Laparoscopic sigmoidectomy following inadequate endoscopic resection margins of pedunculated polyp

The value and efficacy of laparoscopic colorectal surgery has been validated by large multicenter, randomized, controlled trials. This video shows a laparoscopic sigmoidectomy in a 74-year-old woman who underwent an incomplete endoscopic resection of a T1 adenocarcinoma tumor. Four trocars are used: two of 10mm and two of 5mm.

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Laparoscopic   sigmoidectomy   following   inadequate   endoscopic   resection   margins   of   pedunculated   polyp

Authors
F Corcione, J Marescaux
Abstract
The value and efficacy of laparoscopic colorectal surgery has been validated by large multicenter, randomized, controlled trials. This video shows a laparoscopic sigmoidectomy in a 74-year-old woman who underwent an incomplete endoscopic resection of a T1 adenocarcinoma tumor. Four trocars are used: two of 10mm and two of 5mm.
Classification
clinical cases
Keywords
Laparoscopic sigmoidectomy following inadequate endoscopic resection margins of pedunculated polyp
Media type
Duration
19'24''
Publication
2009-05
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, May 2009;9(05).
URL: http://www.websurg.com/doi-vd01en2636.htm

Laparoscopic   sigmoidectomy   following   inadequate   endoscopic   resection   margins   of   pedunculated   polyp

2. Start of dissection 01'31''
I start in the middle of the transverse colon, the assistant takes the colon and I work my left hand. I pull the greater omentum and with the right hand I go from right to left to detach the greater omentum from the colon. It is a pity about the snow storm but it’s not too bad. The problem with the Ultracision is that you should not put the camera too near to what you are doing because then you have the smoke. I stop this dissection when I arrive on the splenic flexure. Sometimes during this dissection, you have to pay attention to not get too close to the colon so as to not injure it. I will show you the lesser sac. After the detachment of the greater omentum from the transverse colon, the second step of this technique is to look for the mesenteric vessels, artery and vein. I suggest that you should always start this dissection from the mesenteric vein. We open this space a little bit and very gently. As you can see, now we have found it and we prepare this dissection from medial to lateral, from down to up. Usually, around the artery there is some lymphatic tissue. Now we have the artery; see the difference in colour between the artery and the lymphatic tissue. I guess that might be a little nerve going into. Now I have to connect the intraperitoneal space of the artery with the artery’s extraperitoneal space, and all the extraperitoneal structures are behind this plane. Do you think that by opening the angle, we can be safer or not? For the nerve, I think that it is much better to go this way, and we have to arrive under the left colon. Now we arrive behind the left colon. The big problem is that when you see people with good experience, they don’t do that anymore. Normally if you place counter-traction, the person who is operating has the grasper down and the assistant has the grasper up in a triangulation; that is disappearing, now you go for one trocar sigmoidectomy and all these good principles are disappearing in order to have fewer trocars and fewer instruments. We are going to complete the dissection, but we have to watch the pancreas, which is here. We have to mobilize the splenic flexure completely from the lower edge of the pancreas. Always do the dissection of the vein under the lower edge of the pancreas. The mobilization now goes this way. Here we have the vein, here we have the mesocolon that I lift: this is the passage under the lower edge of the pancreas. We are arriving at the end of the pancreas. We are on the tail of the pancreas now. This is a very beautiful anatomical demonstration. We now put the gauze sponge on the pancreas to be sure that we don’t injure it during the last step. We go to the monk line to prepare the dissection of the parietal gutter. As you can see, the pneumoperitoneum helps you in this dissection. The posterior preparation is the better solution to avoid injury to Gerota’s fascia. The gas pressure is at 12. I think that after this dissection the splenic flexure is completely taken down. We can see very well the pancreas undamaged. We leave the gauze in the pelvis. I don’t see any signs of a tattoo, but sometimes it happens. But in this case, we have two clips on the site of the polyp, we can check later. We are now approaching the mesorectum’s fascia. How are you going to locate these clips? I think it is impossible, perhaps with a good echo-laparoscopy, it is possible and sometimes it is difficult even with echo-laparoscopy. I don’t know if it is useful because now we dissect the rectum at 15cm from the anus, if we have or not the clips. This is the rectal artery. Those are the superior rectal vessels divided into two I think and that is the right one you see there. The Ligasure device would be an option there. Yes, but I did not use the Ligasure in this case. That’s the left branch of the superior rectal artery in the mesorectum I think. In the old days when we took something, we thought was the middle rectal artery coming from the internal iliac, it was very often that we were barrowing into the mesorectum and really dividing an intra-mesorectal artery, leaving big chunks of mesorectum behind. We are ready to put the stapler and do the rectoscopy, but only at 20cm to be sure that we don’t leave the clips in place.