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Totally laparoscopic right colectomy for caecal cancer

This is a live video demonstration of a totally laparoscopic approach to right colectomy. The surgeon stands on the left side and performs a medial vascular approach including medial mobilization of the right colon and hepatic flexure. The specimen is resected and extracted before pneumoperitoneum is re-created for an intracorporeal ileo-colic stapled anastomosis. This technique is suitable for advanced laparoscopic surgeons.

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Totally laparoscopic right colectomy for caecal cancer

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摘要

This is a live video demonstration of a totally laparoscopic approach to right colectomy. The surgeon stands on the left side and performs a medial vascular approach including medial mobilization of the right colon and hepatic flexure. The specimen is resected and extracted before pneumoperitoneum is re-created for an intracorporeal ileo-colic stapled anastomosis. This technique is suitable for advanced laparoscopic surgeons.

關鍵字

laparoscopic, right colectomy, ileocolic vessels, colon, pneumoperitoneum

媒體類型

手術影片

期間

24'00''

刊物

2007-04

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Apr 2007;7(04).
URL: http://www.websurg.com/doi-vd01en2123.htm

Totally laparoscopic right colectomy for caecal cancer

1. Trocar placement 00'20''

We put two trocars, the first is for my right hand in the left hypochondrium, the second one is in the iliac fossa, the optic is in the para-umbilical region. I now put another trocar under the xiphoid and the fifth, a 5mm trocar to remove the transverse colon in the right hypochondrium. I usually use a 30° optic.

2. Exploration 01'10''

Here is the last part of the small bowel, the caecum, ascending colon is here. I think that here is the division. The first step is to identify the landmarks. Here we have the duodenum, these are the ileocolic vessels.

3. Division of ileocolic vessels 02'00''

Do you begin with artery ligation? Yes, the first step is always the vessel dissection and ligation. I always use the ultrasonic shears. I do not use the Ligasure for this, I use the Ligasure only for diverticulitis, for rectum and colon I prefer the ultrasonics. Why do you choose for the left colon the Ligasure and for the right the ultrasonics? Because I preserve the inferior mesenteric artery and I divide only the sigmoid vessels, with the Ligasure it’s easier. Do you dissect in all cases all the length of the artery? Yes, I do. Here is the superior mesenteric vein, so we are at its origin. This is the duodenum. This is the artery, this is the vein. Is it easier to go to the artery first or to the Toldt’s fascia? I divide the artery first, and then I try to find the Toldt’s fascia. I do ligate the artery first in all my procedures. We’re always doing the same procedure in laparoscopic surgery and this means that we always dissect first the main or the superior mesenteric vein because sometimes the artery is going downwards, and sometimes the artery is going above, you must know that before you dissect the vessels. This way you are always central and you do a lymph node dissection from there.

4. Medial mobilization of right mesocolon 05'50''

As an open surgeon, I always start with the vein exactly how you described it, but before that, I divide the terminal ileum before I approach the vein and the artery, and then take the ileocolic vessels. I always feel that right hemicolectomy is a dissection in detail of the duodenum and the anterior surface of the head of the pancreas, all of this starting medially and working laterally.

5. Control of middle colic vessels 07'26''

Is it necessary or not to take the lymphatic field associated with the right branch of the middle colic in addition to the ileocolic and right colic? In this case, this is the middle colic artery, it is frequent to find this position. This is the left branch of the middle colic artery and this is the right branch. I dissect the right branch, I cut the right branch only. I think that’s what most of us would do, it’s occasionally permissible to settle for a low caecal lesion for the ileocolic and right colic territories but nobody would argue with taking the right branch of the middle colic. The next question is how much of the omentum are you going to take?

6. Mobilisation of hepatic flexure of colon 10'10''

I only have 4 trocars because the position is good. My assistant is retracting the mesocolon with his forceps and I am trying to reach the right colic flexure from medial to lateral to open the colophrenic ligament. You can see the liver. For the oncologic resection, I always use the ultrasonics forceps. I only use the Ligasure for benign disease because the dissection is not precise enough for an oncologic resection. It is possible to divide the mesocolon with its vessels quickly and easily. This is where we divide the colon.

7. Mobilisation of ileo-caecal junction 16'35''

I dissect the ligament on the sacrum and the last ileum, this is the last loop of the ileum so we are ready to divide the bowel. Are you going to make an extracorporeal or intracorporeal anastomosis? Intra-abdominal anastomosis, in the last cases I have always used this technique, I think it’s better than the extracorporeal anastomosis.

8. Specimen resection and extraction 17'20''

I always use the white stapler on the small bowel, also in morbid obesity surgery as it is more hemostatic. In the colon, I guess you’re using the blue one. The dissection is now complete, you can see the transverse colon, the right flexure. Now I put the loop here.

9. Intracorporeal anastomosis and mesenteric closure 19'41''

Now I close the mesentery. It’s important to remove the Endo-GIA closed to avoid enlarging the enterotomy.