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Laparoscopic sigmoidectomy for T3N2M1 sigmoid cancer

Introduction: This is the case of a 65-year-old gentleman who presented with blood per rectum (PR) and symptoms of subacute obstruction. He was diagnosed with a stenotic invasive adenocarcinoma at 15cm from the anal verge and with liver metastases. After discussion at our multidisclipinary meeting, he was recommended to undergo palliative chemotherapy in the form of FOLFIRI and Avastin. Unfortunately, his symptoms of subacute obstruction worsened and it was recommended that he undergo a palliative resection. Methods: He underwent a palliative Laparoscopic Anterior Resection (LAR). Professor Armondo Melani utilized a 4-port technique with a 10mm umbilical optical port and 3 by 5mm working ports (2 on the right-hand side and one on the left). He used a medial to lateral approach starting with the splenic flexure takedown. This was achieved by entering the retroperitoneal plane cephalad to the inferior mesenteric artery (IMA) and inferior to the inferior mesenteric vein (IMV). Once the correct plane has been entered, the IMV was skeletonized and divided with a Ligasure® vessel-sealing device. The lesser sac was then entered superior and cephalad to the IMV, superior to the pancreas and to the left of the middle colic vessels. This novel approach allowed for easy identification of the pancreas and retroperitoneal mobilization of the mesocolon from the pancreas. The lesser sac was then entered above the transverse colon, the omental attachments divided and splenic flexure mobilization completed. The retroperitoneal plane was then entered caudally to the IMA, which was subsequently skeletonized and divided after identification of the left ureter and gonadal vessels. The rectum was then mobilized to >5cm below the tumor, the mesorectum divided, the rectum transected with an articulating linear stapling device. The specimen was delivered through a Pfannenstiel incision (with a wound protector). The specimen was transected and the anvil of a circular stapler inserted into the proximal colon with a purse-string suture. The colon was returned to the abdomen and the colorectal anastomosis was completed with the insertion of the circular stapler transanally.

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Laparoscopic   sigmoidectomy   for   T3N2M1   sigmoid   cancer   

作者群
A Melani, J Marescaux
摘要
Introduction:
This is the case of a 65-year-old gentleman who presented with blood per rectum (PR) and symptoms of subacute obstruction. He was diagnosed with a stenotic invasive adenocarcinoma at 15cm from the anal verge and with liver metastases. After discussion at our multidisclipinary meeting, he was recommended to undergo palliative chemotherapy in the form of FOLFIRI and Avastin. Unfortunately, his symptoms of subacute obstruction worsened and it was recommended that he undergo a palliative resection.

Methods:
He underwent a palliative Laparoscopic Anterior Resection (LAR). Professor Armondo Melani utilized a 4-port technique with a 10mm umbilical optical port and 3 by 5mm working ports (2 on the right-hand side and one on the left). He used a medial to lateral approach starting with the splenic flexure takedown. This was achieved by entering the retroperitoneal plane cephalad to the inferior mesenteric artery (IMA) and inferior to the inferior mesenteric vein (IMV). Once the correct plane has been entered, the IMV was skeletonized and divided with a Ligasure® vessel-sealing device. The lesser sac was then entered superior and cephalad to the IMV, superior to the pancreas and to the left of the middle colic vessels. This novel approach allowed for easy identification of the pancreas and retroperitoneal mobilization of the mesocolon from the pancreas. The lesser sac was then entered above the transverse colon, the omental attachments divided and splenic flexure mobilization completed. The retroperitoneal plane was then entered caudally to the IMA, which was subsequently skeletonized and divided after identification of the left ureter and gonadal vessels. The rectum was then mobilized to >5cm below the tumor, the mesorectum divided, the rectum transected with an articulating linear stapling device. The specimen was delivered through a Pfannenstiel incision (with a wound protector). The specimen was transected and the anvil of a circular stapler inserted into the proximal colon with a purse-string suture. The colon was returned to the abdomen and the colorectal anastomosis was completed with the insertion of the circular stapler transanally.
關鍵字
Laparoscopic sigmoidectomy, T3N2M1 sigmoid cancer
媒體類型
期間
28'08''
刊物
2011-12
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Dec 2011;11(12).
URL: http://www.websurg.com/doi-vd01en3540.htm

Laparoscopic   sigmoidectomy   for   T3N2M1   sigmoid   cancer   

3. Beginning of mobilization 01'43''
I’ll now look for the vein and we’ll expose the vein. My auxiliary grabs the vein for me and you have this kind of exposure. Finding the retroperitoneal plane is not so difficult. Armondo, if I see things correctly, you’re trying to make a window inside of the meso, is that correct? Exactly. I’m looking for the retroperitoneum. Here we’re working with a 30-degree scope. So you’re working medial to lateral, correct? Yes, medial to lateral. And you’re above the sacral promontory? And you can see here, you’re cephalad to the sacral promontory, correct? Yes. I just release here and then down the promontorium to ligate the artery because probably you don’t need to take down the splenic flexure. You can see the plane here. I’m pushing the kidney down, going to lateral as much as I can. I release the mesocolon in this position. That’s a difficult place to get a good exposure because the small bowel always wants to obstruct your view. Yes, we put the patient in a right lateral tilt about 25-30 degrees; sometimes we can use a compress to help us and stop the bowel. We cannot go so high here cephalad because here we have the pancreas. We follow this plane. We will raise up the pancreas. We don’t need to do that and so we go to lateral, just lateral as you can see here. That’s a great point because especially in someone with a lot of fat, you can easily accidentally get behind the pancreas in that plane if you’re not familiar with the territory. Here’s the pancreas. You’re going here, and it’s OK now for me.
6. Mobilization of mesocolon from pancreas 05'48''
We can see here the plane of the pancreas. We’re going to the lesser sac. I will change the position of my auxiliary to grab here and so we can see here the plane we’re following. I now use a gauze to help me and compress, to help me expose this area. And now we’re going to the pancreas. The danger of this is that you have to be sure that you don’t get your mesentery. Exactly. We have to be careful here and look for the plane and avoid any lesion in the marginal arcade. Because if you stay in the wrong plane here, you lose the colon and so you probably need to extend your surgery. And what I prefer to do is not to entirely detach the splenic angle here. I prefer to go in the upper side when I can show you. Like Armondo does, if you begin by the median way, you try to go as far as you can as long as you feel secure and you recognize your planes. It’s not very frequent that you can do all the angle by this way. It seems that you have some adhesions on the omentum. Now I release the greater omentum and now it’s easier to find the pancreas, and everything is down and we don’t have much risk here. The question is you are faced with some dilatation, did you observe some dilatation of the colon? Yes, just a little bit. So it seems OK to make this case elective, it’s perfect. Do you use stent if you have obstruction? Yes, we do, as a bridge to surgery. Actually, that’s one of the good indications for the stent of this left colonic obstructive cancer. You put a stent, you des-obstruct the colon and then you go for elective surgery. That has become pretty standard now. Again this is the lesser sac and that’s the plane.
8. Sigmoid mobilization 10'01''
And now we’ll change the position and we’ll start grabbing the meso, the sigmoid and to see where the artery is. Can we see where the tumor is? Yes certainly. The tumor is here. It’s down there. Just on the corner. And there’s a huge sigmoid loop in this case. Exactly. Here we can follow the vein. The vein is here. And probably the artery will be here in this position. We’re going here parallel to the aorta. Things that can happen when you try that is that sometimes the left colic artery is not from the IMA but it can be from the left renal and we can have a very low branch from the left branch of the middle colic and come over towards the flexure, so there’s a few things you have to be aware of. I am hoping that the pneumoperitoneum and the gas will help me find the correct plane. I need to avoid here the nerve lesion, and again I lift it up, just lift it up, do not grab the tissue. And another very important thing: just lift it up, do not grab the tissue because if you grab, you will make an injury and it will start to bleed. See the nerves here. Go in to the meso, we can ligate here, just in this part. I’d like to ask you: why did you change your strategy? Because following the vein, you see I’ll find the artery. Now that you’ve changed your strategy, you’ve passed from down to up. First because when I have residents to teach, we look for the easy way to start the surgery. It’s easier for them to find the plane between the vein and the artery and so we decide to start in the vein because it’s easier. It’s easier to teach, it’s easier to find the plane, and here to look for the plane, join the artery –it’s a little bit more difficult for them. And doing this in the beginning of the surgery, we can help them become more skilled and more confident. And because of that we changed our way to start the surgery.
9. Division of IMA 12'49''
I see that you’re clearing off the inferior mesenteric artery. Have you shown us the ureter yet? I think the audience would benefit from having to know just in case. Because in case you’ve got a little bit of bleeding, it’s nice to know where not to grab. Look, I’ll show you. No, not that deep. It’s here, we see it. Yes, here it is. And now the gonadal vessel is behind the ureter. I’ll now prepare the artery, and you can see we have adhesions here between the nerves and the artery. I’ll just prepare here a dissector. You have very nicely dissected down the hypogastric nerves—if you could show the hypogastric nerves now to the audience, that would be great. You can see here one of the nerves. Yes. I’ll try to divide. Here’s the artery. Please give me a dissector. You’ll first prepare here the right branch. It’s nice to see what you do. And I want to say that what you are doing is very important. Sealing the surrounding tissue with a lymphatic inside, because if you don’t use this technology, harmonic or Ligasure™, if you only cut with monopolar at this level, the danger is to have a postoperative injury. Using a monopolar to open the peritoneum is not a problem but what you are doing is very important in oncology. And here we have the artery. And now, less traction and Ligasure®. I think once again you said something important: “less traction”. When you use the Ligasure™ and you want to cut the artery with the Ligasure® you have to avoid the traction, otherwise it’s not enough. But in this case, you have seen how important it is to be cautious. Another thing for which you have to be cautious here is the patient has a lot of arteriosclerosis and calcification, so it cannot be safe to cut it with the Ligasure®. Now I have here the left branch of the nerves, and now I can cut the left branch. And now we will prepare the meso, to take it down, the entire meso, and the ureter and everything going medial to lateral.
10. Completion of mobilization 16'01''
And then you go back to the plane you just chose before. Exactly. We sometimes use clips, sometimes the Ligasure®. We used to use staples, but for us in Brazil it is very expensive, it’s about 900 dollars for each cartridge, so we cannot use this routinely. But the important message to use with staplers is to always find the ureter, because you have a massive ligation, and so you must find the ureter before doing a ligation of the artery. How about using the Harmonic® scalpel to take the IMA on the aorta? That scares me, but I know that there are people that do that”. Don’t do it, it is dangerous. Another reason is the temperature of Harmonic®, not only between the jaws but around all the metallic part, the temperature is not 80, it is 263 degrees. So close to the nerve, there is a danger. And we see the difference between a surgeon using Harmonic® and another using Ligasure® because surgeons using Harmonic always use traction to go faster, and they are applying traction on the nerve as well, and it is dangerous. You now have what I’m guessing is the promontorium. Yes, quite there. Is there a tattoo on your target? Do you know where the tumor is? No. But you see again the movement is from up to down just to push back the posterior sheet, so that the retroperitoneum remains protected with the ureter in it. You see now the vessel. The retroperitoneum is open at this point, so it means you have to be absolutely sure of where the ureter is. Now we go to the lateral. Reverse, what is your patient’s position? Yes, in Trendelenburg. Usually in reverse with the right side down, and as you go to the pelvis you’ll actually go into a Trendelenburg. Look this exposure, and now. You connect the two dissections very nicely. Exactly. A lot of people are convinced with your approach now I think. Thank you. Can you show us the kidney down there? We discussed that before. Yes. You see the plane here? Yes. This is the superior part of the kidney, if you go too deep on the right side you will be in the back of the kidney, be very cautious. In the left side of the pelvis, we are going down. Yes, we see the iliacal vessel on the left side. Someone used to say in the past that we lose our feeling with laparoscopy. But when we start to do laparoscopy we can feel with our forceps how the tissue is. We can look for the right planes and we can go on without problems. We have here normal tissue, normal planes, that we can go easier, and now I change my position. I put the patient out of the lateral position. We can see here the tumor. I need to avoid here lesions of the branch of the nerves. You want to preserve the nerves but on the other hand the most important thing is clearing the cancer. Most of our patients have been irradiated, many of them, so there’s also that issue. The key thing is you want to get the entire mesorectal envelope and the plane and as Mark was saying when you get in posteriorly, it’s easiest to get in there. Armondo how distally in this tumor do you intend to go? 5cm. That’s approximately the end of your dissection Armondo is that correct? Exactly, I just need to divide here. Can you give us some tips on retraction anteriorly?
11. Rectal mobilization 21'01''
My assistant helped me here placing the traction from the sacrum to the interior abdominal wall, and now I am placing a traction to pull it out of the pelvis, and sometimes when we go down we cannot do this, we must tract in direction of the sacrum. I guess I tend to run into some bleeding anteriorly, maybe it’s not good for this case because you’re not quite as low. This looks very nice. The anterior part is going to be the trickiest part certainly in males, you want to stay, depending on if the tumor’s not anteriorly then you want to preserve Denonvilliers’ fascia. If you’ve had a hysterectomy, it can be very hard to find a vagina, so one thing we could do is put a proctoscope or something in the actual vaginal wall, if you get down there you can have an idea of where that is if you’re really lost. Armondo, I think you are showing us a very nice trick. Can you show us the avascular plane between the meso and the colon? He always goes inside just to prepare very narrow from the colon. This is avascular and he comes from the colon to the meso down. One thing you tend to do when you work laparoscopically is to not do enough posterior mobilization at your point of transection. So if you don’t clear up some of the mesentery like Armondo is doing here, when you go to put your stapler in, the stapler will go anterior, and it will not put your staple line where you want it, which is over the middle of the circular. I think this is a very important point. Here I am dissecting the rectum, the rectum wall is here, and now I can use this new 5 Ligasure® tip, which has the possibility to divide these tissues. Here we have a blunt tip, and so it’s easy to make this movement. The one thing that is scary with the tip when you are dissecting is that you can actually cause an injury. More careful, but then it could then damage the vessels. Not the grasper, the vessels it could be a problem. Any tip to be really at ninety degrees?