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Laparoscopic subtotal colectomy with ileo-sigmoid anastomosis for cancer in an elderly patient

Surgery in patients who have previously undergone abdominal operations is always difficult and the risk of complications is high. The objective of this film is to demonstrate a laparoscopic subtotal colectomy in an elderly female patient aged 89. This patient had undergone a laparoscopic right colectomy for cancer in previous years. The film also aims to show the possibilities of a laparoscopic re-intervention.

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Laparoscopic subtotal colectomy with ileo-sigmoid anastomosis for cancer in an elderly patient

作者群

J Leroy, J Marescaux

摘要

Surgery in patients who have previously undergone abdominal operations is always difficult and the risk of complications is high. The objective of this film is to demonstrate a laparoscopic subtotal colectomy in an elderly female patient aged 89. This patient had undergone a laparoscopic right colectomy for cancer in previous years. The film also aims to show the possibilities of a laparoscopic re-intervention.

關鍵字

Laparoscopic subtotal colectomy, ileo-sigmoid anastomosis, cancer, elderly patient

媒體類型

手術影片

期間

21'00''

刊物

2010-06

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Jun 2010;10(06).
URL: http://www.websurg.com/doi-vd01en2880.htm

Laparoscopic subtotal colectomy with ileo-sigmoid anastomosis for cancer in an elderly patient

1. Introduction 00'09''

The objective of this film is to demonstrate a laparoscopic subtotal colectomy in an elderly female patient aged 89. This patient had undergone a laparoscopic right colectomy for cancer in previous years. The film also aims to show the possibilities of a laparoscopic re-intervention. To do so, different ports are introduced.

2. Exploration of the abdominal cavity 00'46''

The abdominal cavity is explored to search for potential adhesions, which are found to the right of the previous extraction scar on the supra-umbilical median line.

3. Identification of the previous anastomosis 01'01''

The first operative step is to identify the right transverse colon and the previous ileocolic anastomosis, which represents the division limit defined to remove the entire colon. In this patient who had had a laparoscopic right colectomy, there are few adhesions to the omentum on the supra-umbilical median scar where the specimen had been formerly extracted. The ileocolic anastomosis is first identified. It is situated in the right hypochondrium underneath the right liver along the transverse colon that has got fixed into the right hypochondrium. Once the mesentery has been divided, the ileocolic junction is reached and the anterior aspect of the pancreas can be seen at this stage as it was the case in the former right colectomy procedure.

4. Freeing of adhesions 02'28''

Once identified, the ileocolic anastomosis can be freed of its posterior attachments in order to divide the ileum, which is in contact to the ileo-transverse anastomosis. About 10 centimeters of ileum will be resected after the mesenteric division. This will allow for the identification of the posterior insertions of the transverse colon.

5. Division of the terminal ileum 03'15''

Here we can see an Endo-GIA® linear stapler, which is applied to divide the terminal ileum and remove approximately 10cm of terminal small bowel in contact to the ileocolic anastomosis. The posterior attachments of the ileocolic anastomosis fixed in the right hypochondrium remain to be taken down. A medial approach is used since it is unnecessary to perform a lateral approach in the present case; the posterior approach allows for a perfect visualization of anatomical planes. The right hypochondrium and the root of the transverse mesocolon can now be seen.

6. Dissection of the transverse mesocolon 04'18''

At this time in the procedure, division of the transverse mesocolon’s root can be carried on in order to reach the middle colic vessels. As a reminder, this patient presents with degenerated polyps of the transverse colon, which will be removed in compliance with oncological principles. Therefore, the middle colic vessels are approached at their origin. The patient’s age is of major importance in this case.

7. Dissection of the greater omentum 05'10''

The greater omentum that is fixed to the colon and to the greater curvature of the stomach is resected. To respect oncological principles, it is essential not to manipulate the transverse colon where the adenocarcinoma is located. The transverse mesocolon’s root is therefore divided using a primary vascular approach not only to respect oncological principles but also to facilitate the division and avoid any excessive manipulation of the transverse colon. One can see that, using a medial approach, all the vascular pedicles can be divided without the need for transverse colon manipulation. The posterior attachments and attachments of the greater omentum can be further divided using a medial approach. Division of the greater omentum can be seen on the border of the greater curvature of the stomach using a caudal approach. However, this approach will be carried on laterally in contact to the greater curvature of the stomach as numerous adhesions can be found in contact to the gallbladder. It is recommended to continue this dissection using a superior lateral approach. Here the attachments of the greater omentum to the gallbladder are visible. These attachments must be divided without injuring the vesical wall. The attachments on the first jejunum are also divided and attention must be paid to avoid wounding the gallbladder. The detachment of the greater omentum from the greater curvature of the stomach is completed on the first duodenum. It is pursued laterally and to the left. The objective is to perform an “en bloc” removal of the transverse colon and of the greater omentum where many lymph nodes are located. As we are faced with a lesion of the transverse colon, it is recommended to remove the transverse colon, the vascular package and the greater omentum “en bloc”. Once the greater omentum has been completely detached from the greater curvature of the stomach, attention is turned to the descending colon. It must be emphasized that this 89-year-old patient does not present with any sigmoid colon lesion, but merely with lesions of the left transverse colon and of the splenic flexure, especially on their descending portion. Consequently, the decision is made to preserve part of the sigmoid colon and to remove the splenic flexure, the descending colon, and the proximal portion of the sigmoid colon.

8. Division of the left colic vessels 09'30''

The left colic vessels are divided using the 10mm vessel-sealing Ligasure® Atlas® device. The medial approach is then continued from caudad to cephalad until reaching the space anterior to the pancreas. In the meantime, the prerenal space is dissected using a medial access. A renal cyst is found. The transverse mesocolon’s root is then divided just above the duodenojejunal flexure until the lesser sac is opened. This is the landmark for the division of the transverse colon’s root anteriorly to the pancreas. This detachment, now performed using an inferior medial approach, must be carried on by staying anterior to the pancreas to avoid any injury to its body or tail. The division is achieved using the Ligasure® Atlas® device, which is a very helpful instrument when taking fairly large vascular and adipose bites. Laterally, the greater omentum is further detached from the diaphragm towards the splenic flexure. Laterally, the diaphragmatic attachments are divided. Additionally, during traction, caution must be exercised to identify the attachments to the spleen and particularly to the splenic capsule that would be at risk of rupture. The division of the transverse mesocolon must be continued by staying on the anterior aspect of the pancreas and by progressively lowering the splenic flexure. Using caudal traction, the posterior attachments of the splenic flexure are divided. This represents a lateral approach to the mobilization. At this moment, the descending colon is attached only by its posterior attachments, anterior to the kidney. Here a voluminous cyst of the kidney’s inferior pole is visible; it will be respected in the present case.

9. Dissection of the descending colon 13'12''

The dissection is carried on anteriorly in order to avoid any renal injury until reaching the Toldt’s line running laterally. This line represents the lateral limit of the descending colon’s fixation. This lateral attachment of the descending colon may be freed using a posterior medial approach, but also using a lateral approach. Here we can see the end of the division of the Toldt’s line through a posterior approach.

10. Dissection of the sigmoid colon 14'13''

The freeing of the sigmoid colon can also be performed using a lateral approach. Once again, the benefit of using the Ligasure® Atlas® device here is demonstrated. This instrument allows for large and effective bites and ensures an adequate hemostasis, particularly interesting in adipose tissues. As mentioned earlier, due to the patient’s age and to the absence of polyps in her sigmoid colon and of suspicious lesions in the lower part of her descending colon, the decision is made to preserve the distal portion of the sigmoid colon. This portion seems in a healthy condition to avoid major functional disorders. As a matter of fact, the total resection of the colon may be followed by episodes of diarrhea and functional disorders that can be avoided by the preservation of a distal sigmoid colon segment.

11. Anastomosis 15'45''

An ileo-sigmoid isoperistaltic side-to-side anastomosis can now be performed intra-abdominally. The anastomosis will be created using two fixation stitches of Ethibond 2/0. They will allow for the perfect positioning of the two bowel segments before stapling through mechanical sutures. The second stitch allows for a proximal fixation on to the colon and the small bowel in order to obtain an isoperistaltic side-to-side anastomosis, which is, in our view, much more functional. Once the two landmark stitches have been placed, the colon is opened on its anterior aspect close to the anterior taenia. The small bowel is then opened; the incision should be sufficiently large to allow for the anvil’s introduction into the colonic lumen; similarly for the small bowel, the digestive lumen should be perfectly visible in order to avoid any false passage. The blue-colored, rigid part is first introduced. The bowel segment is then positioned running parallel to the stapler in order to allow for a mechanical side-to-side anastomosis. The orifice will then be closed using a suture that will also allow for the enlargement of the stapling area. The objective is to perform a complete suture of the opening along the extension of the stapled area. The use of Maxon® 3/0 monofilament material allows for the placement of several stitches before traction is placed. Indeed, monofilament slides well and sutures are therefore easy to perform. This is a time-saving method since tractions generated each time the thread is passed are avoided. Here, we can see a second suture originating from the lower angle reaching the earlier cranial to caudal suture until achieving a final stitch that will be attached to the previously performed suture. Here the end of the suture is visible. It has been achieved by two half-running sutures stitched medially.

12. Completion of the resection 19'35''

Once the suture has been completed, the distal stapled area on the colon and on the small bowel may be buried. We do not make it a principle to carry it out. However, it could have been done through a mini-incision, which would have shortened the operative time. Similarly, the ileo-sigmoid anastomosis could have been performed through the suprapubic mini-incision. Once the colectomy and the ileo-sigmoid anastomosis have been completed, it is recommended to conclude the procedure by closing the mesenteric defect and by resecting the specimen. The extraction will be carried out through a suprapubic mini-incision.