Laparoscopic treatment for right colon cancer

This video demonstrates an uncomplicated laparoscopic right hemicolectomy in an obese lady with cecal cancer. The surgeon uses 4 trocars to achieve medial mobilization of the mesentery, divide the ileocolic at the root and then mobilize the right colon up to proximal transverse colon. The terminal ileum is divided intracorporeally and the specimen is retrieved through a right lateral skin crease muscle splitting incision. An extracorporeal stapled anastamosis is made and the mesenteric window is not closed. This video is a good demonstration of key anatomic landmarks, surgical planes, and surgical approach to a right hemicolectomy for cancer using the medial approach.

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Laparoscopic treatment for right colon cancer

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Abstract

This video demonstrates an uncomplicated laparoscopic right hemicolectomy in an obese lady with cecal cancer. The surgeon uses 4 trocars to achieve medial mobilization of the mesentery, divide the ileocolic at the root and then mobilize the right colon up to proximal transverse colon. The terminal ileum is divided intracorporeally and the specimen is retrieved through a right lateral skin crease muscle splitting incision. An extracorporeal stapled anastamosis is made and the mesenteric window is not closed.
This video is a good demonstration of key anatomic landmarks, surgical planes, and surgical approach to a right hemicolectomy for cancer using the medial approach.

Classification

routine cases

Keywords

cecal cancer,right colectomy,medial approach, stapled anastamosis, colectomie droite,laparoscopic approach

Media type

Surgical video

Duration

21'00''

Publication

2006-01

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E-publication

WeBSurg.com, Jan 2006;6(01).
URL: http://www.websurg.com/doi-vd01en1879.htm

Laparoscopic treatment for right colon cancer

1. Trocar placement 00'11''

This lady is quite obese and she’s having a right hemicolectomy for cecal carcinoma and the first 12mm port above the umbilicus and then further 12mm ports, one in the left iliac fossa and one suprapubically right upper quadrant which will subsequently get converted to a mini-laparotomy for the specimen extraction and extracorporeal anastomosis. I’ve grasped the fat pad on the cecum and I am pushing the cecum towards the right iliac fossa.

2. Exposure 00'42''

And what that does is tent up the ileocolic vessels as you can see. The transverse colon is quite low in this lady and it’s very full of gas and doesn’t really want to stay out of the way. The duodenum is just here. So we’re going to divide the ileocolic vessels approximately at that level. So first of all, we need to get a bit more of small bowel out of the way. She’s actually a maximum lateral tilt towards me but despite that, she’s got really a lot of quite dilated small bowel and quite dilated transverse colon as well and that’s really not helping matters very much. So we may need to put another port in just to keep the bowel out of the way but we’ll see how it goes. So I’m operating through the suprapubic port and the umbilical port. Then I push up the ileocolic vessels -- there’s usually not much room here.

3. Vascular dissection/Medial approach 01'38''

I’m going to make an incision parallel to the ileocolic vessels. I’m just going to push my instrument in and underneath the vessels and gently develop this plane underneath the ileocolic vessels. I’m going to make that window a bit broader. You have to be careful when you first start here with the position of the superior mesenteric vein which you can’t see in this lady because she’s so fat. It’ll be running along here in this direction. You don’t want to damage any of the other retroperitoneal structures. I’m being as meticulous as possible in keeping it dry. There’s a lot more bowel in here because of a particular habitus and as we come more medially, we start seeing the duodenum and if you’re looking through the hole there, that’s the duodenum and that’s obviously a potential point of danger. The duodenum is here on my right so I know that if we cross the pedicle at this point we’ll safe. We’re just going to open the peritoneum over the top now. Obviously in this circumstance we’re being very careful. So very unusually actually and partly because of obesity we put a further 5mm port in the right iliac fossa to help suspend the transverse colon out of the way. The problem we’ve had is when we put the head down, the transverse colon goes out of the way but the small bowel makes an appearance. So what we’ve done here is put a fairly flat if anything a little bit in a head up position to keep the bowel out of the way and there you can see that little window that we’re making from the other side. So now if we look down into the hole, we see the duodenum well out of the way and we have the vascular pedicle. So what I’m going to do now is divide this vascular pedicle with an Endo-GIA. And that’s the ileo-colic pedicle done. We’re now in a position to extend down our dissection towards the terminal ileum where we’re going to divide it. It’s our next step. I’m going to use this swab to try and keep that small bowel out of the way and also to protect the small bowel from the Autosonix. So if some people would go up at this stage and try and divide the right colic vessel if indeed there is one I prefer to do this and effectively operate from below. The same fascial layer we’re looking for is not so clear in this lady – because she’s got quite that sort of fat that bleeds very easily. We’re trying to get into the right plane so that the ureter and the gonadal vessels will be behind us. So there’s often quite a big vessel in this area skirting around the terminal ileum and it usually doesn’t require anything other than ultracision, or Autosonix or Ligasure. You very rarely need to clip anything or staple it. So I’m going to drop that now and I’m just going to lift up underneath my left hand. Let’s try and get into that right plane -- it’s all without tension, this is the back of the right mesocolon and I’m just letting this tissue flow and fall away. I’m going to continue now head off towards the terminal ileum. Sometimes at this stage it is often necessary to move the retractor which is going through the right upper quadrant to help you delineate where your terminal ileal division is going to be. So you can see that this hole is the terminal ileal mesentery and that is the back of the cecum there. I’m just going to go through here slowly, quite a big vessel here.

4. Ileal dissection and transection 07'20''

So what we try to do very slowly is get there’s that window that I’ve just made on the other side. And right to the edge of the bowel wall, we’re now going to staple across the terminal ileum and I think life will be a lot easier. I think we can staple at that stage. So that’s the terminal ileum just going into the cecum there, we’ve come back a few centimetres from it. So that’s the terminal ileum divided now. I’m just going to cut through that last attachment. This bit is going to be exteriorized, saved, and trimmed when we did the anastomosis.

5. Colonic mobilization 09'35''

In my right hand, it’s the vascular pedicle. That’s the mesocolon to the cecum and over here the terminal ileum is flipped over above the cecum, and if we look down here this is where we have to go bearing in mind that our appendix is quite bound down. So I’m going to grasp the appendix. So now we’ve done the appendix. It should make a bit more sense if it hasn’t done already. So now we’re operating in a caudal cranial direction from below so we’re trying to get that Toldt’s fascia layer to fall down, that layer that you can see quite nicely. We’re gently passing the tissues. This part of the operation can very easily be done with diathermy. It’s usually pretty avascular. We haven’t seen the ureter but I don’t think we need to because we’re in the right plane. Normally we will see it in due course. This is clearly the back of the right colon. So we’re operating on quite a broad front here, just trying to keep in the right plane, just there. It’s quite subtle, getting into the right plane especially when there’s fat like this. In fact just gentle pressure and the plane develops all on its own but no real tearing as such because if you tear things they bleed so it’s very delicate. So we’re going up towards the hepatic flexure now from underneath, always moving the left hand in order to get the best view. You can come with the hepatic flexure from underneath if necessary. It’s a cecal tumor so we’ll probably need to come round here and medialize it in order to make a nice anastomosis on the transverse colon. One thing you do need to be wary of around here as you come round the top is the gallbladder. We’re a long way from it at the moment but I think this lady had a cholecystectomy so we don’t need to worry. But the gallbladder can suddenly make an appearance. It can be very disconcerting. We should see the duodenum coming into view now. There it is and again it’s just a question of being in the right plane it can always just peel off. You can often see the right colic coming across at this stage. All these ultrasonic devices get hot. I have a lower operating temperature in the diathermy but they get hot enough to damage bowel so whenever you’re doing this you can just make out where the plane is meant to be and that bit of fat gets down and that bit doesn’t. So I touch the fat with the ultrasonic to cool it down before just pushing the duodenum away. So now we’re making our way up towards the hepatic flexure from below. This is the kidney over here. So I’m pushing the cecum over itself. It will allow me to peel these retroperitoneal structures off the back. So this is kidney here. We’re just peeling it off. So we’re now moving more medially off the kidney. We’re going to take these hepatic flexure adhesions down. We’re going to go down from the medial side now. So we’re now underneath the right upper quadrant, well the hepatic flexure. So we’re careful not to touch the duodenum after I’ve activated. Here’s the back of the transverse colon and in this lady I’m a long way away from my port site. I think we need to take a little bit more laterally over the top. This is where I need to go through just to release the hepatic flexure. I’m right on top of the kidney here where we’ve been before from underneath. So we’re right on the liver back here. It’s just a question of dividing that thin stuff there. Just some scars from a previous cholecystectomy there. So now we need to find the appendix. That’s the cecum here. So we make most of the incision lateral so that we don’t need to divide the rectus sheath in any way.

6. Extraction 17'49''

Here’s the appendix. That’s the tumor. The small bowel is still up here somewhere. There it is; it’s just coming here. We use the scissors and Babcock forceps. We carry out the anastomosis.

7. Anastomosis 19'31''

Here we have a last look inside.