentum to help in hemostasis. Once we have completed the medial mobilization, we will now transect the transverse mesocolon, the transverse colon and the greater omentum in succession. Once this is complete, we will then transect the ileum at the terminal ileal junction. Here we introduce our GIA stapling devices through our trocars and transect at the mid-transverse colon level. The Harmonic scalpel can be used to complete the dissection. Inferiorly we place the GIA stapler on the terminal ileum and perform a transection. This now completes our medial mobilization of the right colon. We will now go laterally to free the right colon in the right colic gutter continuing cephalad towards the hepatic flexure. We will dissect along the line of Toldt. The colon is retracted medially and sharp dissection is used along the line of Toldt in a cephalad fashion to free the right colic gutter up until the hepatic flexure towards our previously transected transverse colon. Once the specimen is completely freed, an Endocatch bag is introduced into the abdominal cavity and the specimen is placed within the Endocatch bag. As you can see, we have removed through a suprapubic incision by a protected drape and here we have contained the entire right colon up to the transverse colon. The sterile drape through a suprapubic incision is closed. The pneumoperitoneum is reinsufflated and 2 sutures are placed to help aid in the side-to-side anastomosis of the transverse colon and the ileum. These sutures are placed intracorporeally. In this case, we chose to perform the anastomosis exteriorly. The colon is brought out through the suprapubic incision. A GIA stapling device is placed within the colon to perform the side-to-side anastomosis exterior to the abdominal cavity. Once performed, the colon is reintroduced into the abdominal cavity as you can see here, with good viable bowel at the area of the anastomosis. There are several variations to this technique and one would include the intra-abdominal anastomosis. When this is performed, the stapling devices are placed through the trocar sites, the GIA you can see here being placed in a side-to-side fashion and being closed also by a 2nd GIA. A 2nd variation in technique includes an extra-abdominal transection of the transverse colon. Once the dissection is completed before dividing the colon, the colon itself is brought through the suprapubic incision protected by the sterile drape. The tumor is identified and the transection of the colon is completed along with an extracorporeal anastomosis. The 3rd variation in technique includes the closure of the mesentery. Some surgeons prefer not to close the mesentery. However, we show here an easy and safe technique to close intracorporeally laparoscopically the mesentery by using a stapler device. Individual clips are placed to re-approximate the mesentery with a good closure seen here at the end of the dissection. This completes our right colectomy laparoscopically.