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Laparoscopic segmental resection of the transverse colon

This video demonstrates the unusual procedure of segmental transverse colon resection performed for an adenocarcinoma in the distal part. All oncological principles are obeyed and a stapled colo-colic reconstruction is performed totally intracorporeally. This video is suitable for digestive surgeons. The author opens the mesocolon in the shape of a V and uses the Harmonic scalpel to divide the mesocolic fat. Dissection proceeds from the base of the mesocolon towards the colon, where the author carefully isolates Drummond’s marginal artery. Attention then turns to complete the resection of the mesocolon on the right limb of the V. The author identifies the mesocolic vessels as they emerge from the superior mesenteric vessels. This approach requires care because of the number of major vessels in the area. The dissection continues upward to divide the mesocolon on the right side.

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Laparoscopic segmental resection of the transverse colon

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摘要

This video demonstrates the unusual procedure of segmental transverse colon resection performed for an adenocarcinoma in the distal part. All oncological principles are obeyed and a stapled colo-colic reconstruction is performed totally intracorporeally. This video is suitable for digestive surgeons.
The author opens the mesocolon in the shape of a V and uses the Harmonic scalpel to divide the mesocolic fat. Dissection proceeds from the base of the mesocolon towards the colon, where the author carefully isolates Drummond’s marginal artery. Attention then turns to complete the resection of the mesocolon on the right limb of the V. The author identifies the mesocolic vessels as they emerge from the superior mesenteric vessels. This approach requires care because of the number of major vessels in the area. The dissection continues upward to divide the mesocolon on the right side.

關鍵字

laparoscopy, transverse colon resection, segmental resection, mesocolon dissection

媒體類型

手術影片

期間

09'41''

刊物

2007-07

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Jul 2007;7(07).
URL: http://www.websurg.com/doi-vd01en2130.htm

Laparoscopic segmental resection of the transverse colon

1. Division of mesocolic vessels 00'40''

This video demonstrates a segmental resection of the transverse colon with reconstruction by a totally intracorporeal colo-colic anastomosis. The patient is a 60-year-old male with a histologically confirmed adenocarcinoma in the distal part of the transverse colon. A preoperative colonoscopy is performed and methylene blue injection is used to mark the tumor. During the exploration, the location of the tumor is confirmed. The margins are judged to be adequate to perform a segmental resection of the transverse colon, including the middle colic vessels for full oncological clearance. A primary vascular approach is used. Therefore, the first part of the surgery is division of the middle colic vessels and mesocolon. The colon is displayed with the help of graspers placed through trocars in the right and left flank, and the mesocolon is opened in the shape of a ‘v’, commencing first with the left side. The ultrasonic scalpel is used here to initially open the peritoneal covering, and then to divide the mesocolic fat. The dissection proceeds from the base of the mesocolon towards the colon, where the marginal artery of Drummond is encountered. This vessel is isolated carefully before double clipping and division. Attention then turns to complete the section of the mesocolon on the right side - the other limb of the ‘v’. This dissection has to be performed very carefully as these are major vessels emerging directly from the superior mesenteric vessels. Once again, clips are applied to the artery and vein individually before division. After this key vascular division is completed, the dissection then continues upwards to divide the mesocolon on the right side. This is a favored method of dissection, especially in cancer cases because in this way, the lymph node package is preserved in the mesocolic fat together with the colonic specimen. Once the mesocolic dissection is completed, the next step is to divide the greater omentum, starting distally and working towards the colon. This is again started on the left side. Once this is completed, we then proceed to mobilize the splenic flexure. Mobilization of the splenic flexure is important to reduce the tension on the colo-colic anastomosis, which will be performed later. The same division of the greater omentum is then carried out on the right side, and the hepatic flexure of the colon is also mobilized in a similar fashion.

2. Section of colon 05'39''

Once all the dissection is complete, the colon is then transected with an endoscopic stapler. This is performed first on the right side, and then the left side is transected. Sometimes it is necessary to use more than one fire of the stapler in order to divide the colon. A segmental colonic resection such as this is not typically performed for cancer for 2 reasons: the first is that the lymph node clearance must be adequate, and this always necessitates removing the main vascular pedicle, which is where the lymph nodes are located.

3. Colo-colic anastomosis 06'15''

This then leads to the second reason, and this is that when the main vascular pedicle is removed, the viability of the remaining colon may be compromised, leading to ischemic necrosis, gangrene, anastomotic leak or stenosis of the colon. However, in this case, the resection margins are more than adequate; a full oncological resection is performed and the vascularity of the remaining colon is very good; therefore the decision to perform a segmental resection instead of, for example, an extended right hemicolectomy, or even a left hemicolectomy, is quite justified. Having completed the segmental colectomy, the specimen is first left in the peritoneal cavity while the colo-colic anastomosis is completed. The proximal and distal ends of the colon are brought together and checked to see that there is no tension. Then 2 stay sutures were placed at opposite ends to approximate the 2 ends of the colon. Each limb of the colon was opened with an ultrasonic scalpel, and the endoscopic stapler advanced through these openings. A stapled colo-colic anastomosis was performed. The remaining colotomy is then closed with a running suture. The suture is locked using clips at both ends, avoiding the need for intracorporeal knotting. However, if one is familiar and capable of doing intracorporeal knotting, this can also be performed with ease.

4. Closure of mesocolic defect 08'00''

Now, all that remains is the closure of the mesocolic defect. This is also done using a running suture in the fashion previously described. From the experience in bariatric surgery, laparoscopic surgery is associated with a higher incidence of developing postoperative herniae. This is because the rate of postoperative adhesions is much less in laparoscopic compared to open surgery. This is why many surgeons elect to judiciously close all mesenteric defects during laparoscopic surgery. The advantage of performing a totally intracorporeal anastomosis is that the incision made for specimen retrieval can be placed in an esthetic location, which can be discussed prior to surgery with the patient. This preserves all the advantages of laparoscopic surgery.

5. Specimen extraction 09'20''

Therefore, once the surgery is completed, the specimen is placed in an endoscopic bag, and this bag is passed into the abdomen through a trocar which is placed in a suprapubic location. Histological assessment of the specimen confirms adenocarcinoma.