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Laparoscopic sigmoidectomy for cancer

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Laparoscopic   sigmoidectomy   for   cancer

作者群
J Leroy, J Marescaux
關鍵字
rectum,operation,laparoscopy,abdomen,perineum,resection
媒體類型
期間
24'00''
刊物
2003-11
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Nov 2003;3(11).
URL: http://www.websurg.com/doi-vd01en1519e.htm

Laparoscopic   sigmoidectomy   for   cancer

1. Case presentation 00'12''
It is another unusual case, in a very slim patient. The pubis is here, the xiphoid angle here, the umbilicus here. Midline, two other vertical lines, the left mid-clavicular line and the right mid-clavicular line and another horizontal line at the level of the umbilicus. I introduce my first port in the supra-umbilical area, it is port A, then I introduced another port at the crossing between the horizontal line through the umbilicus and the right mid-clavicular line, it is port B; the port C was introduced on the same vertical line 8 to 10cm under the previous one, port B. I chose to introduce under visual control to avoid the adhesions of the caecum, it is a 12mm port, the port D is on the left at the crossing between the left mid-clavicular line and horizontal line through the umbilicus. I introduce through the supra-umbilical area where I will do the extraction of the specimen so I don’t hesitate to introduce a 5mm port to expose the mesosigmoid. If I have to introduce another port due to exposure difficulties particularly in obese patients when I have a small bowel falling in the operative field, I will introduce it here under the right subcostal area on the mid-clavicular line. I introduce a grasper or retractor here and I push the small bowel behind my trocar and maintain it laterally. I also use this trocar to expose the splenic flexure and to work, but in this case as you will see, it is not necessary, I have a long sigmoid loop, and no difficulties to perform the anastomosis, it is really for beginners, it is not usual to have this kind of patient. I introduce a grasper in port D on the left and first I will push the omentum, not a really fatty omentum; you see it is a very dilated bowel, colon, so we will have no problem to introduce a big circular stapler. I push my omentum cephalad above the transverse colon, no problem here. This is probably the pancreas, I will now retract the small bowel laterally to the right. We place the patient with his head down with a right tilt, so we are also using gravity and I push laterally. Really it isn’t a fatty patient, it’s an easy case. In order to obtain maximum safety, do you think it is better to use open laparoscopy or a Veress needle? It is faster to use, particularly in this case, open laparoscopy because you perform a small incision, you incise the aponeurosis and you are immediately in the abdominal cavity. It is a mini-open, it’s not a wide open like Hasson’s with a specific trocar, particularly with a Step-trocar we have the possibility to introduce a Veress needle with a sleeve we can dilate, it is an expandable sleeve. I continue to retract the small bowel loop laterally to the right, loop after loop,;when you retract a loop, you take it not too far and push it above the previous one, I usually use two instruments to do that, but it is so easy here that I don’t need to do that. It is not necessary to use another trocar here but I will use this trocar for exposure. It is really a long loop, as you see the sigmoid loop is in the pelvis, the polyp is here. I can feel it is rigid when I push down. I have preserved the adhesions to maintain the caecum fixed to the right iliac fossa, we have the iliac vessels, we have the ureter here, we can’t see it, I think it is here but I am not sure, yes it is moving. The umbilical artery, left, we have grasped and lifted anteriorly to the left the meso not the sigmoid, same as in fatty patients, to use the meso as a retractor and I maintain the sigmoid loop laterally and to the left. The iliac vessels here, the aorta, we can probably see the vena cava here or it is just behind, a fibrosis here, the promontory is here. I will perform the approach at the origin of the inferior mesenteric artery using scissors. I think it can be very dangerous to make the colonoscopy during the operation especially if the polyp is before the left angle, because then the air is trapped and doesn’t go out. We had the experience of that and we couldn’t do laparoscopy because of the air. What you can do with Chinese ink is to do it 2 days before, and I would like to ask Joël why he doesn’t do it 2 days before the operation. Or the day before, but I don’t agree because I have performed intraoperatively, you have to change your gastroenterologist! it is a problem of organization. If you do this 2 days before that it is good using ink, but sometimes you have ink in the abdominal cavity. I agree with you, we don’t use methylene blue because otherwise everything is blue, but with Chinese ink it’s temporary. I think that with the application of the clamps and careful colonoscopy that it is a very viable thing to do even in the right transverse colon, so we use liberal intraoperative colonoscopy with the clamps and the key thing is not too much air being put in and it takes a very good colonoscopist, preferably someone on the surgical team. For left and right colon. Really the problematic identification of smaller tumors is actually in the hepatic flexure and ascending colon, at least in Texas, the gastroenterologist can be off as much as one flexure, so they say it’s in the hepatic flexure and it’s really in the splenic flexure. If we can’t see the tumor, feel it or haven’t been able to see it on the barium enema, we don’t hesitate one second to do an intraoperative colonoscopy. As far as fixation of the patient is concerned to the table, we do fairly rigidly fix the patient, and I think maybe the reason you had the problem with the popliteal artery thrombosis was that you were defending too much on your knees to hold the patient in place whereas we tape the shoulders to keep any slippage and then double pad the knees, in over a thousand cases we’ve yet to have one solitary problem, I think it’s a matter of if you are going to fix the patients, fix them well, if you are going to do a colonoscopy like we do then it is very important to probably have better anal access, particularly if you are going to do a trans-anal extraction like we would do many times. Here we have the aorta, the origin of the inferior mesenteric artery is here. As you have seen, we have incised the peritoneum first, only the peritoneum, we lift anteriorly, so we have pneumodissection. I am dissecting slowly, I have the superior rectal vessels, I know that in Japan perhaps for this kind of tumor they would try to keep the superior rectal vessels but I will not do that here. These are branches of nerves, I cut laterally. What is the diathermy setting for this operation? Yes, I use coagulation or section, small coagulation, 25 Watts is too much here because it is a very slim patient. I use as a hook, coagulation, cut. The danger is the plexus here, you have seen the ureter moving. We change our grasping technique, in this case we can keep the left colic vessels but it’s not really necessary. We’re at the origin of the artery, the plexus is behind, you see the plexus to the left. Joel, are you going to take down the splenic flexure? No, not in this case. Anti-plexus branches between the superior and inferior mesenteric trunk. Do you spare the left colic artery? No, not today, but I will show that you can. I want to show that you can seal, because until now I have only used scissors. Could you explain where your instruments are and what they are doing? I want to show you the plexus branch, I cut, I don’t seal. We have the plexus trunk here, we have the branches that are going to the left, I cut, I don’t seal but it is an error. I have cut an artery by going too far, suction. Cutting without sealing was a small error. Can you explain the choice of your instruments, you are working with scissors and the Ligasure, some work with just Ultracision, why this choice? I am sure that the standard will soon be the use of the Ligasure because it is so easy to reproduce surgery with this instrument. It is not a fatty patient so you will not see the interest here. Now I have just found the plane behind, you see the Toldt’s fascia is here, behind that there is the mesocolon. Is this instrument easier to use than the Harmonic scalpel? No, it is not the same principle. It takes longer to use here and it is not sure that you have a perfect hemostasis. The temperature around this is 35 degrees Celsius. I think you have to make a choice if you use Ultracision and Ligasure, it’s much too expensive, either use Ultracision, then clip the bigger vessels. Usually you keep Ligasure for bigger vessels, then you go with scissors, but dissection with scissors is more difficult than with Ultracision. The diameter is 10mm but it is well adapted, but you have the same in 5 or 3mm. I think we have 2 aims in surgery: maintain our field very dry and avoid any lymph node capsule rupture, so if you are in the right plane, you can use both Ultracision and the Ligasure Atlas safely. You see there is no danger, I am putting my blade against the bowel and there is no danger, I can put my finger against it. One of the most important facts for cancer is to have very stable trocars, especially the 5mm ones, do you have a trick for that? Yes I use the Step-trocar, I use a small needle for the 10mm like for the 5mm. It seems very easy to free the sigmoid over there, but in practice, it’s maybe more difficult, do you feel or see where the exact cleavage plane between the sigmoid and the mesosigmoid and the vessels? Well yeah, I have the feeling. Due to the size of the instrument, you slide on the structures around and particularly the sigmoid. If I do that, I will not take the sigmoid because of the size of the instrument; if you have a 5mm, you will cut more. How do you choose the distal section like you have? It is not sigmoiditis, so it is not a problem and I have seen that I can put a clip on the polyp. Why don’t you irrigate before cutting the rectum? Yes we can, I did, not always, I don’t because Jacques Marescaux don’t believe in that. I am far from the tumor, when I am very close I do. One of our experts found a recurrence of tumor even in the colonic pouch in 5 cases and this was quite far from the tumor. It is a very small procedure, it takes about 5 minutes and I think, even though we don’t have a scientific proof it’s helpful, that it can do something. I have chosen here to do a minimal anastomosis, for cancer normally it’s 10cm above the tumor. But in this case, it is more because it is a long loop. I have chosen here the limit that is here, I will probably perform the transection here so I grasp the bowel here and try to push, I will have to mobilize a little. I think we can probably resect 5 to 10cm lower. Now I am dividing my meso, you see my instrument is in this direction so I ask my assistant to change the exposure of the colon. I have this target and divide the meso step by step. About the blood supply, are you taking the left colic, what vessels are you taking and what are you leaving behind? The vascularization is performed by the marginal artery and vein, if it is not the case, I can keep. I show you what we do as a standard in Europe, and in France. The French association has shown that for sigmoid adenocarcinoma in a randomized study, if you cut after the left colic or at the origin there is the same prognosis. So it think you should first just try to keep it if you can, and then if the left colic is causing any problems to go down to the rectum, I think you can cut it at the base and I don’t think you will have any vascular problems, these are logical steps. I don’t keep a vessel until I am sure that I either have to cut it for oncological reasons or I have to cut it because it doesn’t let the colon go down. I would like to repeat that laparoscopy is not a new surgery, it is a new approach for the same surgery. You can do a sigmoidectomy as you do in open, you can do a left extended colectomy, it depends on the volume of resection you like. But you can do everything, you can spare the left colic, you can cut it, you can do everything because the procedure inside is the same. Now I incise in the suprapubic area, perform a small incision, I can reduce the length of my incision because I will use a double protection. I have introduced a grasper here, I introduce my finger too and increase the size, I need the inside picture, I then install the drape. We place the specimen in an Endocatch bag. We perform the closure now. We use a double protection. We have to find the colon and pull it outside. We can have a pressure particularly when it is bulky. The polyp is coming now. We now need to find the proximal part of the colon. I have to complete my mobilization. Do you think that this bag is mandatory for cancer or not? Through a study, Michel Gagner found that cells can migrate from the plastic through high pressure. That is why it is necessary to incise enough but as you have seen, I use a double protection on the abdominal wall and I think it is better and it try to avoid high pressure into the bag. I think it is mandatory to use a wound protector and a bag to extract the specimen, it is elegant to see but I don’t think it is mandatory except for T3 tumors. I have assisted the work of Larry Whelan, it was a demonstration that it is dangerous to use hand-assisted laparoscopy because there is a rate of contamination of the abdominal wall in the learning curve that is very high, as for laparoscopy in the beginning. That means that it is not only the protection that is useful but also the technique. If you have a protection and you operate for 8 hours, then it is not really good in the technique. I think it is enough for this case, now I pull the colon through the suprapubic incision with the meso, I now apply the purse-string. We have finished introducing the 34mm anvil and we reintroduce it in the abdominal cavity; now we lift the drape anteriorly and the ring is as you see pushed against the posterior wall. I clamp with this to have a good pressure and compression between the posterior abdominal wall and the anterior abdominal wall. I have a perfect patency. We have introduced the stapler into the rectum. I now have to introduce this, I choose the orientation of the stapler with my grasper. I control that there is no twist and no tension. Remove, pull and do an air test too. Suppose there is a very small air leak, what do you do? I have only had 2 cases in 10 years, and in 1 case I performed a new anastomosis, in the other I realised anterior sutures with a stapler, it was a wide anastomosis and I did with two sutures to lift and completed with linear sutures. If there is a high risk of leak, do not hesitate to do another anastomosis and to protect, it won’t avoid the leak but it is less dangerous. Air test, I clamp now on the promontory and we insufflate as you have seen, no bubbles. I remove the trocar in the sleeve and check that there is no bleeding.