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Laparoscopic right colectomy in an obese patient with a dysplastic adenoma

This video demonstrates a laparoscopic three-port right hemicolectomy in an obese patient with a dysplastic adenoma. A stepwise approach including landmark identification is undertaken during the procedure. The specimen is extracted through a small laparotomy, which will be protected by a plastic bag. An extracorporeal mechanical side-to-side anastomosis using a 60mm Endo-GIA is made and the mesenteric window is closed using a monofilament 2/0 running suture. This video is a good demonstration of key anatomic landmarks, surgical planes, and surgical approach to a right hemicolectomy.

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Laparoscopic right colectomy in an obese patient with a dysplastic adenoma

作者群

C Huscher, J Marescaux

摘要

This video demonstrates a laparoscopic three-port right hemicolectomy in an obese patient with a dysplastic adenoma. A stepwise approach including landmark identification is undertaken during the procedure.
The specimen is extracted through a small laparotomy, which will be protected by a plastic bag. An extracorporeal mechanical side-to-side anastomosis using a 60mm Endo-GIA is made and the mesenteric window is closed using a monofilament 2/0 running suture.
This video is a good demonstration of key anatomic landmarks, surgical planes, and surgical approach to a right hemicolectomy.

分類

basic techniques

關鍵字

Laparoscopic right colectomy, obese patient, dysplastic adenoma

媒體類型

手術影片

期間

13'00''

刊物

2009-02

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Feb 2009;9(02).
URL: http://www.websurg.com/doi-vd01en2498.htm

Laparoscopic right colectomy in an obese patient with a dysplastic adenoma

1. Case presentation 00'08''

I would like to show this 3 port technique, this is the greater omentum that I try to push over the liver. Here is the transverse colon. To lift up the transverse colon mesentery, I use a stitch that comes from the abdominal wall. The patient is rotated towards the left so that the small bowel falls in the left quadrant. I go up some more. This is an oncologic resection, so we have to ligate the ileocolic artery and vein; to do this, we have to identify the caecum and the last ileal loop. I think that this is the ileocaecal artery and the bifurcation of the arch of Treves. We open the peritoneal sheath and we go inside it dissecting between the Toldt’s fascia and Gerota’s fascia. I need the Ligasure now, see the duodenum is very visible within the field. I go gently between the Toldt’s fascia and the Fredet’s fascia. With all of these operations, if you are in the right plane, it is actually very bloodless, it’s usually just the peritoneal edge or the mesenteric edge that bleeds, but you can do a lot of blunt dissection to develop the planes and if there isn’t much bleeding, then you are probably in the right plane. You see the right plane is completely avascular. Now I look for the origin of the ileocaecal artery and vein. I try to avoid any traction on the superior mesenteric vein in order to avoid any thrombosis. You see the duodenum coming up. The right plane is completely open now, we have the artery.

2. Artery dissection 03'45''

You see the Ligasure coming. I try to clean all the tissue around. The artery is completely dissected free and divided. See the duodenum now. We can divide gently with the instrument as if it was a finger.

3. Last small bowel loop identification and Treves\' arcade division 04'52''

Now we are very close to the abdominal wall, we look for the last small bowel loop so I can divide the arch of Treves in front of us. In patients where the right colic artery is a good one, you don’t have any problems, but in some patients you have the Jaboulay’s point that we have to look for to avoid any ischemia. Now we are behind the caecum behind the small bowel loop; the last small bowel loop, it could be very useful to perforate. I have to go slowly. The goal is to dissect free in order to do a good anastomosis. We also have to expose this adhesion. Young surgeons in this corner have to be very careful. In this case, we can cut the gonadal vessels. So we have to lift the peritoneal sheath all around the small bowel loop. We have some bleeding here. I stretched the mesentery too much.

4. Last small bowel loop division 08'13''

We have done all the dissection and now we have to gain the hepatic flexure. This is the Morrison’s pouch. We quite like the view inside at the moment. I have the polyp dissected free and in front of you, you have the previous dissection performed from below. I have 2 main concerns in a right colectomy: avoid any pancreas injury and avoid any traction on the gallbladder. See the right plane. I try to avoid any lesion on the right gastro-omental vessels. I think we are ready to do the small incision, here is the duodenum in front of me. The colon is completely avascular. The appendix, small bowel loop, and the mesentery you saw previously. Before opening it, we go to look for the last small bowel loop. To avoid any rotation, we put a forceps and fix it on the table. Now I look for the specimen. This is the last small bowel loop so I can retrieve the specimen via the mini-laparotomy.

5. External view specimen extraction 11'21''

The specimen is extracted through a small laparotomy, which will be protected by a plastic bag. The vascularization of the colon is checked and proves to be in good condition.

6. Transverse colon division 11'38''

The distal end of the division is determined at the level of the transverse colon and the division is performed using a 55mm TA linear stapling instrument.

7. Mechanical side-to-side anastomosis 11'53''

We then perform a mechanical side-to-side anastomosis using a 60mm Endo-GIA. The intestinal incision will be closed using a monofilament 2/0 running suture. As you can see, the wall had been protected by a plastic wound protector. A final laparoscopic check is made and we can observe the good vascularization of the anastomosis as well as the absence of bleeding. No mesenteric defect can be observed.