Three port technique for laparoscopic left colectomy

With advancing surgical technology and technique, truly minimally invasive surgical procedures are feasible. Three port laparoscopic colectomy should offer minimal scarring without compromising the surgical outcome. This video demonstrates the technical details in performing the three port colectomy in a 40-year-old man with a BMI of 29, with several episodes of diverticulitis of the left colon.

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Three   port   technique   for   laparoscopic   left   colectomy

Authors
C Huscher, J Marescaux
Abstract
With advancing surgical technology and technique, truly minimally invasive surgical procedures are feasible. Three port laparoscopic colectomy should offer minimal scarring without compromising the surgical outcome. This video demonstrates the technical details in performing the three port colectomy in a 40-year-old man with a BMI of 29, with several episodes of diverticulitis of the left colon.
Classification
new techniques
Keywords
Three port technique, laparoscopic left colectomy
Media type
Duration
24'00''
Publication
2009-05
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, May 2009;9(05).
URL: http://www.websurg.com/doi-vd01en2635.htm

Three   port   technique   for   laparoscopic   left   colectomy

3. Lesser sac opening and splenic flexure freeing 02'31''
See the lesser sac, and now we can use diathermy just to open this adhesion. Now we are nicely in the lesser sac. Do you sometimes use a vascular stapler in colorectal surgery? When I have a very old or very sick patient and I have to go very fast, I do just to cut the IMA distally. But with the Ligasure device, I think it can be done safely. You see the stomach and the posterior aspect of the stomach and the transverse colon mesentery. By lifting up the stomach, we can see the pancreas. I change the position of my instruments: I put my forceps in the lower port and I can expose the splenocolic ligament. I place the Ligasure device in the second port. You see every vessel can be divided. See how useful the diathermy can be. Is it right that this is the way you start every operation on the rectum or colon? Yes, coming up from the right iliac fossa and dropping down the splenic flexure. I would like to show that this tip is very useful to dissect gently and safely; you create a hole with diathermy and then you can go on with the Ligasure device. The secret is to change the position of your forceps every time you grasp, you can expose what you are dissecting free. I am cutting the gastrocolic ligament because the omentum has to fall down with the colon to cover the anastomosis and the vascular supply is provided by the Barkow’s arcade. This is the splenic flexure falling down. The “killer ligament”, the bigger it is, the less dangerous it is? The killer ligament is very close to the spleen. Yes, but when it is very big, you have a better adhesion to the spleen so it is less dangerous; the more dangerous one is when it is very thin. I completely agree with you. Because if you have traction on this ligament, you can have a spleen rupture. See my tip dissecting with diathermy. This is the Treitz’ ligament, I have dissected all the splenic flexure free. I try to hold on the transverse colon mesentery and now I have the IMV in front of me. I will cut this vein. Why are you cutting this vein in a benign disease? To avoid any traction, I think that we have to do it. I would suggest the only reason you ever divide the vein at this point is for mobility of the left colon; you don’t do it for oncological reasons and especially not if there is no tumor. Do you see the tunnel? We change the patient’s and the scope’s position. We can do this artery, this is a benign disease so we stay far away from its origin. What I would like to show you is that if we open the Bacon axilla done by IMA and aorta, we can stay far away from the nerves. This is the colon, the spleen, and now the splenic flexure, very mobile. I try to show you now the IMA. This is the right ureter, the right iliac artery, this is the Gruber’s fold that we can open. This is the hypogastric nerve. When we use the Ligasure device, particularly in big vessels like this, it is important to reduce the traction on the vessels when we close. The danger, particularly in elderly patients, is to break the vessels when we close. Reducing the traction is better because it is sometimes divided before the sealing. See the ureter. Combining and using both bipolar and monopolar cautery, we can carry on in a nice way. This is the dissection I did previously.
5. Final dissection and anastomosis 16'24''
We are ready to divide the junction. Now we go back and expose the promontory in front of us like this. The promontory is here. It’s the start of the mesorectal space, so you just stop there. I think this is the right position to do it. Now you go around the entire rectum with the Ligasure device? I try to avoid it, I try to find the artery first and then all around. In this case, my trocars are very badly positioned because they are conflicting all the time. You will free a little more on the caudal border of the pancreas. This is the transverse colon mesentery. I think that this is a demonstration that we can do it using 2 forceps only. You see the transverse colon is falling down, and all the greater omentum covers the anastomosis, so I think we can do an omentoplasty. Now to the dissection. I would like to show you this greater omentum, we have the artery, the IMA, and this is the left colic and the flexure dissected free. Where is the diverticular disease? All over, the mass is here, the bigger mass is here. This is the IMV, and the omentum; this is the IMV, and I resect here; I think that if you do not cut the IMV, you cannot mobilize well. You have put a purse-string to go faster, this is an argument in favour of doing an end-to-end, because you can put a purse-string. I use a silk stitch. You don’t see any diverticula here? No. In my opinion, it is very important to remove most of the linear stapler line. No studies have been done but we think that removing this line is very important. Very nice anastomosis.