Laparoscopic right colectomy for voluminous tumor of the ascending colon: oncologic approach

Authors

B Salky, J Marescaux

Abstract

This video shows a laparoscopic right colectomy performed during an IRCAD course.

Classification

live recorded

Keywords

Laparoscopic right colectomy, voluminous tumor, ascending colon, oncologic approach

Media type

Duration

32'00''

Publication

2011-07

Popular

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Audio

E-publication

WeBSurg.com, Jul 2011;11(07).
URL: http://www.websurg.com/doi-vd01en3371.htm

Laparoscopic right colectomy for voluminous tumor of the ascending colon: oncologic approach

1. Introduction 00'20''

I need the 10 scope. I need the table down and right side up. First of all, we have been working for about 45 minutes getting the adhesions down because she had an umbilical hernia repaired. I\'m not sure if it\'s incisional or umbilical hernia. The little bit of blood you see here is from the lysis of adhesions. I\'m just beginning to look around and see what\'s going on. Maybe we could take the tube out? And she\'s had a couple of cesareans so the uterus is stuck up here. I\'m just looking around. I have to replace some trocars. Ordinarily I would put… my inferior trocar is the uterus so that\'s not going to happen.

2. Tumor identification 03'00''

Let\'s see if I can find where the tumor is. This is supposedly at the right angle but as you know, sometimes the right angle is at the left angle, so we have to be sure about that. And she has got some redundancy here. I think it\'s here. She’s a little fat. The tumor is here, and it\'s really the ascending colon, it\'s not the angle, the angle is over here. Here\'s the angle, it\'s below the angle. But it\'s mobile. I think this would be a standard right hemi-colectomy. The tumor is here. The gallbladder is here. This is plenty here. This would be a right hemi-colectomy. Now the question is that the omentum? The answer is that whatever is attached over here is coming, and whatever is over on the mid-transverse colon will stay.

3. Trocar position 04'58''

This is the umbilicus and this is the head. The pubis is here. Although her BMI is 34 I have very little distance between the umbilicus and the pubic bone, which is here. A 10mm or 12mm port for the video is a little bit higher than usual, because this is the umbilicus, which is a little bit higher. I usually put it at the umbilicus. This 5mm port, I usually put in the midline just above the pubis. Because when I make an incision, I incorporate that. So it\'s a little bit more on the right side than usual. This is a 12mm port and I use this because this is where the stapler is going to go. And I use a 10mm Ligasure™, I just happen to like that better. This is more or less in the right place. This one is definitely much more on the left side than I ordinarily use for right hemi-colectomy, I usually have it over here, in the midline. This is the midline, this is the left upper quadrant. I use this entry point because of the previous incision. So I changed a little bit, but not dramatically. We have the grasper towards the ileocolic. This is the cecum and the appendix over there. I know some people just use the 10mm Ligasure™ to open but I really like to put the energy where I want it, so I open that up. If you look, I already see the duodenum.

4. Duodenum identification 07'26''

This is the landmark – the duodenum, this makes this the retroperitoneal fascia. As long as you stay above that fascia, I don\'t think it\'s possible to injure the ureter, as the ureter doesn\'t go below the fascia. It\'s ok to begin to divide the ileocolic once you see this plane. The traction was like this at the beginning but when you divide it, you release it – that\'s very important. I feel very comfortable taking it with the fat as long as I\'m behind it, which I am. I think by doing the peritoneum it allows the energy to be put on the vessel, as opposed to being put on the peritoneum and then the vessel, and I think that makes a big difference. By the way, the reason it\'s so close together is because the ascending colon has a loop in it, has a redundancy to it, so it\'s altogether. This is the transverse colon over here already. As you know there was a terrible case in the United States where the Ligasure™ went across the aorta, it transected the aorta completely. It will go through anything, so you have to be very careful with it.

5. Retroperitoneum dissection 09'44''

We\'re not ready to divide yet because the retroperitoneum is still attached, so we have to get the retroperitoneum down first. The duodenum is down here. I believe that\'s the iliac. Whenever there\'s a question about where the base of that mesentery is, then I let go of this and I will go laterally right now – we\'re going to lift up the appendix. In a thin person, it\'s never a problem but in fat people sometimes it can be a problem. I\'m being a little bit careful, as one should always be. I\'m coming closer. This is too deep. I have to have something to show me where it is so. Usually at our place, we tattoo them, and if I get in and there is no tattoo, then obviously it\'s a little bit of a problem, then we will do on the table an endoscopy with CO2 and put a clamp across the ileocecal valve or ileum so that we don\'t get gas up in there. Here\'s the plane up here, it\'s much higher than you think. I\'m going back to the ileum. I want to show you what the advantage of me going laterally was at that point in time. Here\'s the ileum, here\'s the terminal ileum here. This is where I was doing the medial dissection, I was having a little difficulty in terms of finding exactly the plane, but now with that little maneuver (by doing the lateral dissection) it becomes very simple. Here\'s the mesentery, here\'s the ileum and I\'m around it completely already as you can see. That makes it very simple to do, so I do that from time to time. The other thing I do which I think helps for people who are just starting is that you get a little imprint in your brain if you work in a two-dimensional system, then if you put the instrument – whatever instrument you\'re using, a 5 or a 10, it doesn\'t make any difference – behind it, it helps you know where to put the instrument instead of just doing this. The other option of course is just to do this, and keep going and just keep doing this. But for me, it makes me feel a little bit better to know exactly where I am, so after every time I stick it back there, I make sure that I\'m seeing what I want to see, and then I do this. It\'s just a little technique, everybody does it differently. The other thing is it\'s so good of an instrument, that everybody wants to do this and cram it in there and take a bite, but if you look you see these black lines in here and obviously the energy is between the black lines. And you will not infrequently get a little bleeder in this area if you do that. So if you look, I\'m pretty careful about just doing a little bit at a time, like this, and make sure that I don\'t have it crammed all the way in.

6. Ileum dissection 15'21''

Now I\'m just preparing the ileum. I don\'t use energy by the bowel wall by the way as you can see. I honestly think that anywhere over here is fine from a bowel point of view, and I\'ve already divided the ileocolic. I think I got the right colic too but I\'ll double check that. I think this is more than adequate, I really do. Now I\'m going to change the position to head up. Generally speaking in laparoscopic surgery, I think that "slow" is actually very fast. There are no records for speed in these cases, you want to see the anatomy, stay in the right plane, there\'s no bleeding – if you\'re in the wrong plane, you get bleeding. The truth is that if you don\'t see it right, you\'re not in the right place. I usually do a medial to lateral dissection, and sometimes I do a lateral to medial dissection just depends on what’s easier, and I have no hesitation about going back and forth. You can see the redundancy of the colon, that\'s the reason why the mesentery I showed you a bit earlier looked a bit funny. I use a 30-degree camera. You could use scissors for this, it would actually make it quicker. I\'m being a little hesitant because in this position I think the tumor is rotating more towards the midline and I want to be 100 per cent sure I\'m in the right place. So let\'s unrotate the patient and make the patient totally flat. I feel it here for sure. The anastomosis is right there, so we\'re going to transect it around here. Can I say that probably at this point because the patient is fatty, the last small bowel loop is sectioned, you could make the incision and extract the specimen and section the bowel outside? It might be easier. I don’t think so. The problem is the colon, the small bowel\'s not the problem at all. You\'ll see what I\'m going to do which is taking a little bit longer because she\'s fat.

7. Vascular structures 21'46''

Can you show us the vascular structures? That\'s the right colic… Here\'s the bowel. There is a colon. I\'m trying to make sure I go across this in a right angle, but she\'s so fat I\'m just having trouble seeing that. It\'s almost done, but not quite – and then we can do the anastomosis. There you go, I think that\'s probably enough. It\'s going in this direction, I have to make sure I go in at a right angle. There you go, that\'s where I\'m going. In such a difficult case, why don’t you divide immediately the bowel and then you go on the mesentery? I could have, I guess. It didn\'t look like it was going to be that hard at the time – yes, that\'s the other option. I don\'t like to use two across the colon, but I may have to, it\'s a big colon. I\'m just trying to make sure I\'m at the right angle, and it\'s not exactly the case. I think it\'s OK. Yes, it\'s fine.

8. Completion of mobilization and anastomosis 25'36''

OK, so I think we\'re mobilized completely now. I think I still have a little attachment. Let\'s get this out of the way. I agree it\'s a pretty big piece of bowel. I think it looks just fine, this is what you should see; you should see the duodenum, and it\'s OK. It hasn\'t been touched. You should see that posterior plane. The kidney area is here. And there is a lot of fat in Gerota\'s, that\'s why I was going across. Here\'s the kidney. Now, we need to just line up – and this is why I think it\'s so easy to do an intracorporeal anastomosis – because I can see the mesentery. This is what we\'re looking for, right here, here\'s the cut into the mesentery. We\'re going to trace that down. Now we can make sure that the mesentery is not twisted. Do we agree it\'s not twisted? Yes, we do. The end of the bowel\'s viable, it looks quite good. How nice is that? And how far from your stapler are you making that cut? I\'m estimating that\'s about an inch, maybe two centimetres. I\'m in the lumen. Make sure that staple line is OK. You grab the colon and pull it on. And the time to look for the hemostasis would be now. Now to the suction-aspiration. I will now make a running suture. I\'m going to pull it so it\'s in a straight line. My assistant is holding it out this way, and this is a 90-degree angle. So all you have to do is sew. I think it\'s important if you\'re going to do laparoscopic surgery that you know how to sew – I don\'t think that\'s a skill that is special. I\'m making the incision a little bit below the umbilicus. I would say this incision is probably 5 to 6cm. I think if you did this laparoscopic-assisted that in this big person, it would be a lot bigger than that, so we will see. It\'s one of those types of benign polyps that kill you. And that\'s a very good demonstration of why if you think that\'s still a benign polyp preop, well you have to do a cancer resection. Here\'s the completed anastomosis here, it’s the transverse colon, it’s the cut into the colon down here, and here\'s the completed anastomosis.

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