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Laparoscopic right colectomy for polyp

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Laparoscopic right colectomy for polyp

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colectomie droite,abord médial

媒體類型

手術影片

期間

16'00''

刊物

2004-12

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最愛

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數位出版

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1594.htm

Laparoscopic right colectomy for polyp

1. Trocar placement 00'08''

The head of the patient is this way, the xiphoid process is right here, the pubic symphysis is here, we’ve put our camera port just below the umbilicus, this is an 11mm port and we are using a 0 degree 10mm scope. We have a 5mm port in the left upper quadrant, which is just about 3 fingerbreadths below the costal margin and then we have a 12mm port 4 fingerbreadths below that, this is the main operative port for Ligasure and for stapling, and then we have a final 5mm port about 4 fingerbreadths below the optical port in the midline.

2. Dissection of ileocolic and right colic vessel 01'01''

We identify the junction of the ileum and the cecum, this is the ileocolic vessel and I am going to start working on this. I think it’s a good idea to take it in the same place but you can never be 100% certain that it’s benign. One of the things that’s important here is that you have to be certain about where the disease is and in this case if it is a polyp inside the ileocecal valve, usually it is important to know where it is, it is our practice that if the lesion is anywhere beyond the side of the valve that we tattoo, so we have to come back in and do a separate endoscopy. We do our own tattooings of the lesions if they don’t already come tattooed. The right colon especially for hepatic flexure lesions, it is often very difficult to find them. If there is a question we can put a loop tie on this but it looks OK, we are going to try and find the plane running laterally. We try to find this plane between the anterior aspect of Gerota’s fascia and the back of the mesocolon, so far I haven’t really found it yet. This is beginning to be the Gerota’s fascia coming down, we are working from a medial to a lateral approach. One of the things about laparoscopy is that it lends itself to this because you can work centrally and then move outwards, it is a better way than when we do open, at least the way I was taught open. We go as far laterally to the side wall on the side of the colon there. I think you have to be careful with the Ligasure because even though it is a wonderful tool, you can injure the bowel nearby so you have to be careful to know that the bowel is not too close. A few times when mobilising the splenic flexure we’ve burned the bowel a bit and had to put some stitches in. We’ll get the middle colic in a second. We work more with the traction to determine where the vessels are, so the first thing we have to figure out is where the middle colic vessels are coming. Some people have a single trunk, we find most people have two trunks, sometimes there are even three middle colic vessels so it is important to try and understand what you are dealing with in these cases. This is probably benign but we are still going to take this main vessel, I’m going to work around it first. We think this is the branch here, the one thing you have to watch out for is that sometimes you can be too close to the pancreas and you can actually injure that. At this point, I might hold off on the rest of the mesentery until I get the lesser sac mobilised, this is pretty safe to do but we will not divide the bowel yet though. Now we are going to stop and go back down to our medial to lateral part of this. I’m going to try and do as much as we can of this inferiorly as well, then we’ll go down and free up the bottom of this. The order of this is to get the ileocolic vessels first and while you’re there, you might as well get the middle colics. It is possible to mobilize the ureter with you on this so you have to be careful. You avoid that. You don’t have to see the ureter but you have to be careful about it, if you have the right plane and have the mesentery alone. If there was a cecal tumor, we wouldn’t want to grasp this part of it so we are going to avoid that but we are going to score some of these attachments.

3. Colon mobilization 07'30''

The mistake people make here is they start to go laterally, you need to do all the medial part first. Mostly cutting, it is less dangerous, less current. We don’t think it is anything too major so now we are going to resume the dissection here. Obviously, we try to avoid touching the tumor or even touching the bowel. Here is more opportunity to do some blunt dissection here. At that point, we’ll go over to the middle portion, I get into the lesser sac and so start at the middle of the transverse. We use the cautery very carefully or the Ligasure. This is a nice operation to learn but I think the hardest part of it is getting into the lesser sac and getting that part by the middle colic vessel and by the right gastroepiploic vessels separated.

4. Greater omentum and ileocolic transection 10'45''

This is the difficult area where the middle colic vessels come off and are very close to the gastroepiploic vessel at the origin of that and you have to be careful. The problem if you have a short mesentery, if middle colic vessels are short no matter how much you mobilize, it will be hard to get it out through the abdominal wall if the patient is fat, I think this is another reason why this is important to try and get this. This is the liver and gallbladder here and then the flexure, its attachments. So we find the vessel here, for a cancer case in the cecum we would take something around 8 to 10cm of the distal ileum just to get the lymph nodes. We bring this up like this and I am going to try and grab both.

5. Extraction 13'40''

6. Anastomosis 14'40''

At this point, it is important to follow your finger down the edge of the mesentery to make sure it’s straight and not twisted. Now it looks fine so we are going to go ahead and do our anastomosis. Thank you for this demonstration, it was not easy with a fatty patient and quite difficult.