The objective of this film is to demonstrate an oncologic segmental resection of the splenic flexure in a woman presenting with a T2 adenocarcinoma of the splenic flexure.
WeBSurg.com, Mar 2012;12(03).
1. Primary vascular approach 00'19''The objective of this film is to demonstrate an oncologic segmental resection of the splenic flexure in a woman presenting with a T2 adenocarcinoma of the splenic flexure. Once a few intra-abdominal adhesions have been taken down, the root of the transverse mesocolon and of the splenic flexure is exposed in order to approach the inferior mesenteric axis, proximal to the duodenojejunal junction. The dissection in contact with the inferior mesenteric axis can clearly be seen here, and some oozing originating from a few lymphatic ducts can be noted. As a result, these ducts are divided after sealing. This is why it is recommended, when using an oncologic approach, to use either ultrasonic scissors, or, like in this particular case, to use the Ligasure® vessel-sealing device. The Ligasure® device is an effective instrument to perform a hemostasis once tissues and lymphatic ducts have been sealed. An elective left colic vascular approach will be used in this patient once vessels have been skeletonized. This approach is carried out in contact with the inferior mesenteric axis. The left colic artery is identified. It has just been divided, and the inferior mesenteric vein will then be gradually skeletonized in order for venous drainage to be sustained, while ligating the left colic veins which originate from the upper part of the descending colon and from the splenic flexure. Here, one can observe the skeletonization and the removal of cellular and lymph node tissue which surrounds the mesenteric vascular axes. The skeletonization of the vein can progressively be seen here as well as the resection of the tissue containing lymph nodes of the colonic segment at stake.
2. Splenic flexure mobilization 03'06''The dissection is carried on using a posterior medial approach, by detaching the descending mesocolon and the transverse mesocolon from Gerota’s fascia. The dissection is continued on the posterior aspect of Toldt’s fascia. The superior sigmoid vessels can clearly be seen here. They divide into two branches: a superior branch for the descending colon and an inferior branch for the sigmoid colon. The Ligasure® blunt tip 5mm device is used to divide these vessels and the meso in order to have a good hemostasis, but also a good lymphostasis, which prevents postoperative serous effusions. Through the posterior approach, the parietocolic gutter is reached. It will be incised using a medial approach. The dissection should now be pursued towards the root of the transverse mesocolon. As can be seen here, it is anterior to the pancreas, at the level of the inferior mesenteric vein which courses posteriorly to the pancreatic body, that a window will be created in the lesser sac. Opening the lesser sac allows to find the posterior surface of the stomach, and to keep detaching the root of the transverse mesocolon, as can be seen here, until the inferior border of the pancreas, the tissue of which are carefully preserved. The dissection is continued in this fashion, as lateral as possible on the posterior aspect of the splenic flexure. Until now, the dissection had been carried out without directly handling the colon in contact with the tumor. The splenic flexure should now be freed from its posterior and lateral attachments. This can be carried out using a medial and a lateral approach, which is the case for the freeing of the left transverse colon, gastric attachments of which will be taken down.
3. Preparation of segmental resection 05'57''Prior to doing so, the transverse mesocolon is progressively divided, until contact is made with the transverse colon, where the division of the transverse mesocolon will be carried out, using one 60mm staple firing. In order to comply with oncologic principles, this division will be performed at least 10cm proximally to the tumor. The procedure may be continued with stapling performed on the mesocolon and on the greater omentum. The division of the greater omentum should now be carried out. It is also fixed to the greater curvature of the stomach and to the gastrosplenic omentum. Once the omentum has been detached from the stomach making sure that the network of marginal arteries of the stomach has been preserved, freeing of the splenic flexure is carried on using a lateral approach. Here, the end of the freeing on the stomach as well as attachments on the posterior aspect of the splenic flexure are clearly visible. Laterally, residual attachments at the level of the parietocolic gutter are divided. As a result, every aspect of the splenic flexure will be freed. A left colonic segment proximal to the splenic flexure has been isolated and devascularized. The sigmoid colon still needs to be mobilized sufficiently in order to easily perform a tension-free anastomosis on the two bowel segments, namely the left transverse colon and the sigmoid colon. Here, the difference in color clearly demonstrates that the sigmoid colon vascularization has been preserved and that the descending colon is ischemic. The proximal portion of the sigmoid colon is then divided. Consequently, there is a totally isolated bowel segment containing lymph nodes and the tumor.
4. Anastomosis 09'02''The anastomosis may now be prepared between the isolated transverse colon and the sigmoid colon. The middle portion of the transverse colon and the sigmoid colon are re-approximated in order to perform an isoperistaltic side-to-side anastomosis as can be seen in this film. Here it is an anastomosis between the transverse colon and the sigmoid colon. The first stitch will help to fix the sigmoid colon onto the proximal portion of the transverse colon. The second stitch will fix the distal and medial portion of the sigmoid colon and the distal portion of the transverse colon. Once the two bowel segments have been re-approximated, the anastomosis can be carried out through mechanical stapling. The anastomosis can be facilitated via a left flank or left iliac fossa incision; hence specimen extraction will be further improved and operative time will be shortened. The 60mm long Endo-GIA® linear stapler, blue cartridge, will be introduced. Stapling will be carried out exclusively intra-abdominally. The stapled area will be controlled since hemorrhagic problems may frequently occur. And such hemorrhagic problems can only be controlled either using bipolar cautery as in the present case or using an internal covering suture at the level of the stapled area. In any case, it will be necessary to close the stapler’s introduction site using an absorbable monofilament Maxon 3/0 suture. A running suture will be achieved as in the present case. Closure of the mesenteric defect still needs to be addressed. It is a mandatory step in order to avoid the risks of loop incarceration and internal hernia, and especially so in the immediate postoperative period. This may be delicate and uneasy to achieve in the presence of tension. Therefore, it may be very helpful to use omental folds to complete the closure. Here, closure is made easier through the use of an Endo Universal™ stapler. The anastomotic area remains to be controlled. One can see here that the stapled closure may be slightly traumatic. Consequently, it is common to add a suture to cover the stapled area on the terminal portion of bowel segments.
5. Specimen removal 13'05''Through an incision situated on either part of the abdominal wall suprapubically or elsewhere, a large extraction Endo-Catch™ II bag is introduced. It will allow to retrieve large and bulky specimens. In the presence of a bowel segment, it is useful to place a loop-type thread on one of the bowel extremities—keeping quite a long thread. Indeed, once the bowel segment has been introduced into the extraction bag, it is exteriorized through a small incision with a wound protector.