Totally laparoscopic right colectomy using the medial approach for caecal cancer

The advantages of a total intracorporeal anastomosis are as follows: no need to enlarge the incision and no traction of the pedicle during the extracorporeal anastomosis. This video shows a right colectomy for a polyp of the ascending colon in a 50-year-old female patient presenting with a Lynch syndrome.

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Totally laparoscopic right colectomy using the medial approach for caecal cancer

Authors

J Leroy, J Marescaux

Abstract

The advantages of a total intracorporeal anastomosis are as follows: no need to enlarge the incision and no traction of the pedicle during the extracorporeal anastomosis. This video shows a right colectomy for a polyp of the ascending colon in a 50-year-old female patient presenting with a Lynch syndrome.

Keywords

Totally laparoscopic right colectomy, medial approach, caecal cancer

Media type

Surgical video

Duration

27'38''

Publication

2010-09

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E-publication

WeBSurg.com, Sept 2010;10(09).
URL: http://www.websurg.com/doi-vd01en2873.htm

Totally laparoscopic right colectomy using the medial approach for caecal cancer

1. Introduction 00'21''

We will see a right colectomy for a polyp of the ascending colon in a young 50-year-old female patient presenting with a Lynch syndrome. We decided to do a right colectomy because of the risk of cancerization. Her mother had 5 cancers of the digestive tract several years ago. She was operated 5 times but she died. Concerning the landmarks we use for doing this surgery, they are always the same. Concerning the abdominal cavity, we have the limit of the ribs, the limit of the pubis, anterior superior iliac spine and several virtual lines, the midline through the umbilicus, the mid-clavicular line on the left and on the right, and the anterior axillary line, and the horizontal line through the umbilicus. We will use at least 4 trocars even if we can do this surgery with one trocar or three trocars.

2. Trocar insertion 01'46''

The classical technique we use is a medial approach and to do so, we will begin introducing the first trocar on the midline 8 to 10cm above the umbilicus. This is also the site where we will do the incision where the specimen will be extracted later on and/or the anastomosis. Then we will introduce trocars approximately at the level of the anterior superior iliac spine and the midline. This will be the optical trocar for the introduction of the 0 or 30 degree scope. I prefer using a 0 degree scope. Then on the left subcostal area we will introduce a trocar to retract the transverse colon and expose. We will use also a trocar in the right iliac fossa to manipulate the colon. This will be the trocar for the surgeon’s left hand, and to facilitate the procedure, we will introduce another 12mm trocar or perhaps a 5mm one in this case because we will use the Ligasure® Advance. We will introduce the device for the dissection in this trocar as well as the stapler or the stapler will be introduced in trocar number 1.

3. Abdominal cavity exploration 03'41''

The first step is to do a panoramic exploration to rule out any errors regarding the introduction of the trocars and to rule out the presence of carcinomatosis for example. We introduce the other trocars, that is the optical trocar just on the midline at the level of the anterior superior iliac spine. This is a one-Step trocar we introduce and we will change now the position of the trocar using the zero degree scope. It’s time to introduce a 5mm trocar. See the second trocar was just introduced in the left subcostal area. Next step, we put a trocar in the right iliac fossa, a little lateral to the mid-clavicular line; it’s a 5mm trocar too.

4. Transverse mesocolon exposure 04'59''

The first step is to expose and to do so, we introduce a forceps inside just introduced the right iliac fossa trocar and on the left hypochondrium, and we push cephalad and we move back the camera a little. We ask the assistant to grasp the omentum like this and we have a perfect exposure of the root of the transverse mesocolon. As you see, the objective is to see the duodenojejunal junction we have there and to see the ileocaecal junction. To complete this, we will put the patient in a left lateral tilt. Perhaps it will be better to grasp at this level to have a better exposure and see the duodenum. See the left lateral tilt that facilitates the exposure. So we have to see the ileocaecal junction. We will see it better. We can see that the caecum is very deep in the pelvis but it seems very mobile. We have the ileocaecal junction. Why? It’s necessary to see. It’s because this is the root of the mesentery and only to remind you: the ileocaecal junction is there. So this is the root of the mesentery. It’s a 5mm trocar. So I will add a trocar to have a perfect exposure. This is to expose better and better understand the anatomy. We’ll give my assistant another forceps introduced in the supra-umbilical trocar in order to have a good exposure of the duodenum, the root of the mesentery and the axis of the inferior mesenteric vein probably. These are the ileocaecal vessels. I change the grasping there to have a better view like this. I use the Ligasure® Advance.

5. Peritoneal opening 07'11''

The goal is to incise the peritoneum and only the peritoneum. As soon as it is done, we can complete lower. We use the Valleylab mode. We can use traction and counter-traction to open the plane to rapidly find the duodenum. This is a good landmark. The best is to change the traction on the vessels like this and to find the lateral side of the SMV. That is the key of the dissection in oncologic procedures. We have to dissect without traction to avoid the risk of bleeding when we are sealing and using good traction and counter-traction, we find the right plane. This is a medial approach. We do not touch the colon. Remember that we have on the right ascending colon a polyp. It’s not a cancer until now but this patient has a risk of cancerization because he has genetic evidence of a Lynch disease. We have the head of the pancreas; anterior to it, we are dissecting. This is the right colic vein; we will divide it soon not too close from the gastrocolic trunk of Henlé. Due to the risk of degeneration of this polyp (60% in the literature), we have decided to do a segmental right colectomy because a mucosectomy was also tried but impossible due to the localization and the difficulty to have a perfect access, and probably it’s reasonable to do a right colectomy because of this risk in this patient.

6. Duodenum identification 10'34''

This is the first duodenum and the insertion of the omentum; we have just opened on the duodenum. You can see it very well here.

7. Transverse mesocolon dissection 10'48''

So we continue straight to divide the transverse mesocolon until we reach the colon. We continue the dissection. This is the omentum.

8. Colon division 11'29''

We are dividing the colon. It is important to have a right-angled division. We are lucky: the colon is mobile. We will see that it is soon finished. As you can see, we divide the omentum also with a stapler or with the Ligasure® device. I’m dividing the transverse mesocolon, the insertion, the root with the help of my assistant doing traction and counter-traction. I’m using the Valleylab mode to divide (with a power of 20 Watts). This is the right flexure. I’ll do the division. We are anterior to the kidney at this moment. We will stop there and change and continue the dissection distally. The forceps that was maintaining the transverse colon is changed at this moment in this position to re-grasp the ileum.

9. Ileum division 13'41''

As you see, we have the ileum, and we will divide the ileum at this moment. Until now, it is not necessary to see the ureter because we are at a distance from the ureter. Through the epigastric 12mm trocar-- the first one that we have introduced, we push the stapler and divide the ileum with a 60mm long Endo-GIA linear stapler to have a long division perpendicular to the small bowel. We will continue the dissection. I’m dividing and not closing the Ligasure® completely because there are staples and contact with staples will induce a defect in the sealing.

10. Ureter identification 15'01''

We have to locate the ureter and it is at this moment that it is time to see just behind, we have the ureter moving. See it moving just behind. It’s also a danger when we do a traction like in this particularly easy case not to be in the right plane and to injure the retroperitoneal structures, and particularly the ureter. That’s why it’s good to do traction and counter-traction and to find the right plane using this technique. This is a good technique to do the dissection with a minimum of manipulation on the colon and the tumor, if there is a big tumor, particularly in the case of cancer, we see very well the end of the posterior attachments. The right colectomy is finished. We push the colon in a temporary place above the liver.

11. Preparation for anastomosis 16'08''

Now we have to do and prepare the anastomosis inside and we will ask the assistant to grasp the transverse colon to see the extremity of the transverse colon we divided before. It is necessary to follow the edge of the mesentery divided and I ask my assistant to maintain it in this position to expose. Now I have to find the small bowel. How do we do? Similarly, we follow the edge, the limit of the division of the mesentery and finally we will have the extremity of the ileum.

12. Stump fixation 16'53''

Now we will do a side-to-side isoperistaltic anastomosis and to do so, we will fix the bowel like this. We can also do the anastomosis outside. Even if we do it outside or through a small incision, we fix together the two stumps to avoid a twist when we do the anastomosis outside with a small incision. Because we will not see very well the twist so what we do now, we fix with two stitches, which are landmarks not far from the anterior taenia. We can do the knots inside but the goal is only to fix together and not to make a suture. The second stitch is fixed distally. See we have the taenia; we try to be just anterior to the taenia and same, anti-mesenteric side, a little more on the small bowel. Second stitch and now it’s enough. It’s mainly to help me expose. I use the Ligasure® Advance. We have opened now. Now we do the same on the colon. The risk is to do a submucosal dissection. We don’t have to incise too much. Now it’s opened. We’ll change the position of the supra-umbilical scope to introduce a stapler. We’re changing our position.

13. Stapling 19'34''

I want to angle like this. So the stapling line is done. We remove now and change once more the scope’ position coming back in the suprapubic trocar to have a better axis view to finish the anastomosis. See it seems that we have all closed. The danger is to forget a posterior hole. It’s why we have to remove the stitch to be sure that we have the exact angle. This is a risk of fistula if we don’t close. And in this case, we did the hole in the right position, at distance of this stitch but sometimes we are very close and the risk to forget a small hole back to it so I propose to remove the stitch.

14. Defect closure 21'03''

This is monofilament Maxon 3/0. I’m coming around, grasping, tightening. It’s good and we come back. The advantage of the monofilament: very good suture first, and also we can pass using extramucosal sutures, different stitches before pulling. This is better because it’s easier to work and it’s not necessary to change our position, as you see thanks to the good preparation of the section with the Ligasure® Advance. We can complete like this. We can use another suture to do two half-running sutures but I don’t think it is necessary in this case because it’s a very small incision. As you see, I’m now pulling the sutures and because it’s a monofilament, it’s sliding very well. I think that I’ll do one more. So we will prepare the Endo-Hernia Universal. It is ready and I’ll do the knot. I think the monofilament is really the best because we have a memory of the sutures, easy to work in laparoscopy. We will keep these sutures because they will maintain the two stumps fixed together.

15. Mesenteric gap closure 23'07''

Now we have to close the mesenteric gap. Different possibilities exist: choosing the closure like this so we have to re-expose. It is necessary to close the mesenteric gap because there is a risk of internal hernia. It depends on the closure as we have demonstrated it and published. So we have different possibilities, using a stapler; in this case, we will use a running suture. It’s cheaper. A running suture is interesting because it’s cheaper and it’s not necessary to introduce a 12mm trocar to do the dissection. Another closure technique is not to use a medial approach but a lateral approach. It takes longer though. It’s why we don’t hesitate to use a stapler, but I remind you that it’s not a 5mm trocar that we are obliged to use but a 12mm one in place of a 5mm. And probably, it’s better to use a 5mm trocar when we do this surgery. So we have finished to close the gap.

16. Specimen extraction 24'37''

I will give you a trick to remove the specimen more easily. When we have a long and big specimen, sometimes it’s difficult to find the good extremity and on the extremity, we will fix a loop. This loop is not to close but it is to find the segment of bowel more easily. Now we have to remove the specimen. Different options exist. We can remove it through the vagina if we want to be very cosmetic. We can remove it through a suprapubic incision. That’s what we will do. Now we continue the procedure introducing the sleeve. This is a plastic wound protector, a very small one. The size of the incision is 2cm. So we introduce the Endo-Catch and we control the patency. We will put the specimen. In right colectomies, it is always a huge specimen inside the plastic bag and as you see, we have the stitch inside. The best is to maintain it outside the bag. So we have the plastic wound protector you can remove. It’s difficult to remove through a small incision. We have the bag and you see we have the sutures, and thanks to this, we can find the right extremity of the colon that will come first and thanks to this, it’s easier to remove the huge specimen. The size of the incision is 3cm. So the procedure is complete. We will close and remove all the trocars to control there is no bleeding left. We close the aponeurosis in this case.