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Three trocar technique for laparoscopic left colectomy for cancer: difficult mobilization of the splenic flexure in an obese patient

This video demonstrates a three trocar technique for mobilization and resection of the left colon for malignancy despite some considerable technical difficulty due to the patient’s body habitus. It concentrates in most detail on how to obtain the exposure necessary for radical oncology resection using this technique.

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Three trocar technique for laparoscopic left colectomy for cancer: difficult mobilization of the splenic flexure in an obese patient

作者群

C Huscher, F Costantino

摘要

This video demonstrates a three trocar technique for mobilization and resection of the left colon for malignancy despite some considerable technical difficulty due to the patient’s body habitus. It concentrates in most detail on how to obtain the exposure necessary for radical oncology resection using this technique.

關鍵字

left colon, colectomy, laparoscopy, splenic flexure, morbid obesity, three ports

媒體類型

手術影片

期間

25'30''

刊物

2007-11

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Nov 2007;7(11).
URL: http://www.websurg.com/doi-vd01en2171.htm

Three trocar technique for laparoscopic left colectomy for cancer: difficult mobilization of the splenic flexure in an obese patient

1. Trocar position 00'20''

The first one is for the scope, it’s between xiphoid and umbilicus, the second one is on the umbilical line and the third one is in the lower right quadrant. It’s like a triangle as you can see.

2. Vascular anatomy of greater curvature of the stomach 00'43''

You have to look for the epiploic arteries and vein which we call the Winslow arcade. This is the left epiploic artery and this is the right one. This is exactly the one good point where the left epiploic arteries join the right one. As you can see, the small arteries change direction, left coming down, and right coming up.

3. Entry into the lesser sac 01'37''

Then in the gastrocolic ligament, we have to find this translucent area, the Bouchet area, now we call it the Heald area, and as you can see when looking for this area, you can enter the lesser sac easily. This is the same technique for gastric tube tailoring for esophagectomy. Now we go straight for the spleen, opening the gastro-colonic ligament.

4. Division of the gastrocolic ligament 02'31''

Is this instrument good for fatty tissue? I think the ligasure is the best for this kind of patient, I would like to show to young surgeons how this instrument is safe, because you can explore, you can touch, you can expose like with your finger, and then you can use it to coagulate and to cut. This is bipolar electricity remember followed by a knife through the fried and compressed tissue. I try to do all the same, usually as I do in open surgery, I try to see everything and every detail I am dissecting free.

5. Exposure of the pancreas 03'32''

You see my posterior aspect of the stomach. As you can see, if I lift up my stomach I can see some adhesions between pancreas and stomach, but the pancreas is very visible in the field. We are in an adhesion between pancreas and the stomach and I am trying to show you how nicely we can see the pancreas. Even when the patient is a difficult case and in fatty people but it’s very important so you can see the pancreas and the origin of my mesentery.

6. Root of the transverse mesocolon 04'42''

This is the transverse colon mesentery route, when you have few instruments, you have to move your instruments many times to expose every anatomical detail so you can know exactly where you are going and where you are.

7. Spleen and splenic ligaments 05'11''

Now I expose the spleen, the ligament and I go through slowly to avoid any injury to the spleen; you have to see where you are, you have to be gentle.

8. Mobilisation of splenic flexure 05'50''

I started using ultracision but now I think that ligasure is safer. For young people it’s much easier to use ligasure. To dissect artery IMA I think that you have to gain experience. Look at how close we are to the spleen. How do you control the colon? I pull it down as you can see and I move it all the time to check where I am. Like a finger, I enter my peritoneal sheet, I lift it up and I cut and I look at the colour of the colon, the colour should not change; but it’s too late when it changes! I think this splenic flexure is going to be dangerous to that spleen however it’s done because the colon is nestling up around there. We have a name of a person for the killer ligament as you call it, the one that we pull on in open surgery and tear the spleen, it’s called the ligament of Gubravich. What is your attitude when you make a lesion to the spleen during the deflation of the splenic angle especially in obese people? I call a vascular surgeon, otherwise I use a mesh all around the spleen and I never remove the spleen for this reason. When there is some bleeding, I try to stop it, then I decide what to do. So we expose the right plane, completely avascular. Usually in my hospital I use a 10 mm forceps just to avoid injuries on the bowel as you have seen.

9. Inferior mesenteric vein 10'00''

Now we try to expose the IMV, inferior mesenteric vein, to do so I must remove the reverse Trendelenburg position and put a stitch here now;

10. Suspension of the transverse mesocolon 10'46''

I am suspending the mesenteric transverse colon. I would like to show you that we can do this safely in many ways. This is a simple stitch; now I try to show you how to keep and how to expose the vein. You see the right plane, this is used like a finger and now I cut it.

11. Division of the inferior mesenteric vein 11'57''

It’s a safe procedure because you dissect like when using a finger and you can cut with the same instruments and you are in the right plane. Now we remove this stitch, not very expensive, you have no port now and you can go on.

12. Change of camera position 12'50''

Now my scope is in the umbilical line port and I try to move all the small bowel from the right lower quadrant. This is the sigmoid loop, all the time with 30° scope. Now I have my left colon in front of me, it’s a very cheap technique; one re-usable German forceps, very strong and very good and one ligasure and left colectomy can be done safely.

13. Dissection of the sigmoid mesocolon 13'40''

Can I see my right iliac artery and gonadal vessels and the promontory? Now I am sure that I am in front of the Gruber ligament and I open here. Do you look for the right ureter? Yes, you can do this very nicely if you look for the gonadal. We open the Gruber ligament and we go straight to the ureter.

14. Inferior mesenteric artery 14'35''

The origin of the inferior mesenteric artery is called Bacon axilla. Don’t begin with this type of very difficult case. Now to avoid this mesentery, I try to remove this adhesion. Now we can lift up the mesentery.

15. Lateral dissection of sigmoid colon 16'05''

I am in front of the artery so the nerve is behind it but I try to show it, it’s not so easy, believe me. I think that you can use what you like, as you have seen I put all my stitches on the mesentery not on the bowel. Now I go in a safe region, I am all around my IMA. This is not an easy case. This is the IMA, this is the left colic and now we can dissect. The problem is, another one, are we safe enough for oncological dissection. Do you see my artery? Not very well skeletonized but believe me it is my artery.

16. Dissection of colorectal junction 18'35''

Now I am in front of the promontory of the upper rectum, from a vascular point of view I think that we have to remove all the sigmoid colon. We are in front of the bifurcation of the superior rectal arteries. The first polyp is 35 cm from the anal verge so I am very safe now. In this step of the operation a 5 mm ligasure could be much better because it’s very difficult to do step by step all the layers of this mesentery.

17. Distal transection of left colon 20'26''

18. Exteriorisation of left colon 20'46''

19. Resected specimen 22'50''

The specimen is not bad from an oncological point of view because as you can see the sigmoid colon there is some diverticular disease and the mesentery is very thick as you can see but the artery was removed. This is the mesorectum, the artery and left colic artery. Even in open surgery we can use ligasure for the marginal arteries, this is the Diamond artery and we can dissect it like this and now we are ready for the purse-string. Just to show you that sigmoidectomy was completely done, the specimen is very long. Do you feel the polyps, the clips? No. Would someone open the specimen so we can see? Yes, immediately. We see the clips and the polyps very well. Now we are going to do the anastomosis.

20. Colonic re-anastomosis 24'15''

This is the Gerota’s fascia completely preserved, these are the gonadal vessels coming up and in front of us the ureter crossing vessels. This is the splenic flexure. You see the IMA done by ligasure.