Totally laparoscopic right hemicolectomy for a pT2 N0 M0 adenocarcinoma

This video demonstrates a right hemicolectomy for pT2 N0 M0 adenocarcinoma at the level of the caeco-ascending junction using a medial approach. The medial approach includes a primary vascular access, dissection into Toldt’s area and total freeing of the right colon. Once the terminal small bowel and the transverse colon have been divided at the junction of the proximal middle third, an isoperistaltic side-to-side anastomosis is carried out using a 60mm Endo-GIA linear stapler. The introduction site and the mesenteric window are re-approximated using a PDS 2/0 suture.

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Totally laparoscopic right hemicolectomy for a pT2 N0 M0 adenocarcinoma

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Abstract

This video demonstrates a right hemicolectomy for pT2 N0 M0 adenocarcinoma at the level of the caeco-ascending junction using a medial approach. The medial approach includes a primary vascular access, dissection into Toldt’s area and total freeing of the right colon. Once the terminal small bowel and the transverse colon have been divided at the junction of the proximal middle third, an isoperistaltic side-to-side anastomosis is carried out using a 60mm Endo-GIA linear stapler. The introduction site and the mesenteric window are re-approximated using a PDS 2/0 suture.

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contribution

Keywords

Totally laparoscopic right hemicolectomy for a pT2 N0 M0 adenocarcinoma

Media type

Surgical video

Duration

11'34''

Publication

2009-11

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E-publication

WeBSurg.com, Nov 2009;9(11).
URL: http://www.websurg.com/doi-vd01en2790.htm

Totally laparoscopic right hemicolectomy for a pT2 N0 M0 adenocarcinoma

1. Patient and trocar positioning 00'15''

The patient is placed on the operating table in a supine position, with the left arm alongside his body and the monitor to his right. Four trocars are placed, one in the umbilicus for the optic, a 12mm left subcostally, a 5mm right subcostally and a 5mm suprapubically.

2. Exposure of the ileocaecal vascular axis 00'45''

A slight left tilt allows to move the right colon, and by lifting near the ileocaecal valve, we manage to place tension on the ileocaecal appendicular vascular axis.

3. Dissection of the mesocolon’s posterior sheath 00'58''

This will allow us to divide the right mesocolon’s posterior sheath and the last portion of the small bowel in a V fashion from the terminal loop to the origin of the ileocaecal appendicular artery and continuing on the transverse mesocolon up to the junction of the proximal third, medial third of the transverse colon. By placing tension on the vascular axis, we can easily perform a lymphadenectomy by dividing the lymphatic vessels and the nodes located in this area. The lymphadenectomy having been performed in that area, the artery and the vein will be clipped separately and divided.

4. Approach of the Toldt’s space 01'58''

We then approach the Toldt’s space, an avascular space that separates the meso from Gerota’s fascia. The Gerota’s fascia covers the ureter and the spermatic or ovarian vessels. The dissection is performed with ease and speed as you can tell, in slightly above 2 min 30, all of the right colon is freed by medial approach without having to use excessive cauterization. It is important to keep an intact Gerota’s fascia in order to avoid lesions to the retroperitoneal structures, namely the vessels, the kidney and the ureter.

5. Dissection of the duodenal recess 03'07''

The superior recess of the duodenum that we can see here in the foreground will be freed by dividing several fibres that fix it to the posterior surface of the transverse mesocolon. This freeing will include all of the second duodenum. By preparing the posterior surface of the transverse mesocolon, we will discover the right branches of the middle colic vessels: these will be isolated and divided after completing the duodenum’s freeing.

6. Identification and division of the middle colic artery and vein 04'20''

Here we can see the origin of the middle colic artery and vein that will be divided between clips once they have been isolated. In this way, we will have isolated the tumour of its venous and arterial lymphatic vessels. The posterior dissection brings us to an easy freeing of the colon’s hepatic flexure and we can identify the liver through this route. The division of a few remaining fibres in the right laterocolic ligament completes the freeing of the ascending colon that had been prepared by posterior approach.

7. Completing the dissection 05'34''

Here we see the freeing of the remaining adhesions, and the operative specimen, including the terminal ileum, the caecum, the ascending colon and the proximal third of the transverse colon, is completely freed. The Gerota’s fascia that we can see here covers the kidney, the gallbladder and the liver. The location of the colonic resection has been chosen, the omentum is divided, and we complete the mesenteric division progressively by using ultrasonic scissors. We can also use the Ligasure device for this part of the procedure.

8. Division of the terminal ileum 06'39''

Here we see the transverse colon’s preparation at the junction of the proximal and medial two-thirds, we then divide the meso of the terminal ileum and the latter is divided with a white cartridge 60mm linear stapler.

9. Division of the transverse colon 07'06''

The transverse colon is then divided using the same instrument. We can also use a blue cartridge for this, but we favour the white cartridge.

10. Specimen introduced in extraction bag 07'26''

In this way, the operative specimen is entirely freed and will be placed in a plastic bag to be extracted at the end of the procedure via a 5cm small Pfannenstiel incision.

11. Side-to-side anastomosis 07'50''

To perform a side-to-side isoperistaltic anastomosis, we bring the transverse colon’s stump to the anti-mesenteric ileum at around 10cm from where it was divided. A small incision in the colon’s anterior tenia and in the anti-mesenteric surface of the small bowel allows to introduce the white stapler 60mm linear stapler to perform the side-to-side anastomosis. When removing the stapler, we make sure to close it in order to avoid enlarging the incisions. A gauze protects the intestine of matter extravasation and the trocar is cleaned and disinfected using a gauze soaked with disinfectant.

12. Closure of the stapler’s orifice 08'58''

The orifice used for the stapler’s introduction is then closed using a continuous suture with slowly absorbable 2/0 PDS material. This closure completes the anastomosis, isoperistaltic in this case; of course, we can also perform an anisoperistaltic anastomosis. To do this, we would have to place both divided ends next to each other. We see here the end of the anastomosis’ closure; one plane should be enough; it is large enough and to block this suture, another suture leaving from inside will allow to securely tie and close the orifice. The anastomosis control demonstrates its water-tightness, and we complete the procedure by closing the mesenteric window between the colon and the small bowel using a slowly absorbable continuous suture. Here we see the end of the running suture, the operative field, and the suprapubic incision allowing to extract the specimen, along with the other three incisions. Here is the opened-up operative specimen showing the tumour in the middle of the caecum and the meso.