Totally laparoscopic right colectomy for T3, N+, M0 stenotic adenocarcinoma

We present this video for a standard oncological laparoscopic approach for a T3 cancer in the right colonic flexure. The patient presented with asthenia but no symptoms of occlusion. A right colectomy is performed by a medial to lateral approach. A stepwise approach is chosen and anatomical landmark identification is explained along the procedure.

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Totally laparoscopic right colectomy for T3, N+, M0 stenotic adenocarcinoma

Authors

J Leroy, J Marescaux

Abstract

We present this video for a standard oncological laparoscopic approach for a T3 cancer in the right colonic flexure.
The patient presented with asthenia but no symptoms of occlusion. A right colectomy is performed by a medial to lateral approach.
A stepwise approach is chosen and anatomical landmark identification is explained along the procedure.

Classification

complex cases

Keywords

Totally laparoscopic right colectomy, T3, N+, M0 stenotic adenocarcinoma

Media type

Surgical video

Duration

21'59''

Publication

2009-01

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E-publication

WeBSurg.com, Jan 2009;9(01).
URL: http://www.websurg.com/doi-vd01en2529.htm

Totally laparoscopic right colectomy for T3, N+, M0 stenotic adenocarcinoma

1. Clinical case presentation 00'19''

This patient was managed because of major asthenia and anemia with 5 grams of hemoglobin. The patient had no previous surgery, this is the CT-scan showing the lesion at the level of the right colonic flexure and the barium enema also found this stenosis to be quite evident and Professor Leroy will perform the right colectomy now.

2. Trocar positioning 00'48''

We have introduced the different trocars. I will explain later my landmarks. The patient is in a right supine position, his left arm along the body. I will operate standing between the legs of the patient. So midline, two mid-clavicular lines, the right and the left, and the anterior axillary line, the horizontal line through the umbilicus, the anterior superior iliac spine and the pubic symphysis. This is the first trocar I introduced to the panoramic exploration of the abdominal cavity. This is the trocar that will be used to introduce the scope and I will use a 0 degree scope. Then I have introduced the third trocar in the left subcostal area lateral to the mid-clavicular line. Trocar four will be used for my left hand: this trocar will be used to expose, retract, and introduce the stapler too.

3. Exposure 02'33''

First, we place the patient head up and we will grasp the omental loop to expose the root of the transverse mesocolon. It is important to see the duodenojejunal junction and the ileocaecal junction. Behind this, you have the tumor with the omentum fixed on the tumor and the beginning of the neovascularization, the stenosis is just behind this side. We use 15 Watts.

4. Medial approach (dissection and ligation of the colonic vessels) 03'38''

This is a new Ligasure that I am using now as a Ligasure. This is the opening of the mesentery. I continue the dissection until I open the retroperitoneal space. I am doing a primary vascular approach using, as I did in the previous sigmoidectomy, a medial approach. I have exposed all of the right and transverse colon. They are well exposed, particularly the meso and I will do the division of the vessels at their origin. The first landmark I will find when I open the retroperitoneal space behind the ileocolic vessels would be the duodenum. I am dividing the peritoneum first and slowly I will see the duodenum coming. It is very sick, very hard. How large a vessel will you take with this new Ligasure? Up to 7mm but it is no different to the others. It is not easy because the nodes are fixed to the origin of the IMA. We can see it is very difficult. Yes, because I am sliding on the nodes. I am dividing the artery. This is the SMV, it is just behind there; the danger is to injure it. It is coming, see the vein. The cross just under the pancreas. See the pancreas falling. I am behind the gastrocolic trunk, the head of the pancreas is down. See the genus superius. It is the right branch of the right colic. This is a loop. I prefer to put a loop, it is not a problem of Ligasure, it is due to the quality of the tissue. These are the nodes I will try to remove later, anterior to the superior mesenteric artery. Now we will complete the division, it is finished by going straight, we can go more lateral or medial depending on the resection limit we want. This is the beginning of the attachment, this is the duodenum, the attachment of the omentum is free.

5. Transverse colon division 09'56''

Now I will divide the transverse colon. Ok, we open this, we have to be perpendicular to the colon. The problem is when you mobilize the colon and it’s loose, it is very difficult to lift it up to give traction, so it’s best to leave it fixed until the very end so you can use traction and counter-traction to dissect the mesentery. Why do you never use a vascular endo-GIA on the vessels? In this case, it’s difficult to be very close to the vessels if you don’t do a skeletonization of the origin of the end of the vessels and putting a stapler will be very close and difficult. See the duodenum. I’m dividing the omentum now. I did a division of the attachments of the omentum before and you have seen it, and I’m finishing now.

6. Ileal division 11'35''

And now we have to divide the ileum to complete the medial dissection. I want the free the ileocaecum before dividing the small bowel. I have not changed the position of my instruments. This is the freeing. I use a 1mm blade. It’s the Valleylab mode so it’s a monopolar current less dangerous than usual because there’s electronic control more than 3,000 times per second. These are the genital vessels. Remember that the ureter is medial. You have to imagine the lateral side in your mind, medial side, and a mesenteric bridge between. I now introduce my Endo-GIA stapler in the supra-umbilical trocar as you can see. I’ll divide the ileum I have just freed using a vascular cartridge and I’m dividing safely with control perpendicular to the bowel or with a shorter side on the antimesenteric side on the part of the bowel that will stay in place. Don’t cut the staples with a knife, use the monopolar blade for cutting more like this. I have to stay in the right plane to find the plane anterior to the Gerota’s fascia, the primitive peritoneum. We slide back. Did you dissect the right branch? Yes, I divided it.

7. Lateral dissection 14'17''

Slowly I’m pushing the right colon cephalad and I’ll free the posterior attachment step by step. Will you do an intracorporeal anastomosis or extracorporeal? Normally I’ll do it intracorporeally. I think the postoperative recovery is faster due to the non-traction on the bowel. We do a side-to-side isoperistaltic anastomosis. Do you remove the specimen suprapubically again? Yes, we can choose if you do the anastomosis inside the site or if you prefer to do it differently, you can do a small supra-umbilical incision just in front of the transverse colon exactly where I have put my trocar before. So you’re supra-umbilical then.

8. Intracorporeal anastomosis 16'42''

Now we can fix together the 2 stumps using Ethibond. We’ll do an isoperistaltic anastomosis. For this, we fix the 2 stumps. We’ll do the same on this side. The advantage is that gravity does the exposure. So we’ll pull this. Vascularization is good.

9. Specimen extraction 20'50''

We remove suprapubically. I introduce this. We remove the trocar putting my finger. The next step is to introduce the Endo-catch II like this. First, we’ll push it inside. I’m closing now. I’ve closed the plastic bag. You can grasp this and I’m removing the loop.