Single incision laparoscopic-assisted right hemicolectomy for a caecal cancer

Single port operations are usually presented for appendectomies and cholecystectomies. We present the case of an 84-year-old man who presented recently to our department with Iron Deficiency Anemia (IDA). A CT-colonography identified a caecal tumor, which was proven malignant by biopsies taken at a subsequent colonoscopy. Radiologically, this appeared to be an early T3 N0 tumor. Because of his favorable body habitus and well-localized lesion, we elected to perform his laparoscopic-assisted right hemicolectomy by a single port technique.

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Single incision laparoscopic-assisted right hemicolectomy for a caecal cancer

Authors

R Cahill, S Ahmed, C Cunningham, N Mortensen

Abstract

Single port operations are usually presented for appendectomies and cholecystectomies. We present the case of an 84-year-old man who presented recently to our department with Iron Deficiency Anemia (IDA).
A CT-colonography identified a caecal tumor, which was proven malignant by biopsies taken at a subsequent colonoscopy. Radiologically, this appeared to be an early T3 N0 tumor.
Because of his favorable body habitus and well-localized lesion, we elected to perform his laparoscopic-assisted right hemicolectomy by a single port technique.

Classification

single port, contribution

Keywords

Single incision laparoscopic-assisted right hemicolectomy, caecal cancer, SILS

Media type

Surgical video

Duration

11'08''

Publication

2010-01

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E-publication

WeBSurg.com, Jan 2010;10(01).
URL: http://www.websurg.com/doi-vd01en2851.htm

Single incision laparoscopic-assisted right hemicolectomy for a caecal cancer

1. Clinical case presentation 00'19''

An 84-year-old man presented recently to our department with Iron Deficiency Anemia. A CT-colonography identified a caecal tumor, which was proven malignant by biopsies taken at subsequent colonoscopy. Radiologically, this appeared to be an early T3 N0 tumor. Because of his favorable body habitus and well-localized lesion, we elected to perform his laparoscopic-assisted right hemicolectomy by a single port technique. While we have used different types of single port access, in this case we used a SILS device placed at the sub-umbilical position. The plan was to mobilize the entire right colon laparoscopically but perform the anastomosis extracorporeally through the port site as the single abdominal wound. The Single Incision Laparoscopic Surgery or SILS system manufactured by Covidien comprises a cylindrical soft, molded port with three pre-bored channels that accept a cannula of 5mm internal diameter. The port can be inserted using a Robert forceps into a 2cm incision in the abdominal wall. The cannulas are then placed into the channels to maintain the air seal and their positioning at differing depths of insertion helps minimize instrument clash. A dilator to expand one of the conduits to allow 12mm instrument access is also supplied. The SILS port is placed subumbilically for this single port laparoscopic right hemicolectomy for an elderly patient with a small caecal cancer. A 5mm camera is used throughout the procedure.

2. Exposure of caecum 01'41''

The caecum is grasped and elevated towards the anterior abdominal wall. Aided by right side up positioning of the patient, this allows the ileum to be removed from the operative field. Repositioning of the holding graspers displays the lie of the ileocolic artery and we then also establish the relative position of the duodenum, moving the omentum to ensure high vessel ligation is facilitated.

3. Peritoneum incision at ileocolic vessels 02'01''

The peritoneum over the ileocolic vessels is divided using high-frequency diathermy and then a tunnel is made underneath the mesentery of the right colon by blunt dissection. Efficient progress here is dependent on the distracting hand maintaining tissue tension and so frequent repositioning of the instruments is required. Because of the proximity of instruments and camera within the port, this is best done by discrete movements of each instrument individually rather than the normally more fluid operative motions seen with conventional multiport laparoscopy.

4. Identification of duodenum 02'31''

Once the duodenum is identified, selective use of sharp tissue division can then be used to extend the dissection up towards the hepatic flexure and proximal transverse colon. Returning now to the top surface of the mesentery, a window is made to connect into the previous plane of dissection and thereafter the ileocolic artery and vein are skeletonized to allow high clipping and division. An apical lymph node is seen here and therefore the distracting instrument is repositioned to ensure this is incorporated within the oncological specimen. Further thinning of the vascular bundle allows its sealing and division by the Ligasure® device and this sequence is shown here without editing. Optimum sealing requires the tension on the tissue to be released while the device is firing. Two overlapping seals are applied and then the vessels are divided. The sufficiency of the seal is assured before continuing with the operation.

5. Dissection of ascending and proximal transverse colon 04'24''

Further blunt dissection now allows the more cephalad posterior aspects of the ascending and proximal transverse colon to be freed.

6. Lateral dissection 04'41''

We next address the omental attachments of the proximal transverse colon before proceeding with lateral dissection of the ascending colon. Because this patient is 84 years of age, we had decided before commencing the operation not to extend the dissection to include the right branch of the middle colic artery, electing to prefer maximal preservation of the blood supply over the potential 6% gain in lymph node yield obtained by extended resection. The colon is then released fully from the lateral abdominal wall. To maintain effective dissection, the traction, counter-traction needs to be continually re-adjusted. The confined range of movements due to the limited space within the port means this is best done in a stepwise fashion. The SILS port currently lacks a dedicated smoke extraction channel (as indeed do the other commercially available ports). By proceeding predominantly along the correct tissue planes, the use of energy application is minimized and so too therefore is the potential for smoke accumulation. Next the caecum is held up by placing the retracting graspers on the appendix. This allows exposure of the lateral attachments of the caecum and thereafter the terminal ileum. Of course, in such a thin patient with a preoperatively confirmed caecal cancer, it could be proposed that an open operation of the same extent could have been performed via an appendix-type incision of similar size. What distinguishes this approach, we believe, is the excellent visualization of all relevant structures and the clear definition of tissue planes.

7. Dissection of posterior attachments 06'25''

Following this, the entire right colon can be retracted towards the midline allowing further division of its posterior attachments by a combination of both blunt and sharp dissection. This allows the entire retroperitoneum to be exposed and, in this relatively thin patient, both Gerota’s fascia and the second part of the duodenum are readily visualized. The colon is then returned to its anatomic position and a ratcheted grasper is placed near the caecal pole to allow extraction of the specimen via the port site.

8. SILS removal 07'35''

The SILS port is then removed from the abdominal wall.

9. Specimen extraction 07'38''

In order not to damage the specimen during its extraction, we elect to slightly increase the sub-umbilical incision. A wound protector is then placed over the port and the grasper that is still in place on the caecum. The design of this Alexis wound-guard made by Applied Medical allows flexible positioning and, regardless of the wound size, a snug fit. The specimen is then gently removed and the small cancer at the patient’s caecal pole readily appreciated.

10. External resection and anastomosis 08'16''

We then proceed to perform an extracorporeal specimen resection and ileocolic re-anastomosis. We use the diathermy cautery to prepare the mesenteric aspects of the bowel. Following this, a linear GIA stapler is used to transect both the terminal ileum and the transverse mesocolon. An enterotomy is then made in both limbs and the reloaded GIA stapler is used to create a side-to-side anastomosis. After checking to ensure hemostasis of the staple line, the entry sites of the stapler are oversewn first from one end and then from another to allow tying of the knot in the middle of the closure site. A hitching suture is then placed into the angle of the anastomosis to minimize the potential for distracting tension to disrupt the join. The anastomosis is then returned to the peritoneal cavity and the wound protector is removed.

11. SILS replacement 10'28''

The SILS port is now replaced into the wound to allow final laparoscopy confirm the lie of the anastomosis and to check to ensure hemostasis. The three cannulas are re-inserted into the port to achieve effective air sealing of the wound and the pneumoperitoneum is re-established. With its position confirmed, we place some omentum over the anastomosis and then conclude the operation.