Laparoscopic right colectomy for cecal cancer

This video demonstrates the key anatomic landmarks and steps in performing an oncologic resection of right colon using a medial approach to mesenteric mobilization. The surgical steps and anatomy are highlighted by use of artistic drawings. The mesenteric division is carried out intracorporeally and the stapled anastomosis is done extracorporeally through a small suprapubic incision used to remove the specimen. This is an excellent introductory video for laparoscopic right hemicolectomy for cancer.

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Laparoscopic   right   colectomy   for   cecal   cancer

Authors
J Leroy
Abstract
This video demonstrates the key anatomic landmarks and steps in performing an oncologic resection of right colon using a medial approach to mesenteric mobilization. The surgical steps and anatomy are highlighted by use of artistic drawings. The mesenteric division is carried out intracorporeally and the stapled anastomosis is done extracorporeally through a small suprapubic incision used to remove the specimen.
This is an excellent introductory video for laparoscopic right hemicolectomy for cancer.
Classification
basic techniques
Keywords
right colon,resection,cecal cancer,medial mesenteric mobilization,laparoscopy
Media type
Duration
14'00''
Publication
2003-04
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Apr 2003;3(04).
URL: http://www.websurg.com/doi-vd01en1436e.htm

Laparoscopic   right   colectomy   for   cecal   cancer

2. Vascular dissection 02'03''
We will need to begin our dissection by opening the mesentery of the ileum and right colon. Our dissection will proceed cephalad, just adjacent to the superior mesenteric vein. The philosophy of the operation is to separate right from left and splitting the middle colic vessel between its right and left branch. At this point, because it is an oncologic procedure we will take the ileocolic vessels at, or as close to the origin as possible. Right now you can see the base of the ileocolic vessels, both artery and vein being taken by our high energy Ligasure device here, which both cauterises and divides the vessels; dividing these vessels at their base then exposes the duodenum which you see coming into view here. We are exposing the third portion of the duodenum here and going behind the transverse mesocolon and the right mesocolon. The assistant with his trocar F is exposing anteriorly the transverse mesocolon. You can see here we have a lymph node going up along adjacent to the superior mesenteric artery and we are going to take this as part of our specimen. Now you have a nice view of the branching of the middle colic artery. We will take the right branch of the middle colic artery as part of our specimen. And again, we use the Ligasure device to take this vessel, and we take the right branch of the middle colic vein in a likewise fashion. Now we are getting continued exposure posterior to the transverse mesocolon, moving in a cephalad direction until we have exposed the gallbladder behind the mesentery.
3. Mobilization of transverse colon 05'03''
You can see we have a bottom-up or medial to lateral approach. We’ve got some adhesions here to the gallbladder that need to be taken down as well so that we can adequately identify the hole in the root of the transverse mesocolon, through which we will divide the transverse mesocolon--the right portion going with the specimen and the left portion staying intact along with its vasculature. We continue to divide from the root up to the transverse mesocolon itself and then we divide this using a standard endo-GIA stapler; oftentimes this requires more than one firing. Once we have accomplished this, we now have our specimen that we will need to divide the greater omentum which is attached. Fortunately, this can be accomplished easily with our Ligasure device. Now we have completed our medial division. The next step of the procedure is moving down to the ileum, terminal ileum, to divide it. We have repositioned our camera such that it is above the umbilicus and now looking down towards the right lower quadrant and pelvis. We begin by dividing an adequate specimen of the terminal ileum with the endo-GIA stapler shown here, and next we will use our Ligasure device to divide the mesentery feeding the ileocolic junction. This division will ultimately lead into the portion which we have already divided medially, which feeds the right and hepatic flexures of the colon. You can see here our caecum is a bit deformed because of the tumour involving the wall of the caecum. Now we need to have retroperitoneal exposure; and see the appendix, in order to have a complete mesenteric resection of the involved right colon and terminal ileum.
4. Mobilization of ascending colon 07'38''
We continue in the same plane that we previously established, you can see at the inferior portion of the screen, 3rd portion of the duodenum and we will continue a cephalad retraction and division of the retroperitoneal adhesions in order to take all of the lymphatic bed and mesentery of the right colon as well as the right half of the transverse colon lateral to the division of the middle colic vessels. Up to this point, we have not had to handle the colon itself and if maintained in no touch technique, now we will have to begin to take down the lateral attachments of the colon and for this, we can provide traction on the mesentery and the greater omentum rather than the colon itself. Some small amount of manipulation is always necessary to some extent but we prefer to have the vasculature adequately divided prior to doing this and indeed we have been able to accomplish that in this case. You see the remainder of the retroperitoneal adhesions now in the right colic gutter which are taken down. The mesentery and the blood supply of the colon have already been divided. Again you see the head of the pancreas and the duodenum at the inferior aspect in the right side of the screen and we will continue with upward traction on our specimen dividing at the retroperitoneal junction to remove all of the lymphatic drainage as well as the vessels for a true oncologic procedure. And this is the remainder of our dissection bed; here is our ureter, as you can see it is intact.
5. Extraction and anastomosis 09'43''
The next portion of the procedure is to place our specimen into a bag. To maintain oncological principles we place the specimen into a bag and then withdraw it through the abdomen in an incision in the suprapubic region with a wound protector; that way we get a double protection effect against disseminating any of the tumour cells that may occur during laparoscopic surgery. The trocar above the pubis is extended to a mini-laparotomy; our specimen is then removed from the bag and again you can see here that we have this portion of the greater omentum and the entire mesenteric supply to the ileo-caecum and transverse colon taken with the specimen. At this point, we will need to find our portion of divided terminal ileum to create our anastomosis. We can lay the terminal ileum side by side to the transverse colon; we use an anchoring stitch to approximate the two and we use an intracorporeal knot to fix the two together and you can see the two staple lines now; on the left is the transverse colon and on the right is the terminal ileum. We place a second more distant anchoring stitch now in order to facilitate our anastomosis and again we use an intracorporeal technique to do this. You can see now that the two portions of the bowel are side by side. We will exteriorise the specimen; we make a small enterotomy in each side, in each leg of the anastomosis and we will pass an endo-GIA stapler for a side-to-side functional end-to-end anastomosis. The stapler is fired and then the remaining defect is closed with a running suture. The two distant most ends are freed up from their mesenteric supply in order to facilitate the reduction of the anastomosis back into the intracorporeal position. Here is our remaining defect which will then be taken with a standard TA stapler. Once it has been fired, the remaining segments are removed; the anastomosis is complete and we will reinforce our corners where the TA stapling device has gone across the endo-GIA stapling device. This is an extra measure of security and is not used by all teams. Once the reinforcement is complete, we see that we have a 45 cm length anastomosis. Our bowel is viable and we reduce it back into the peritoneal cavity. We do a final survey of the abdomen; we find that we have a hemostatic field; the stomach is in proper position. We check our anastomosis and find that it looks fine, the bowel is lying in an anatomic position and there is no twisting. Some surgeons feel that the mesenteric defect must be closed and indeed if we choose to close this we may. The only disadvantage of closing the mesenteric defect is that if an attempt is made at closing it, it must be absolutely perfect. In other words, a small hole is much more dangerous than a large hole. We choose to leave a large mesenteric defect.