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Laparoscopic segmental oncologic splenic flexure colonic resection for cancer

Carcinoma of the splenic flexure is a rare condition accounting for approximately 3 to 8% of colon cancers. The surgical treatment is challenging and not fully standardized. This video demonstrates a laparoscopic segmental oncologic splenic flexure colonic resection for cancer.

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Laparoscopic segmental oncologic splenic flexure colonic resection for cancer

作者群

F Corcione, J Marescaux

摘要

Carcinoma of the splenic flexure is a rare condition accounting for approximately 3 to 8% of colon cancers. The surgical treatment is challenging and not fully standardized. This video demonstrates a laparoscopic segmental oncologic splenic flexure colonic resection for cancer.

分類

live recorded

關鍵字

Laparoscopic segmental oncologic splenic flexure colonic resection, cancer

媒體類型

手術影片

期間

26'30''

刊物

2011-06

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Jun 2011;11(06).
URL: http://www.websurg.com/doi-vd01en3340.htm

Laparoscopic segmental oncologic splenic flexure colonic resection for cancer

1. Introduction 00'52''

We are going to place the trocars for this operation. It is not a usual localization of the tumor. We will discuss about the strategy for this operation. In this case, it’s useless to perform a very large left hemi-colectomy because it’s quite impossible to have a good anastomosis between the transverse colon and the rectum, and you have the risk to perform a total colectomy. So in this case, we prefer the strategy I will show you.

2. Trocar position 01'46''

The trocar position is the same as the one used in left hemi-colectomy in my experience. We need about four trocars. One trocar for the scope in the middle of the abdomen, a little bit on the right. This is the umbilicus. Two trocars for my hand: a 5mm one and a 10mm one. And a fourth one for the second assistant, Dr. Costantino, in the umbilical line, very, very lateral position. This is the standard position for left hemi-colectomy and at the start of the operation, we use the same strategy. It means that we will open the lesser sac, then we will identify the safer layer, Gerota’s fascia from Toldt’s fascia, and then we will clip the left colic artery, the mesenteric vein. We mobilize all the splenic flexure and then we will perform the anastomosis in-out. We start with the dissection of the gastrocolic ligament, and we are going to identify the area of Bouchet. This is the easy point to reach the lesser sac. It’s easy to identify, it’s just under this cord. I use the ultrasound system, which is good for this kind of dissection.

3. Lesser sac opening 03'46''

Now I think I will open the lesser sac. This is the posterior aspect of the stomach. Now we go from right to left in a medial to lateral dissection. We go to the spleen and the splenic flexure and we will stop a little bit before. It will be preserved with the transverse colon. It is a pleasure for me to show you also another kind of dissection for the rectum in a left hemi-colectomy, because Joel Leroy showed you a standard technique, and he prefers to start from the artery. And now I will show you another kind of dissection. I’m very close to the gastric wall, because my goal is to mobilize the omentum, as I can. We’ll open the lesser sac. The pancreas is there. I almost finished this dissection. I don’t like to go very lateral, because at the end of the operation I will go laterally to laterally dissect the splenic flexure from the spleen only to reach the lesser sac before our dissection. Now you can turn the patient to the right. The patient has had a previous prostatectomy. And now, I move the bowel on the right to identify my first landmark for this dissection.

4. Identification of Treitz’s ligament and duodenal diverticulum 06'15''

This dissection is started from the vein to the artery. I have my first landmark, which is Treitz’s ligament that you can identify in any case, even in obese patients. There is something I don’t understand here. Dr. Bailey, I think there is a possible diverticulum of the duodenum. I mobilize the Treitz as I can in order to detach it from the vein to have a good exposure. This is a very interesting case because now we have these vessels, which are not usual. There is an accessory colic artery so we are going to look for the vein. I’m going to dissect Treitz’s ligament. We have the aorta here. The vein is here. I don’t know if this patient has also a second pathology of the duodenum —it’s very, very large.

5. Inferior mesenteric vein 08'24''

This is the pancreas, this is the mesenteric vein. It’s always very close to the Treitz’s. Dr. Costantino, please take the vein now. Lift a little bit laterally. Now we go to look for the dissection, for two layers, Gerota’s fascia and Toldt’s fascia. And I think if you start from the vein, you’re able to identify this safe plane without danger. And if you identify this layer, Gerota’s fascia, you are able to dissect from right to left, from up to down, to identify the artery in any case, even in this patient with some anomaly. This dissection is also performed without coagulation, with traction and counter-traction. This is the safe layer. Because under this layer, we can go identify the ureter, the gonadal vessels, the nerve. But it’s not my job, because it is a good dissection, so I’m quite sure I have no danger for this retroperitoneal structure. I go to identify the mesenteric artery in order to reach the left colic artery. And I’m quite sure, even if it is very difficult to identify, that it is under this cord. Perhaps you can see here.

6. Inferior mesenteric artery 10'27''

Now I’m going to identify the mesenteric axis. Prepare to free all the lymphatic tissue around this artery. I go from the trunk of the mesenteric artery to identify the rectal artery and the left colic artery. This is our landmark, the mesenteric artery. Bipolar. We identify the mesenteric vein here. And this is the bifurcation, the left colic artery and the sigmoid trunk. I’m not sure in any case if there is a bifurcation here. Mesenteric vein and colic artery. Give me the dissector. As you know, it’s much easier to clip here but it’s the best solution to identify the origin of the colic artery. Clip. Ultrasonic. So we have the mesenteric vein, the left colic artery, Gerota’s fascia prepared: we are safe. So thanks to this previous dissection, now I’m able to join these 2 layers to continue the dissection. Look, it’s very easy because I have already prepared up. I go as I can but until this moment, it’s almost the same resection of the left hemi-colectomy and then we will change because our goal is to mobilize the splenic flexure. Blunt dissection. We identify the left colon here but we’re not happy; we continue our dissection. It’s not enough.

7. Splenic flexure mobilization 15'00''

It’s enough for our dissection and now we go to identify the lower edge of the pancreas to mobilize the splenic flexure from the pancreas. We already have this part of the duodenum, which is very large. I try to mobilize. It’s very dilated. Now we identify the lower edge of the pancreas here. We clip the vein. And we go around the vein to clip. You can use the Atlas® to clip the vein but I open already another kind of dissection. One clip is enough. Now I think this is the best way to mobilize the splenic flexure because the concept even for a left hemi-colectomy is to mobilize the mesocolon from the lower edge of the pancreas. Now I’m in the lesser sac here. And the concept—not easy to understand, but I try to explain it to you, is to mobilize the mesocolon here in order to leave the pancreas down and the mesocolon up. The pancreas is very close. It’s very easy to damage the pancreas. Also in this case, I suggest blunt dissection if you can. This is my standard technique for a left hemi-colectomy. In this case, I have already explained the difference because now the operation is almost finished because we have only to dissect the lateral connection with the left parietocolic gutter, and then we will take out the specimen with a transverse subcostal mini-laparotomy. And we go to perform the anastomosis out. So the pancreas is free, the mesocolon is good. We put this gauze, this sponge under the pancreas to protect during the last dissection. It’s a guide for us. And now the last step is to mobilize the colon laterally. We go on the left colon just to mobilize the left colon as I can. Look: the previous preparation of the posterior layer helps us because everything has been dissected by this posterior approach. Look at the gas and we are going to identify the good layer of dissection. And now I will show you one trick: at this moment, I will change our trocar and instrument position. We are able to go very close to our dissection. My Ultracision® get the lateral trocar and the grasper held by Dr. Costantino takes here in order to have my instrument very close and very perpendicular to our line of dissection, not very far. It’s a video-assisted procedure because this is a bigger tumor, I feel the tumor here but I try not to touch it. In any case, we already performed the vascular dissection so regarding any oncological problems, we are safe. And now you can recognize our gauze, our sponge here that protects the pancreas so I am able to recognize where I am able to go. The tumor is really attached to the spleen as you can see now. This is a big tumor here. And now all the splenic flexure is well mobilized. Now you have to decide for the mesocolon. We can continue a little bit to dissect the gastrocolic ligament in order to have less tension. So we reached our goal to mobilize all the splenic flexure without damaging the spleen, the pancreas, and Gerota’s fascia. We take advantage from this dissection to mobilize the left colon a little bit. And then, we are ready for the open step. Take your grasper now. Take this one. I think that’s a good mobilization.

8. Anastomosis 25'19''

So we performed a latero-lateral anisoperistaltic anastomosis. This is an Endo-GIA of 80. And we put another one here. And the tumor is at least 12-15cm from the distal margin of our dissection. We also dissected the omentum. We cut here. The color looks good. So it’s finished. We need another staple but it’s finished.