Laparoscopic left colectomy with a lateral to medial dissection

The video "Three-trocar laparoscopic sigmoidectomy and transanal extraction of the specimen for diverticular sigmoiditis" authored by J. Leroy and J. Marescaux is analysed by Dr. Barry Salky, MD, sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

This video shows a series of technical tips and tricks for the identification, dissection and ligation of the main vascular elements during a laparoscopic left colonic resection using the LigaSure Advance™.

Laparoscopic surgery for colonic disease has experienced an increased utilization by surgeons. Current techniques require an abdominal incision for specimen extraction. In this lecture, Dr. Franklin presents the technique of total intracorporeal colon surgery using natural orifice for specimen extraction.

Background: Single incision laparoscopic left hemicolectomy is a feasible procedure. A suprapubic access allows to offer satisfactory cosmetic results in case of an extended scar due to a large tumor. An intracorporeal circular mechanical anastomosis is the most common type. A manual anastomosis is feasible and allows to control lumen opening, potential bleeding, and overall to overcome the difficulty of transanal stapler insertion in case of high rectal transection.
Video: This video shows two different types of manual colorectal anastomosis, through a right suprapubic access.
1) Double-layer end-to-end
2) Monolayer end-to-end
Results: After an appropriate learning curve, time to perform the manual anastomosis is 40 minutes.
Conclusions: Different colorectal anastomoses can be performed and the surgeon has to choose the appropriate one, case by case.
To watch the video demonstrating the entire left hemicolectomy, please click here.

Transumbilical single incision laparoscopic sigmoidectomy is feasible by experienced laparoscopic surgeons using current available laparoscopic instruments and staplers. In this live video shot during the IRCAD Advanced Course in Laparoscopic Colorectal Surgery in November 2009, Prof. Leroy shows an extraordinary single port sigmoidectomy.

This video demonstrates a laparoscopic three-port right hemicolectomy in an obese patient with a dysplastic adenoma. A stepwise approach including landmark identification is undertaken during the procedure.
The specimen is extracted through a small laparotomy, which will be protected by a plastic bag. An extracorporeal mechanical side-to-side anastomosis using a 60mm Endo-GIA is made and the mesenteric window is closed using a monofilament 2/0 running suture.
This video is a good demonstration of key anatomic landmarks, surgical planes, and surgical approach to a right hemicolectomy.

A 45-year-old woman with abdominal pain and hematochezia was found with adenocarcinoma of the sigmoid colon causing incomplete obstruction. CT-scan revealed a 5cm exophytic tumor of the superior pole of the left kidney.
Synchronous Left Colectomy (LC) and Renal Tumor Enucleation (RTE) were scheduled. Robotic surgery was preferred for RTE, but when performed first, splenic flexure mobilization could well interfere with subsequent LC.

Starting with a standard robotic LC would make multiple dockings and patient position changes necessary.
To overcome these problems, we adapted the technique of LC to the lateral position required for RTE and performed robotic vascular ligation of the left colon first. Robotic left colon mobilization and RTE were then performed to finally achieve colectomy and colorectal anastomosis by means of laparoscopy with the patient in a standard lithotomy position.
The procedure required only one docking of the robot and only one change in patient position. A compromise in port site positioning was obtained between the two procedures. One short incision was performed to retrieve both specimens and the same robotic instruments were used for both procedures.
Operative time was 350 minutes. The patient recovered well and no complications were noted. She was discharged on postoperative day 7.

The objective of this film is to demonstrate how to perform a total colectomy by means of the new Ligasure Atlas Blunt Tip® vessel-sealing device, which allows for a perfect hemostasis and can be used for dissection like the finger of one’s hand.