Transumbilical single incision total colectomy for carcinoma of sigmoid and descending colon with multiple polyps

Single incision laparoscopic surgery can be applied for colonic resection. This video demonstrates a multiple port transumbilical single incision technique for total colectomy. The procedure is in compliance with oncological principles in cancer surgery. The final wound is slightly larger than the umbilicus, which is necessary for the extraction of the specimen, yet the wound appearance is still pleasing.

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Transumbilical single incision total colectomy for carcinoma of sigmoid and descending colon with multiple polyps

Authors

P Lau, SY Kwok, W Day, A Yip

Abstract

Single incision laparoscopic surgery can be applied for colonic resection. This video demonstrates a multiple port transumbilical single incision technique for total colectomy. The procedure is in compliance with oncological principles in cancer surgery. The final wound is slightly larger than the umbilicus, which is necessary for the extraction of the specimen, yet the wound appearance is still pleasing.

Classification

single port, contribution

Keywords

Transumbilical, single incision, total colectomy, carcinoma, sigmoid colon, descending colon, polyps

Media type

Surgical video

Duration

16'17''

Publication

2011-06

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E-publication

WeBSurg.com, Jun 2011;11(06).
URL: http://www.websurg.com/doi-vd01en3298.htm

Transumbilical single incision total colectomy for carcinoma of sigmoid and descending colon with multiple polyps

1. Clinical case presentation 00'17''

We present a 66-year-old man who suffered from synchronous adenocarcinoma of descending and sigmoid colon. This patient underwent transumbilical single incision total colectomy. He was diagnosed to have iron deficiency anemia and was investigated with colonoscopy. The colonoscopy showed that he has a 4cm tumor in the sigmoid colon and a 2cm tumor in the descending colon. In addition, there were more than 50 polyps distributed throughout the whole colon while the rectum is spared.

2. Trocar position 00'49''

We have performed this operation using the multiple port single transumbilical incision technique. A 7mm flexible port was first inserted at the umbilical scar by the cut-down technique. Another 7mm and a 12mm flexible port were then inserted through separate incisions along a line transversing the umbilicus. Separate incisions were used instead of a single incision to minimize gas leak. The total length of the wound after joining the 3 incisions was 4.5cm, which was the estimated adequate size for the extraction of the specimen. Flexible ports were used because they allow for the insertion of a rigid curved instrument. Additionally, they provide good wound anchorage. In this operation, we have only used conventional straight laparoscopic instruments. We have used a 5mm end-view laparoscope for viewing purposes, a 5mm ultrasonic instrument for dissection, 10mm clips for vascular control and a 12mm flexible stapling device.

3. Patient position 01'50''

With the patient put in a right-side up position, the right colon was first operated on.

4. Ileocolic vessel dissection 01'54''

The ileocolic vessel was dissected. There is usually little fat in the mesocolon over the right side. The duodenum is seen here and protected. The vascular bundle was dissected and skeletonized. Due to the co-axial direction of viewing, the judgment of depth may be suboptimal. Care should be taken to ensure complete vascular control before division. The dissection went cranially. The duodenum, which is seen on the right side of the picture, was further dissected away.

5. Mesocolon dissection 02'58''

The mesocolon was separated from the retroperitoneal space. The right ureter was seen here and safeguarded.

6. Division of right colic vessels 03'10''

The right colic vessel, which was identified here, was running over the duodenum. It was carefully dissected, skeletonized, controlled with clips and then divided. After division of the right colic vessels, the operation moved on to the mobilization of the caecum.

7. Mobilization of caecum and ascending colon 04'00''

The caecum, which is on the right hand side, was retracted medially and the lateral peritoneal attachment was divided. The ascending colon was then retracted cranially and the colon is separated from the peritoneal attachment and dissected away from the retroperitoneal structures.

8. Duodenum dissection 04'19''

Here the duodenum is dissected away from the colon. The lateral peritoneal attachment was further divided. After the right colon was freed up to the hepatic flexure, the transverse colon was mobilized. The greater omentum was retracted upward and using gravity, the gastrocolic ligament was opened adjacent to the transverse colon. The lesser sac was entered.

9. Detachment of greater omentum from transverse colon 05'04''

The procedure was carried on with the complete detachment of the greater omentum from the transverse colon to the hepatic flexure.

10. Left colon mobilization 05'13''

The intervention was then continued by mobilizing the sigmoid and descending colon. The patient was then tilted to a left-side up position. Here the sigmoid colon was in the left side of the picture. It was mobilized from lateral to medial by division of the lateral peritoneal attachment. The descending colon was retracted medically and it was dissected from the lateral peritoneal attachment and Gerota’s fascia. Here the left ureter can be seen after mobilization of the sigmoid colon. The operation then moved on to medial dissection. The sigmoid mesentery, along with the inferior mesenteric vessel, was retracted upward to expose the plane between the inferior mesenteric artery and the iliac vessels. Dissection was kept close to the inferior mesenteric vessel. Alveolar tissue containing the parasympathetic nerves was stripped away to the retroperitoneal plane, preserving its integrity. The sigmoid mesocolon was fully dissected free and the window revealed the left ureter lying on the retroperitoneal plane.

11. IMA division 06'40''

The inferior mesenteric artery is exposed at its origin. The adipose tissue was dissected away and the artery was skeletonized. The artery was clipped at its origin and divided.

12. IMV division 07'08''

The inferior mesenteric vein, which runs separately from its artery, was then exposed at the level of the 4th part of duodenum. It was controlled with clips and divided.

13. Splenic flexure mobilization 07'40''

The splenic flexure was then approached. The proximal descending colon was retracted upward. It was dissected from the left Gerota’s fascia. The lateral peritoneal attachment at the splenic flexure was divided. The gastrocolic omentum on the left side was opened. Similarly, the greater omentum was retracted upward and the transverse colon was mobilized towards the splenic flexure.

14. Middle colic vessel division 08'34''

The next step in the procedure was to control the middle colic vessel. The transverse mesocolon was exposed by retraction of the transverse colon cranially. The peritoneum was opened and the middle colonic vessel was dissected and skeletonized. The middle colic vessel was controlled with clips and divided. The peritoneum and adipose tissue between the middle colic vessels and the inferior mesenteric vein was divided. Adipose tissue was cleared from the pancreatic tail, which is shown on the right lower region of the picture. This frame showed the splenic flexure fully mobilized. The operation was now carried on to the pelvis. The patient was repositioned into a Trendelenburg position. The sigmoid tumor was adherent to the dome of the bladder on the right side. The peritoneum covering the dome of the bladder was opened away from the tumor. The subperitoneal fatty tissue together with a superficial cuff of bladder muscle was excised “en bloc” with the tumor, aiming to gain a clear resection margin.

15. Upper rectum dissection 10'39''

The rectum was now retracted to the right. The peritoneal attachment to the lateral side wall was divided down to the level of upper rectum in the pelvis. Posteriorly, the rectum was dissected along the presacral plane. Distal resection was carried out at the level of the rectosigmoid junction. At this point, the rectum was retracted to the left side. The fascia propria covering the mesorectum was opened. The right superior rectal vessel in the mesorectum is seen at this point. It was isolated and controlled with the ultrasonic instrument. The mesorectum is vascular, and it contains small vessels that can be effectively divided using the ultrasonic instrument. Similarly, the left superior rectal vessels lying in the mesorectal fat were divided. The mesorectum was completely divided from right to left. The remaining mesorectal fat on the left side was cleared, leaving a bare rectal tube ready for division by stapling.

16. Rectal division 13'14''

A flexible 45mm stapler was inserted via the 12mm port. It was deflected to its maximum to achieve an appropriate angle for transection. The stapler engaged the rectal tube and closed. The stapler was viewed from the direction of the mesorectum to ensure an appropriate level of transection, avoiding an ischemic rectal stump. The first firing was achieved near the complete transection of the rectal tube. The stapler was retrieved after straightening of the deflection, then reloaded. A second firing was performed. A thin strand of tissue connecting the mesorectum was divided with the ultrasonic instrument.

17. Specimen extraction 14'13''

A transumbilical wound joining the 3 port sites was made. An Alexis wound protector® was placed into the wound. The total colectomy specimen was retrieved via the wound protector.

18. Terminal ileum division 14'25''

The terminal ileum was transected. The anvil was inserted into the terminal ileum, and the joining limb of the anvil was brought out at a site proximally enabling an end-to-side ileorectal anastomosis. The ileal end was closed, and a purse-string was placed around the joining limb of the anvil. The ileal end was closed, and a purse-string was placed around the joining limb of the anvil. The prepared terminal ileum was returned into the abdomen. The pneumoperitoneum was created again using a surgical glove over the Alexis wound protector® as a glove port.

19. Anastomosis 14'58''

The rectal stump was positioned for the spike to pierce through at the center. The anvil was aligned with the spike at the rectal stump. The orientation of the ileal limb aimed to avoid twisting. The stapler was closed with the ileum correctly positioned. The stapler was fired and the anastomosis was completed. The peritoneum cavity was suctioned clean. The wound was closed with care to create again the umbilicus. The final wound size was 5cm.