Live mentoring of laparoscopic right colectomy for cancer

The purpose of this video is to show the mentoring of a laparoscopic right colectomy routinely used in Professor Marescaux’s department of colorectal surgery. In this video, we see trainees assisted by Professor Leroy as first assistant. Professor Leroy demonstrates the technique in a step by step fashion, remaining faithful to the operative chapter written by himself and available on WeBSurg (Right Laparoscopic Colectomy; http://www.websurg.com/ref/search-ot02en335.htm). This is the last stage before telementoring, which we will show in an upcoming WeBSurg video.

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Live mentoring of laparoscopic right colectomy for cancer

Authors

J Leroy, J Marescaux

Abstract

The purpose of this video is to show the mentoring of a laparoscopic right colectomy routinely used in Professor Marescaux’s department of colorectal surgery. In this video, we see trainees assisted by Professor Leroy as first assistant. Professor Leroy demonstrates the technique in a step by step fashion, remaining faithful to the operative chapter written by himself and available on WeBSurg (Right Laparoscopic Colectomy; http://www.websurg.com/ref/search-ot02en335.htm). This is the last stage before telementoring, which we will show in an upcoming WeBSurg video.

Classification

basic techniques

Keywords

Live mentoring, laparoscopic right colectomy, cancer

Media type

Surgical video

Duration

30'26''

Publication

2009-09

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Audio

Subtitles

E-publication

WeBSurg.com, Sept 2009;9(09).
URL: http://www.websurg.com/doi-vd01en2657.htm

Live mentoring of laparoscopic right colectomy for cancer

1. Abdominal cavity exploration 00'17''

So today we are doing a right colectomy for a caecal tumor; it is a teaching procedure with an assistant doing one of his first procedures. We have chosen the same trocar positioning as described in the chapter and we will do the procedure as a mentoring. So we have chosen the position of the trocar and I will help you and you have to lead your team too. We start with the panoramic exploration of the liver because we have a doubt about a small metastasis. But we see nothing on the surface of the liver, same on the left lobe and under the liver as well.

2. Exposure of transverse mesocolon 01'28''

We will begin the procedure now and we have to expose using retraction of the omentum. This is the left subcostal trocar. I am doing that because we have seen where the mid-colic vessels are. These are the mid-colic vessels, we see them beating. We have to place traction after we have pushed the omentum above, maintaining the traction like this to expose, this is the first step: exposure of the root of the transverse mesocolon. Now we have to expose the ileocaecum some more, this is why I ask for a left lateral tilt.

3. Ileocaecal exposure 02'30''

We see the ileocolic vessels. I am grasping this to expose. What we have to see is the ileocolic junction not far from there, we have to see the ileum and the duodenojejunal junction. So this is the root of the mesentery and these are the ileocolic vessels. It is where you will have some adhesions, there you see, and you will begin dividing there because you will open the peritoneum slowly and you will probably cut there.

4. Peritoneal incision 03'19''

We lift some more, use your two hands, your left hand is ready. Your left hand is always ready, ok you can cut. Continue cutting the peritoneum. Close your instrument; so your landmark is the opening of the peritoneum like this in the direction of the forceps retracting only the peritoneum. We see the mid-colic vessels and you have the right branch crossing there. I think it is enough like this. You are medial to the mid-colic vessels, very good. Use it as a finger, like this, to dissect the plane. I am changing the grasping, your left hand is more lateral for traction and counter-traction, you are reaching the duodenum. See where the pancreas is, we can see the vessels very well, grasp this, we see the artery and vein, I think we will divide them separately. Open like this, this is a vein, check that there isn’t the pancreas behind. Ready, don’t retract the artery too much, ask your assistant to reduce the traction. Stop, open your Ligasure®, don’t cut, I will explain why. You were just before the mark and the danger is to not seal perfectly at this level. Do another sealing, you have to maintain the vessels between the two bars, ok now it is good. I probably have to change my grasping there to have a better exposure. You have to continue the division, this is the SMV just behind the Ligasure®, so you are very close when you divide.

5. Division of SMV 06'18''

This is the superior mesenteric vein. So you grasp there and you have to divide. This is the pancreas, so you have to separate the pancreas and you can now open and divide. We can complete, not too much, danger this is a big vein, go slowly and you will divide anterior to the vein like this. This is a gastrocolic trunk of Henle, divide please. You can only divide the vein, the gastric vein now and the colic vein we don’t know, we will see better. Yes maintain this and we change the grasping. The duodenum is there, continue the dissection of the duodenum to see the genus superius better, yes this is the genus superius, we have to see where it is, maintain this, this is the duodenum ok. This is the insertion of the omental, this is the pylorus. So you have to know where you will divide: you will divide this. Open and divide, ok. You see if you do that, you are not in a good position; you have to be between the two marks. Seal two times. You have to know where the pylorus is and stay anterior to the pancreas in the direction of the anterior aspect of the pylorus. You are not far, you see? This is why you need to know where it is. So we are dividing the omental vessels. This is the insertion of the omentum. We have the greater curvature, we have to continue the division in the direction of the forceps, that is not completely anterior. We have to put it anterior, let your left hand fall, and we continue the division of the transverse mesocolon, change your grasping, right in the direction of the forceps, lateral and right to it. This is the pancreas, this is the stomach.

6. Division of transverse colon 10'09''

Now you should continue the dissection close to the colon, open like this to free a little the transverse colon and you will use the Endo-GIA to divide the colon. You have to change like this and put your stapler perpendicular to the colon. If you consider that it is good, you staple, if not, you have to change. This is why you have to divide perpendicular to the colon. Now you continue your dissection, remember what I taught you, you will have problems. Don’t close completely, coagulate, you can lock, cut a little, not too much. It’s because there are staples. And now you can continue. Change your grasping, close your grasper because this is probably the omentum and you will have to do the de-insertion. Divide and grasp it with your left hand. We now have the stomach there, we have to catch this. We are dividing the attachments of the transverse mesocolon back to the hepatic flexure. We have to do it at this moment because we can see it very well, so we continue to do. This is the superior attachment. Ok we will come back later. You have finished the division, the strategy is good. Now we will do the division of the ileum first, you have to find the ileum, where is it? The distal loop is located here, this is the appendix, it is probably the ileum, we are not sure, yes it is.

7. Division of ileum 13'16''

We will divide at this level. Begin by a division of the ileum. I have changed the scope and put it in the supra-umbilical trocar. I think it is not the best technique: the best is to twist and to open now; because you have to keep a maximum of small bowel, and you divide now. Good division, and you now have to divide to reach the two-bridge, I think you will be better like this. You should grasp strongly and reach for this and this. In your mind, you have to remember that the duodenum is there. Show me where the duodenum’s plane is. You see it, it is here, you have the liver behind, you are back to the hepatic flexure. Continue the division that you did not finish before, back to the right transverse, pull more on the left. It is bipolar coagulation, it is not a Ligasure®.

8. Intestinal segment approximation 15'42''

We will fix the two segments together, you fix with two stitches. Open it, this is two centimetres, so you fix there. Remember that you want to do the anastomosis on the tenia. You have to make a suspension and fix a little anterior to the tenia. You will do a suspension, if you use a stapler, the stapler will be under, so you lift and you put under. If you want to have the stapling line on the tenia, you have to make the suspension. If you want to put you needle there, you have to change your grasping and do that like this because you are sure that it is not moving. You keep the colon long enough to be able to grasp outside, so very long. Ok do the other suture. A little too anterior but not too much, it’s good. You have to be close when you grasp. You have to maintain this, change this, the problem is now the extraction of the specimen, the anastomosis and the closure of the gap. So we have several possibilities, doing the closure of the gap now as we are in the right position to do it. We will do the anastomosis there. I will put a loop on the transverse segment, far from the tumor, to facilitate the recognition of this segment and to do the extraction. I will place the loop using an endoscopic system. Inside, this will be out the plastic bag, ok. So we do the incision there. So we introduce the Farabeuf forceps around the supra-umbilical trocar as we do normally. Introduce it in suprapubic; so we have the plastic wound protector, the Endo-catch®. We will remove the sponge after. Push, maintain this, and I am closing. So you see the suture is out, so I am removing both and as you can see, I have the plastic bag there. To facilitate the extraction, particularly in case of huge specimen, what we do is pull on the sutures, we have the stitch, and we pull and finally we have the transverse colon, we reduce the volume inside the plastic bag slowly. We can pull on the plastic bag and we have the tumor inside with double protection. We clean the camera, we will do the anastomosis now. The assistant maintains the forceps in the left hypochondrium, maintains a stitch. He will move this stitch just above the plastic wound protector, we have to catch the suture like this, we see the forceps, open the forceps and catch the suture. The stitch on the other side is very long. This is why it is important to have another stitch. We will do the anastomosis.

9. Hand-made anastomosis 22'47''

The extremity of the colon is there, well-vascularized, and we will do a hand-made anastomosis. This is a Vicryl, remove this. We do it like this, extra-mucosal and two halves. We do a hand-made anastomosis. We will show the final anastomosis using the scope; we now re-introduce it inside the abdomen. To do the closure of the mesenteric gap, we have two possibilities; either closing medially like this, or using a lateral/mixed approach. Maintain this with your forceps. Good technique, next time we will do another technique working through telementoring, so at distance. You have to remove this swab. The next step in the teaching is to do a procedure like this, and then to do a telementoring. The best is to do a video telementoring, we don’t have it in the room and it’s more stress for the operator. But we have the possibility and by having a standardized procedure we can do that at distance. I’m saying for beginners it’s probably easier to do an anastomosis, not outside but through the incision. So I’m showing an easy procedure, totally laparoscopic dissection and outside anastomosis, but I also do them inside. It is also because we do a DVD in which we show the different possibilities. Doing it inside is sometimes difficult for surgeons, so they prefer to do it outside because they say that they have to remove the specimen. It’s less cosmetic if you do it there but you can do it.