This film demonstrates the oncologic laparoscopic approach to a tumor of the distal sigmoid colon. The colorectal junction was invaginated.
WeBSurg.com, Feb 2012;12(02).
1. Introduction 00'18''The objective of this film is to demonstrate the oncologic laparoscopic approach to a tumor of the distal sigmoid colon. The colorectal junction was invaginated. It was even observed to come out at the anus, truly reflecting a deep invagination. Indeed, tumoral fragments were coming out of the anus. It is decided to perform a laparoscopic intervention, and as can be seen in these pictures, a tumoral mass at the sigmoid colon was rapidly identified inside the abdominal cavity. Care must be taken not to touch this mass. An abdominal ascites associated with massive edema of the tissues was sampled for cytological examination.
2. Mobilization 01'08''Here, as demonstrated by Professor Han-Kwang Yang from South Korea, there is a true interest in sealing lymphatic ducts by means of the Ligasure® device as in the present case while other experts would use ultrasound, in order to avoid postoperative lymphorrhea. These instruments allow for a much more oncologic dissection than monopolar scissors or coagulation that would be too superficial using bipolar cautery.
3. Ligation of inferior mesenteric artery 01'58''Here, the sealing of the artery is completed by means of a Vicryl loop ligature, and one can see that all lymphatic ducts are dilated. These ducts are under pressure mainly due to the digestive tract invagination, which entailed a compression at the level of lymphatic and venous vessels. The inferior mesenteric vein has just been divided once sealed by means of the Ligasure® Blunt Tip device. However, a ligature is used to complete the vascular sealing.
4. Mobilization continues 02'49''A constant oozing related to the presence of edema in tissues may be observed. Dissection is continued while the tumoral mass and the bowel segment, where the tumor is located, have still not been touched. And using a medial approach, the descending mesocolon and the sigmoid mesocolon are further freed. And by using a posterior approach, one gets closer to the lateral attachment of the descending mesocolon, which will be divided laterally, as can be seen here, still by means of the 5mm Ligasure® Blunt Tip device. The advantage of this instrument is that its tip is totally atraumatic such as a mini-finger which allows for safe entrance into tissues. Despite the use of energy that permits sealing of tissues, the tip of this instrument is not hot. Here, one can see the invagination of the tumor and accompanying bowel segment inside the rectum. Dissection is continued laterally by respecting oncologic principles, namely by staying sufficiently distal from tissues and by entering embryological planes only and not in planes in contact with the meso. One must stay sufficiently distal and avoid manipulating the tumor. Here on the posterior surface, one can very well see the plane of the perirectal fascia, which represents the safety margin to perform an oncological dissection. Once again, thanks to the Karl Storz HD camera, one can see the dilatation of the lymphatic ducts as well as the edema within the tissues. The quality of the image allows to well identify the embryological planes, and more particularly to respect oncological dissection principles. In this kind of surgery, the tumor’s extremity will be partly palpated. It is invaginated. As a result, the distal extremity is higher than imagined. However, dissection is performed with at least resection of the mesorectum over a minimum of 5cm. To do so, a cylindrical dissection is carried out as can be seen in these pictures. Consequently, the anastomosis will be performed on the upper rectum. Here, the dissection is well visible. One tends to slightly manipulate the tumoral mass even though it is done indirectly. It is therefore preferable to respect oncologic principles proposed since long in open surgery, namely exclusion underneath the tumor to cleanse the distal stump. To do so, an Ethibond® 0 loop is passed and the rectal lumen is closed and cleansing is performed using a Betadine solution. Half a litre of solution at least is used. Most important is the mechanical irrigation that should be performed even with physiological saline.
5. Transection of rectum and colon 07'22''An Endo-GIA® linear stapler is then applied using two firings of 45mm long staples over an area that has been irrigated, should tumor cells migrate into the bowel lumen. The future proximal anastomotic area should still be determined. Here one can see that the proximal colon tend to dilate because of the invagination, and the difference in color can be observed between the ischemic devascularized colon and the well-vascularized proximal colon. The colon is again divided on its descending portion at the junction between sigmoid colon and descending colon.
6. Specimen extraction 08'47''The objective is to avoid specimen extraction without any protection in a plastic bag. Indeed, in order to avoid tumor cell contamination during extraction, the tumor and the entire bowel segment are placed into a plastic bag. This bag has been introduced through a wound protector to ensure double protection. The proximal colon is then exteriorized through the still protected suprapubic incision and the anvil of a PCEEA™ 31 circular stapler is introduced.
7. Anastomosis 09'32''A trans-sutural colorectal end-to-end anastomosis is then performed by means of the circular stapler.
8. Stoma location 09'42''One must control that there is no twist and that the lowered bowel segment is well-vascularized. The anastomosis will then be protected by means of an everting ileostomy. The ileostomy is positioned in the right iliac fossa or preferably outside the umbilicus to the right.