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Segmental colonic resection for cancer of the splenic flexure

The laparoscopic approach for the treatment of splenic flexure (SF) colon cancer is not standardized and is a challenging procedure. The aim of this video is to show the possible segmental and oncological resections of a tumor of the splenic flexure.

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Segmental colonic resection for cancer of the splenic flexure

作者群

J Leroy, J Marescaux

摘要

The laparoscopic approach for the treatment of splenic flexure (SF) colon cancer is not standardized and is a challenging procedure. The aim of this video is to show the possible segmental and oncological resections of a tumor of the splenic flexure.

分類

basic techniques

關鍵字

Segmental colonic resection, cancer, splenic flexure

媒體類型

手術影片

期間

26'00''

刊物

2010-02

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Feb 2010;10(02).
URL: http://www.websurg.com/doi-vd01en2840.htm

Segmental colonic resection for cancer of the splenic flexure

1. Introduction 00'30''

The aim of this video is to show the possible segmental and oncological resections of a tumor of the splenic flexure. Following a laparoscopic exploration of the abdominal cavity during which we search for a carcinomatosis, we expose the roots of the descending and left transverse mesocolons. To do so, we use retractors introduced in the left flank and suprapubically. This will allow us to begin the procedure by a dissection of the inferior mesenteric artery at its origin.

2. IMA dissection 01'15''

After exposure of the mesosigmoid’s root, we incise the right lateral aortic peritoneum in order to open the meso and identify the inferior mesenteric artery at its origin. Indeed, even when performing a segmental resection, a complete dissection of the inferior mesenteric artery is important to remove all the lymph nodes located at the origin of the inferior mesenteric artery. This artery will be preserved along with the vein in this case.

3. Division of the left colic artery 02'04''

The left colic artery is divided after sealing as it allows to obtain a better view of the inferior mesenteric vein that was crossing the left colic artery in front of the latter. The dissection is continued in contact to the inferior mesenteric artery while being careful of the superior hypogastric plexuses located on the left flank.

4. IMV dissection 02'40''

The dissection is then continued laterally on the posterior surface of the inferior mesenteric vein: the latter is dissected and skeletonized with removal of the cellular and lymph node bundles situated around the vein. This does not impede the vein’s preservation, which will soon be going under the pancreas as can be seen on these pictures. This dissection should be gentle in order to preserve the vascularization. A division of the vein is not dramatic, but in the context of a segmental resection, it is preferable to preserve the entire vascular network as proposed by the Japanese surgical school. The dissection is continued up to the pancreas’ inferior border before resecting the cellular and lymph nodes package, which will be placed in an extraction bag previously inserted in the abdominal cavity.

5. Opening the transverse mesocolon 04'16''

We continue the dissection laterally, with vein preservation, up to the pancreas’ base where we perform an opening of the transverse mesocolon’s root by incising anterior to the pancreas with the monopolar scissors and Ligasure Atlas® device. It is important to find the plane situated just in front of the pancreas, namely the lesser sac. Opening the lesser sac is the key to detaching the root of the transverse mesocolon in safe conditions for the pancreas. We can see that without manipulating the colon, and in particular the splenic flexure of the colon in which the tumor lies, we detach the mesocolon’s posterior attachments. The splenic flexure of the colon now remains to be freed laterally.

6. Incision of the left parietocolic gutter 05'38''

To do so, we incise the left parietocolic gutter from caudad to cephalad, which allows to free the descending portion of the splenic flexure. This is performed with traction and counter-traction that puts the tissues under tension and allows to open the retroperitoneal spaces ahead of the kidney and of Gerota’s fascia. Freeing of the lateral attachments is performed up to the diaphragm and the spleen. We then continue the dissection via a medial inferior approach and we see the transverse mesocolon’s division, which is performed at least 10cm away from the tumour, aided by the use of the Ligasure Atlas® device.

7. Division of the gastro-omental attachments 07'00''

The gastro-omental attachments will then be divided using the Ligasure Atlas® to complete the freeing of the splenic flexure on its transverse colon section. The division of the splenic flexure’s posterior attachments sometimes requires some switching between the lateral approach and the medial approach as can be seen here during this dissection. The hemostasis should be performed with care and one should be attentive of the spleen as it is very close to the splenic flexure’s lateral attachments. The areas in which the distal and proximal divisions will be performed now remain to be determined. For the distal division, we should be at least 10cm away from the tumor’s inferior border while making sure that at least 10cm of meso is resected as the resection should be cylindrical and not in the shape of a truncated cone. We have therefore chosen the zone situated well under the tumor and we divide the meso with the 10mm Ligasure Altas®, which is very efficient in this slightly obese patient with an adipose meso.

8. Division of the distal colon 09'00''

The division continues up to the colon and we apply a blue cartridge 60mm Endo-GIA linear stapler to divide the colon distally. The proximal section of the colon now remains to be determined. We can see that we have hardly ever manipulated the tumoral area.

9. Exteriorization of the colon 09'32''

We perform an exteriorization of the colon through an incision in the left flank that is protected by a plastic drape. The incision is large enough to avoid compressing the colon and the tumor during the extraction and it should be performed 10cm above the tumor, the meso having being resected in the abdominal cavity under laparoscopic control. As this patient has not undergone a complete exploration of the colon’s proximal portion, we decide to perform this exploration peroperatively.

10. Peroperative colonoscopy 10'14''

To do so, we use a sterile camera plastic sleeve to introduce the colon, and a colotomy is performed to introduce the colonoscope and help the endoscopist in the colon’s exploration, which is performed under good conditions as the patient did not have a washout liquid preparation, so that the matter in the colon is relatively solid.

11. Division of the proximal colon 11'04''

After a complete exploration, we perform a division of the colon with a linear stapler. We then also decide to perform an exploration of the distal colon by introducing the colonoscope through the anus and by performing a complete exploration of the rectum and sigmoid colon. This allows to check that there are no polyps and to check that the colon is well vascularized.

12. Side-to-side anastomosis 11'42''

The two colonic segments now remain to be fixed to perform an isoperistaltic side-to-side colo-colonic anastomosis. The two intestinal segments are maintained together by two anchoring stitches of Ethibond 2/0 extracorporeal knots. These stitches fix the intestinal segments on the anterior tenia. These stitches will allow to obtain good exposure of both intestinal segments in order to introduce the endolinear stapler. Once the anchoring and landmark stitches have been performed, we incise the colon on the tenia: this incision is performed with the monopolar scissors as it allows to open both intestinal lumens without blood oozing. This opening is completed in good conditions. The stapler is introduced via a trocar introduced suprapubically, which is not the best position in relation to the two intestinal segments, but as the staple can be angled, we perform a 5cm long stapling. The anastomosis is finalized with two half-running sutures of Maxon 3/0 taking each angle of the incision. The Maxon material is interesting in this case as, like all monofilaments, it slides through easily thus allowing to place multiple stitches without exerting any traction on the suture, resulting in a shorter operative step. It is also perfectly adapted to laparoscopic surgery thanks to its memory. A running suture is performed from right to left and we open the anchoring stitch in order to see the other anastomosis angle. This is important as without the opening of this anchoring stitch, we may forget part of the suture. We complete the closure with a second half-running suture, performed this time from left (patient’s left) to right and with extramucosal stitches, we join the two half-running sutures together on the midline. Here we have a few problems caused by a sero-serosal tear on the distal aspect of the colon. It is important to complete a knot that will join the two half-running sutures together on the midline, which is easily performed here. The mesenteric breach now needs to be closed; this is important as it avoids the risk of an internal hernia and of bowel strangulation. This is all the more important because the resection is extensive and close to the duodenojejunal flexure.

13. Mesocolon defect closure 17'01''

The internal and inferior sections of the transverse mesocolon are exposed and we perform the closure with an Endo-Hernia Universal stapler: this closure should be performed atraumatically while avoiding the vessels. It should also be perfect to avoid any incarcerations, in particular close to the duodenojejunal junction.