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Laparoscopic right colectomy for cancer

This video demonstrates a laparoscopic right hemicolectomy in a patient with cecal cancer. Ileocolic vessels are mobilized through a medial approach and divided at the base using a LigaSure® Atlas device. The right colon is mobilized from medial to lateral attachments and a right hemicolectomy is performed according to the standards of the author. This video demonstrates the crucial steps in approaching a right colon cancer.

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Laparoscopic right colectomy for cancer

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摘要

This video demonstrates a laparoscopic right hemicolectomy in a patient with cecal cancer. Ileocolic vessels are mobilized through a medial approach and divided at the base using a LigaSure® Atlas device. The right colon is mobilized from medial to lateral attachments and a right hemicolectomy is performed according to the standards of the author. This video demonstrates the crucial steps in approaching a right colon cancer.

分類

basic techniques

關鍵字

cecal cancer, laparoscopic right hemicolectomy, medial mesenteric mobilizatin

媒體類型

手術影片

期間

18'12''

刊物

2006-09

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Sept 2006;6(09).
URL: http://www.websurg.com/doi-vd01en2006.htm

Laparoscopic right colectomy for cancer

1. Case presentation 00'20''

First of all she is very thin as you can see. She has a history of a breast cancer and she has a colon cancer, so as you know we must make sure that people with breast cancer get screened for colon cancer and the reverse is true as well. The head of the patient is here and the feet are down here, the patient is supine. I use four punctures and I use a 30° optic so you’re going to look at a 30° optic. Its infra-umbilical and the reason for that is because I extract infra-umbilically, this is where I make my incision in the midline when I extract. Two 5 mm trocars, one is sub-xiphoid and one suprapubic and another 10 mm trocar over here on the left side; I put this in last because I try to figure out what is the best angle for the ilio-colic and the right colic after I’ve looked on the inside view. The upper trocar is for retraction of the ileo-caecal area and then I work out of these two ports. The patient is head down and right side up.

2. Exploration 01'36''

There are a couple of principles involved with cancer surgery which I think are very important. Number one and most important is never touch the tumor; I will touch fat near the tumor but never the tumor with any instrument. The caecum is here, the ileum is fixed over here with some normal adhesion; we’ll have to take that down a little later. You can see the right transverse colon here, this is the ascending colon here; there is a loop in the transverse colon. There are some lymph glands here which we are going to remove but you have to be careful not to get too close to the base of the mesentery because if you have a problem here with control then you can put the rest of the mesentery at risk and the rest of the small bowel at risk which is not a good idea. I saw that Joel uses ligasure at the beginning, I always divide the mesentery with the scissor first. I find that the hemostasis ligasure is enhanced by doing that.

3. Division of the peritoneum 02'46''

Now the key for me is that the peritoneum is one cell thick here and I think that this is where the cut is; it’s very common to get into this layer here which will bleed so you don’t want to do that. I like to divide the peritoneum. I’m going to take one cell thick. It works better on the ceiling when it is thicker. Can you see the window appearing? Yes it’ll be there. You have to be careful with the cautery to make sure your shaft is free and not touching near the bowel.

4. Vascular area 03'51''

So once I have divided the peritoneum, I then go to the vascular area and the other thing I have available on the table I should tell you, is an endoloop just in case I have any trouble with the bleeding. I think that the right colectomies medial to lateral done this way illustrates very well the logic of the lateral to medial approach in laparoscopy. Everybody agree that this is the route, I wouldn’t want to go any further now because down here is a big problem if you get bleeding. The other little thing I do, it’s a Salky thing, every time I put it in, I rotate it to make sure I have what I want, you’ve got to be sure about that; when Joel says it gets warm, he’s not kidding, it gets hot and you can really do some damage with the sides of this thing. So with any instrument you just have to be careful with it. Here of course you are also checking for the duodenum. I have an angle scope which I think is useful, I use a 30° optic so it’s easier to see around it. The proper plane is much more anterior then you think, and almost everybody when I am teaching a fellow or resident always goes down here when its not that, and the thinner a person is, the higher it is. So its way up, very, very high. The good thing about this instrument is that its just like your finger and its gentle and blunt. Are you going to take those right colic vessels? Yes I am. You don’t want to go fast because if do you’ll have trouble with bleeding and all of a sudden the operation is much longer. I really don’t look at the ureter but I look at the fascia and very often I see the ureter behind it and this is the view you should have, I like that very much when it looks like that. You have to be careful in these thin people, the plane is much harder than you think. So now we’ll go over to the right side and I’ll do the lateral side a little later.

5. Right plane 06'50''

You can see the redundancy here, the plane is here. So here is the duodenum, pancreas is over here somewhere. This is one of the advantages of an angle scope, I was looking at it like this and I turned the scope to get a lateral view of it so now I can see that that is pancreas. It is here so you want to make sure that you are above that obviously. I find that if you just stay in this plane and take your time, find the right place, here is the duodenum that it is still very easy medial to lateral, I’m not struggling here. If I begin to struggle, then I switch to another view. That the right colic here, the pancreas right below it there. You can see how thin it is, I am not used to doing it on such a thin person. I think we are free enough now to go lateral. Here is the kidney now you can see. You can use scissors in the right plane; the plane is not there by the way, it is here, its one cell thicker or thinner. My assistant has not helped me before but he is fabulous. You’ve got to be very careful and stay close to the bowel. The plane is not here, the plane is here, on the bowel wall. The patient has no history of appendectomy; he is tilted to the left, right side up a bit. It’s easy to get fooled, this is kidney out there and remember I have already seen that, so we want to be here, this is where I was medially and we will brake into that plane in about a second. Its much more medial then you think, that’s what I mean. I have already mobilised that over there so its here, not here, that a common mistake that people make, they get out way lateral and next thing you know you’re in Gerota’s fascia then you’ve got bleeding. That is the appendix, which is compressed, see how dilated it is, its compressed by the tumour I’m sure.

6. Hepatic flexure 11'41''

So I put the patient a little “head up” to finish off the dissection of the hepatic flexure, you can see here the gallbladder and this is the tell-tale sign that the dissection has already been done, you see a little haematoma up under here. Once I open up here, we are done. I can divide this and I should divide this, the right colon mesentery. For this one I will use the ligasure. The other thing that I do and I really teach this, is I always take the ligasure after I have done it and put it up under what I divide. I think that’s a good imprinting for your brain to know exactly what I’m dividing and where I am going with it and making sure that you don’t catch anything underneath. Those attachments around the hepatic flexure, do you release them in order to allow your colon to come out a bit easier? Yes, I think it should be released 100%, as a matter of fact for all my inflammatory ileo-colic, I mobilise the hepatic flexure, 100% but because my extraction site is going to be infra-umbilical midline and I think once you have mobilised it’s a midline structure. This one is so thin maybe I don’t have to do it, but I like to divide the peritoneum before I use ligasure. When you do this then you don’t have the trouble, its already unsealed and the peritoneum is already divided, so to me it works better. I’ll show you the complete mobilisation and this is enough for me, to do basically a right hemicolectomy. When that happens, this tumour should be sitting on the left floor quadrant and you’ll have to trust me that it is, the whole tumour is in the left lower quadrant. When you do that then I can make a midline incision, not cutting the muscle and so they have a little pain afterwards.

7. End of the procedure 14'51''

All right, so we are going to divide here. We are going to transect here. Do you always do side-to-side antiperistaltic hemostatic anastomosis? I usually do an end-to-side, I have no problem with any type of anastomosis, I think that they both need to be done the right way. Do you close the mesenteric window? Never, I didn’t close them in open surgery I don’t close them now. How often do you run that staple line? I’m going to run it right now. I had a couple of bleeds from the staple line, one through the colon and one that bled so much it actually disrupted the anastomosis, so I oversaw them all. I don’t know if its right but I do it.