Oncologic splenic flexure resection for adenocarcinoma of the left descending colon

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摘要

The objective of this film is to demonstrate a completely laparoscopic technique for left colon resection and for cancer of the descending portion of the splenic flexure.

關鍵字

Oncologic splenic flexure resection, adenocarcinoma, left descending colon

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期間

22'30''

刊物

2011-04

普通的

最愛

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副標題

數位出版

WeBSurg.com, Apr 2011;11(04).
URL: http://www.websurg.com/doi-vd01en3027.htm

Oncologic splenic flexure resection for adenocarcinoma of the left descending colon

1. Introduction 00'22''

The objective of this film is to demonstrate a completely laparoscopic technique for left colon resection and for cancer of the descending portion of the splenic flexure.

2. Abdominal cavity exploration 00'42''

The procedure is started by exploring the whole abdominal cavity, and notably the pelvis, in order to check for the compliance and the quality of the sigmoid colon. The exploration led to the identification of the tumor on the descending portion of the splenic flexure.

3. Left colon exposure 01'02''

The first step of the procedure consists in the freeing of the non-neoplastic adhesions located at the level of the greater omentum with the tumoral area. The left colon is then exposed at the level of its root by pushing the transverse mesocolon cephalad, and by exposing the duodenojejunal flexure and the inferior mesenteric vascular axis.

4. Peritoneal opening 01'32''

After opening the peritoneum, the anterior aspect of the inferior mesenteric artery can be very well visualized. More laterally, the inferior mesenteric vein can also be seen. Both will be preserved.

5. Vascular axes skeletonization 01'48''

The objective is to dissect and skeletonize the main vascular axes so as to allow for a correct vascularization of the sigmoid colon and of the rectum by performing an oncologic resection dividing only the left colic vessels. The skeletonization of the inferior mesenteric vein can be seen here. It courses towards the inferior border of the pancreas. Only the branches coming from the splenic flexure are resected. This is carried out by removing the cellular adipose tissue containing the lymph nodes.

6. Lesser sac opening 02'46''

The inferior border of the pancreas and then its anterior aspect are now reached. The lesser sac is opened by means of the 5mm Ligasure Blunt Tip® device, which is used as one’s finger to open the embryologic planes. Gerota’s fascia is located posteriorly. It covers the left kidney. Toldt’s fascia is located anteriorly. It covers the posterior aspect of the descending colon. The posterior aspect of the tumor can be seen here. It is covered by the meso. The inferior border of the pancreas can also be visualized.

7. Transverse mesocolon division 03'44''

Now it is time to open the lesser sac by passing anteriorly to the pancreas and by dividing the transverse mesocolon’s root. The opening of the lesser sac and the division of the transverse mesocolon’s root from right to left can be seen here. The latter will be divided until the posterior surface of the splenic flexure. Care must be taken not to damage the tail of the pancreas during this surgical procedure. It is essential to perfectly explore the transverse mesocolon’s root using anterior traction, thus allowing to visualize all the attachments on the anterior surface of the pancreas. The external border of the descending colon is progressively reached using a medial approach.

8. Lateral sigmoid dissection 05'01''

The procedure is carried on caudally, anteriorly to the inferior mesenteric artery. The external border of the sigmoid colon is then approached so as to be freed from its lateral attachments by means of the 5mm Ligasure Blunt Tip® device, which allows for a perfectly hemostatic division of the tissues. The hemostasis obtained presents no significant lateral diffusion, as bipolar cautery is being used. Coagulation is achieved at the level of the instrument’s jaws. The sigmoid colon is freed as largely as possible in order to facilitate subsequent anastomosis on a perfectly healthy and vascularized area of the sigmoid colon. The vascularization of the sigmoid colon has been perfectly preserved, since the inferior mesenteric axis has remained untouched.

9. Cephalad mobilization 06'25''

Lateral mobilization is carried on slightly cephalad. The sigmoid colon’s vascularization is controlled. Only the superior sigmoid branches will be divided, as can be seen in this picture. They will also be skeletonized so as to carry out the anastomosis on the higher portion of the sigmoid colon. Mobilization of the splenic flexure is continued after dividing the sigmoid colon at the level of the junction between the descending colon and the sigmoid colon. The division of lateral attachments is performed using the 5mm Ligasure Blunt Tip® device. The tumor is gently manipulated and a medial approach is decided upon in order to avoid an excessive manipulation. This approach includes division of the transverse colon as soon as the mesocolon has been divided. Both distal and proximal approaches are used, and the maneuver is completed by mobilizing the colon containing the tumor.

10. Transverse colon division 08'02''

The progressive division of the transverse mesocolon and of the network of marginal arteries is visible here, as well as the division of the transverse colon by means of an Endo-GIA linear stapler. It is important to control that the preserved colon is adequately vascularized. A 60mm blue cartridge is used. To-date, a tan cartridge would be preferably opted for as it would allow for a better hemostasis of the colon while preserving its vascularization at the level of its division line.

11. Omental resection 08'49''

The omentum, which is fixed onto the splenic flexure of the colon, is resected in compliance with oncologic principles, and the tumor should never be manipulated since the risk would be to disseminate cancer cells. It must be noted that the freeing of the left transverse colon on the transverse portion of the splenic flexure may be carried out from right to left, and from cephalad to caudad, to finally reach the previously freed area. This maneuver should be performed taking care to avoid contact with the bowel segment containing the tumor.

12. Completion of splenic flexure mobilization 09'46''

The splenic flexure of the colon has therefore been widely resected, at least 5cm away from the tumor, by removing the entire vascular pedicle containing the lymph nodes, and by preserving the vascularization of the distal colon and of the rectum. The two bowel segments, namely the distal and the proximal ones, are well-vascularized. The absence of tension will make it possible to perform an isoperistaltic, colo-colonic, side-to-side anastomosis intra-abdominally. It is probably more difficult to carry out the anastomosis externally without any further mobilization of the colon and by respecting cosmesis, hence avoiding extraction of the specimen at the upper part of the abdomen, which might be less esthetic.

13. Anastomosis 11'01''

The two bowel segments are attached by two landmark stitches situated on the anterior and antimesenteric edges of the colon on the anterior taenia, as can be seen here. The thread is introduced and a pulley is placed. Intracorporeal knots can be made. The objective is to obtain traction threads in order to better expose and orientate the colon during the introduction of the circular stapler used for the anastomosis. The Endo-GIA linear stapler will be introduced in the two tails of the colon. The openings are controlled and the two jaws of the stapler are introduced. The stapler is perfectly angulated to achieve the side-to-side anastomosis. The introduction sites then remain to be re-approximated. To do so, two intracorporeal half-running sutures (Maxon 3/0) allow to make the thread slide perfectly. As a result, knots are easier to tie and stitches can be placed smoothly. Passing two or three stitches proves to be time-saving. The procedure can be achieved by passing a second half-running suture from the opposite angle until the mid-portion of the stapled area. In the present case, a full running suture is used, further buried by a stitch to approximate the two bowel segments. The anastomosis is controlled. The presence of twisting is ruled out. Anyway, it is preferable to do this before the anastomosis.

14. Mesenteric defect closure 14'00''

The mesenteric defect is also controlled. The defect is closed either by staples or by a running suture as in bariatric procedures. The specimen still needs to be extracted. To do so, a suprapubic incision is made using a plastic wound protector. The colonic segment is placed in a plastic bag (Endo-Catch™ II by Covidien).

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