Laparoscopic right colectomy for voluminous polyp of the ascending colon

Laparoscopic resection of colorectal polyps is a safe and minimally invasive technique for the management of colorectal tumors. Thus, the laparoscopic approach to endoscopically not resectable polyps with suspicion of malignancy enriches the therapeutic spectrum. The purpose of the video is to show the right colectomy technique for a caecal polyp with a possible degenerative disease. An oncological resection is therefore offered. The positioning of the trocars is no different than usual.

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Laparoscopic right colectomy for voluminous polyp of the ascending colon

Authors

J Leroy, J Marescaux

Abstract

Laparoscopic resection of colorectal polyps is a safe and minimally invasive technique for the management of colorectal tumors. Thus, the laparoscopic approach to endoscopically not resectable polyps with suspicion of malignancy enriches the therapeutic spectrum.
The purpose of the video is to show the right colectomy technique for a caecal polyp with a possible degenerative disease. An oncological resection is therefore offered. The positioning of the trocars is no different than usual.

Classification

routine cases

Keywords

Laparoscopic right colectomy, voluminous polyp, ascending colon

Media type

Surgical video

Duration

19'50''

Publication

2009-07

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E-publication

WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2447.htm

Laparoscopic right colectomy for voluminous polyp of the ascending colon

1. Introduction 00'11''

The purpose of the video is to show the right colectomy technique for a caecal polyp with a possible degenerative disease. An oncological resection is therefore offered. The positioning of the trocars is no different than usual, apart from the introduction of these trocars, that will need to take into account the numerous adhesions that have been caused by multiple laparotomies for hysterectomy.

2. Exposure 01'05''

After having freed the adhesions, we expose the submesocolic region. The landmarks are the duodenojejunal angle and the ileocecal region that marks the boundary between the mesentery and the mesocolon. We will expose the superior mesenteric angle and begin the dissection after having exposed the ileocolic axis with forward traction that allows to expose the peritoneum. The peritoneum will be divided under the vascular axis.

3. Division of the ileocolic vessels 01'57''

With traction and counter traction, the peritoneum’s division leads to a dissection of the retro-peritoneal space and allows to quickly identify the third duodenum. The superior mesenteric axis is perfectly visible here. The peritoneal incision will be done anterior to that vascular axis, slightly external to it in order to best expose the ileocolic root. This peritoneal incision is continued up to the transverse mesocolon’s root, in the direction of its middle section on which we have placed a grasper for identification. Once the superior mesenteric axis has been made clearly visible, we continue the dissection of the ileocolic vessels in order to isolate them and to ligature them as close as possible to the inferior mesenteric axis while avoiding any injuries to this axis, especially to the vein as it can be pulled in by an excessive traction. We will also have to resect all the surrounding tissue as it contains lymph nodes and we will perform a skeletonization of the vascular axis. We can therefore see the ileocolic vein, as well as the ileocolic artery situated just above and anterior to the vein. The vein may occasionally be located anterior to the artery. The vascular pedicle’s division is performed after the skeletonization by using, as we are doing, the Ligasure Atlas, and by keeping a sufficiently long stump to be able to perform a complementary ligature of the vessels if necessary, and by avoiding excessive tractions on the vein especially as that may lead to a thrombosis of the vein’s proximal tip, and therefore a mesenteric infarction. We continue the dissection cephalad by uncovering gradually the second duodenum, followed by the anterior surface of the pancreatic head. This dissection continues without any difficulties thanks to the 10mm Ligasure Atlas that is used atraumatically as a finger.

4. Division of the right colic vessel 06'09''

The dissection is continued up to the first duodenum’s superior border in which the sheath of the right mesocolic transverse root inserts. We continue the dissection above the superior mesenteric vessels, especially the vein, and on the pancreatic head’s anterior surface; we uncover the different venous branches that make up the gastrocolic trunk, with in particular the pancreatic and omental veins and the right colic vein that converge to flow either into a common trunk, or separately at the level of the inferior mesenteric vein.

5. Division of the transverse mesocolon and colon 07'52''

Just before it goes behind the pancreas to make up the portal trunk, we divide the right mesocolic vessels and continue the dissection up to the insertion point of the transverse mesocolon’s root that can be divided at that moment, and we will then see the liver and the gallbladder. This adhesion can be kept in order to avoid having the liver and the gallbladder fall into the operative field. In this case, we free the root of the transverse mesocolon, of the duodenum’s anterior surface a little exterior to the greater omentum’s insertion point. We can see the liver and the dissection is gradually continued here towards the right angle’s posterior surface and towards the diaphragm while dividing the right phrenocolic ligament. The gallbladder is sometimes attached to different elements and we must therefore check that there are no adhesions to the gallbladder. In this case, the liver remains fixed due to adhesional sequels, and this facilitates the procedure. The transverse mesocolon that we had freed is divided. We divide the transverse colon at a point chosen beforehand and marked with a grasper introduced in the left subcostal region. This division is performed with a blue cartridge 60mm Endo-GIA linear stapler. The greater omentum is then divided on its length with a 10mm Ligasure Atlas. At this moment of the procedure, we have separated the left transverse colon from the right one and we can put the left transverse colon away to the left. We see that this colon is very mobile, with very few adhesions, and that it is therefore not necessary in this case to perform an extra adhesiolysis.

6. Division of the ileum 10'18''

The next step is the division of the ileum. This division is carried out approximately 20cm from the ileocaecal valve, since adhesions from previous surgeries were found on the last small bowel loop. The division is carried out with an Endo-GIA linear stapler, white cartridge, either 60mm or 45mm long, depending on the diameter of the small bowel. Then the mesenteric bridge is further divided. This bridge still maintains the mesentery attached to the ascending mesocolon. Then dissection is extended on the posterior surface of the caecum. To do so, we ask the assistant situated to the left to place cephalad traction on the ileocaecum thanks to the grasper introduced in the left subcostal region. Using his left hand, the surgeon further exerts traction during the freeing of the ascending colon from caudad to cephalad and by using a posterior approach.

7. Freeing the right colon 11'24''

Here, we can see the end of the freeing process, which is performed with the 10mm Ligasure Atlas device and by staying as anterior as possible to either the Toldt’s fascia or the Gerota’s fascia that covers the kidney. At the beginning of this dissection, attention should be paid to the right ureter, which is usually easy to identify, as it is safer if the dissection is continued anterior to the Toldt’s fascia. The right colon is now totally freed while respecting oncological principles, namely by a primary vascular approach, the exclusion of the duodenum, and very little atraumatic handling of the colon’s tumoral portion.

8. Preparing the anastomosis 13'03''

The following step is the anastomosis, which is prepared by approximating the colonic and small bowel segments. The small bowel’s identification is performed by following the area in which the mesentery has been incised, which helps to find the extremity of the small bowel and helps to bring it in contact to the transverse colon, thus avoiding any twist. Thanks to two stitches used to fix the small bowel and the transverse colon, the anastomosis can be performed by mechanical stapling of the Endo-GIA, blue cartridge. The stapling technique is well codified. The stapler is introduced from the left to the right. After the stapling, we control the hemostasis of the stapled area. The incision through which the stapler has been introduced is then closed. Beforehand, the guide wire is divided, which helps to clearly see the two extremities of the opening in order to close the incision with two half-running sutures (Maxon 3/0). Each running suture starts at the corners of the incision site. The two running sutures are inverted in order to perform the knot at the mid-part of the suture zone.

9. Closure of the mesenteric gap by medial approach 16'10''

Once the suture has been completed, the mesenteric gap should be closed. At the beginning of our experience, we did not close this gap. We now close it systematically. To do so, there are several options. We either use a monofilament suture material to close the gap using a medial approach as in the present case, or we use a lateral posterior approach, which is sometimes easier in obese patients. We can also use a stapling approach, which allows for a quicker closure and is as safe as the other options. The benefit of using a suture is the resulting suppleness, especially at the level of the superior area where it is sometimes required that closure be performed by resting on the lower aspect of the transverse mesocolon. When this suture has been carried out, any vascular injury at the level of superior mesenteric vessels must be avoided since grasping of the peritoneum is sufficient to close without any traction. This closure is preferable since a certain number of postoperative ileus are probably due to intermittent internal hernias, even if occlusions have never been encountered on the right. It is obvious that the occurrence of postoperative ileus may be favoured by this type of gap. Once the anastomosis is complete and once it has been controlled, the specimen must be extracted. Thanks to the intra-abdominal anastomosis, the specimen extraction may be achieved through a suprapubic incision.

10. Specimen extraction 18'30''

This incision can be minimal. Extraction is carried out after insertion of a plastic drape through the suprapubic trocar entry site. This plastic drape is introduced around the trocar, which serves as a guide. The Endo-catch II plastic bag is then introduced into the abdominal cavity and the specimen is pushed into it. The plastic bag with the specimen is brought out of the abdominal cavity. The specimen is retrieved under visual control. At the end of the procedure, all the incisions are re-approximated. No drainage is used routinely.