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Laparoscopic complete mesocolic excision (CME) for right colon cancer
The aim of the video is to describe the anatomical landmarks and the surgical technique for complete mesocolic excision during a laparoscopic right colectomy for cancer.
Preoperative high-resolution CT-scan and 3D printed models of the patient’s vascular anatomy is obtained to study the peculiar vessels distribution. Four ports are used, all located in the left flank as described in the video. Dissection between the visceral fascia which covers the posterior layer of the mesocolon and the parietal fascia covering the retroperitoneum (Toldt’s fascia) is carried out by means of monopolar electrocautery and combined advanced bipolar and ultrasonic dissection device. Caudocranial dissection of the mesocolon along the route of the superior mesenteric vein is performed, up to the inferior margin of the pancreas, exposing, ligating and dividing the ileocolic, the right and middle colic vessels at their origins. The gastrocolic trunk is fully dissected and the superior right colic vein clipped and divided. The transverse colon and terminal ileum are divided, the colon is mobilized and ileo-transverse intracorporeal stapled anastomosis is fashioned.
Between April 2017 and December 2018, 46 laparoscopic right hemicolectomies with CME were performed. There were no major vascular lesions. All intraoperative bleedings in the peripancreatic area were controlled with bipolar instruments and hemostatic devices, and there was no need for intraoperative blood cell transfusions.
Laparoscopic CME is feasible, but extensive knowledge of the vascular anatomy of the right colon as well as experience in advanced laparoscopic technique is required.
S Macina, L Baldari, E Cassinotti, M Ballabio, A Spota, M de Francesco, L Boni
Surgical intervention
1 month ago
2049 views
12 likes
0 comments
07:10
Laparoscopic complete mesocolic excision (CME) for right colon cancer
The aim of the video is to describe the anatomical landmarks and the surgical technique for complete mesocolic excision during a laparoscopic right colectomy for cancer.
Preoperative high-resolution CT-scan and 3D printed models of the patient’s vascular anatomy is obtained to study the peculiar vessels distribution. Four ports are used, all located in the left flank as described in the video. Dissection between the visceral fascia which covers the posterior layer of the mesocolon and the parietal fascia covering the retroperitoneum (Toldt’s fascia) is carried out by means of monopolar electrocautery and combined advanced bipolar and ultrasonic dissection device. Caudocranial dissection of the mesocolon along the route of the superior mesenteric vein is performed, up to the inferior margin of the pancreas, exposing, ligating and dividing the ileocolic, the right and middle colic vessels at their origins. The gastrocolic trunk is fully dissected and the superior right colic vein clipped and divided. The transverse colon and terminal ileum are divided, the colon is mobilized and ileo-transverse intracorporeal stapled anastomosis is fashioned.
Between April 2017 and December 2018, 46 laparoscopic right hemicolectomies with CME were performed. There were no major vascular lesions. All intraoperative bleedings in the peripancreatic area were controlled with bipolar instruments and hemostatic devices, and there was no need for intraoperative blood cell transfusions.
Laparoscopic CME is feasible, but extensive knowledge of the vascular anatomy of the right colon as well as experience in advanced laparoscopic technique is required.
LIVE INTERACTIVE SURGERY: fully comprehensive demonstration of laparoscopic left hemicolectomy for synchronous adenocarcinoma of the sigmoid colon and rectosigmoid junction in an obese patient
In this live interactive surgery, Dr. Salvador Morales-Conde presents a case of synchronous sigmoid and rectosigmoid adenocarcinoma in an obese patient (BMI of 30). During mucosectomy of a sigmoid polyp at 20cm from the anal verge, a pTis adenocarcinoma was diagnosed when completely resected. A pT1 adenocarcinoma was biopsied at the rectosigmoid junction (12-15cm from the anal verge). Staging revealed no distant metastases. The operative technique shown consists in an oncological resection with mobilization of the splenic flexure.
S Morales-Conde, B Seeliger, D Mutter, J Marescaux
Surgical intervention
8 months ago
4884 views
7 likes
0 comments
43:25
LIVE INTERACTIVE SURGERY: fully comprehensive demonstration of laparoscopic left hemicolectomy for synchronous adenocarcinoma of the sigmoid colon and rectosigmoid junction in an obese patient
In this live interactive surgery, Dr. Salvador Morales-Conde presents a case of synchronous sigmoid and rectosigmoid adenocarcinoma in an obese patient (BMI of 30). During mucosectomy of a sigmoid polyp at 20cm from the anal verge, a pTis adenocarcinoma was diagnosed when completely resected. A pT1 adenocarcinoma was biopsied at the rectosigmoid junction (12-15cm from the anal verge). Staging revealed no distant metastases. The operative technique shown consists in an oncological resection with mobilization of the splenic flexure.
Mobilization of the right colon for Chilaiditi syndrome in a 38-year-old patient
This video demonstrates our laparoscopic approach to the right colon for Chilaiditi syndrome with recurrent episodes of bowel obstruction.
A 38-year-old man with Down syndrome was admitted to our emergency department for acute abdominal pain and vomiting. The objective signs and radiographic findings were indicative of bowel obstruction. In his last few years, he was admitted multiple times to the emergency department for mechanical bowel obstruction. Both CT-scan and MRI showed medial dislocation of the liver and transposition of the right colon and small bowel loops in between the diaphragm and the liver. We propose a specific port-site layout and a counterclockwise approach, to allow for the correct triangulation of surgical instruments especially during the mobilization of the hepatic flexure, which is often the most critical phase of the operation. Starting from the mobilization of the transverse colon and proceeding towards the caecum we take advantage of gravity in handling the right colon. The operative time was 90 minutes. The patient recovered with no complications and was discharged on postoperative day 6. His symptoms disappeared completely.
M Lotti, E Poiasina, G Panyor, M Giulii Capponi
Surgical intervention
1 year ago
2719 views
443 likes
0 comments
11:18
Mobilization of the right colon for Chilaiditi syndrome in a 38-year-old patient
This video demonstrates our laparoscopic approach to the right colon for Chilaiditi syndrome with recurrent episodes of bowel obstruction.
A 38-year-old man with Down syndrome was admitted to our emergency department for acute abdominal pain and vomiting. The objective signs and radiographic findings were indicative of bowel obstruction. In his last few years, he was admitted multiple times to the emergency department for mechanical bowel obstruction. Both CT-scan and MRI showed medial dislocation of the liver and transposition of the right colon and small bowel loops in between the diaphragm and the liver. We propose a specific port-site layout and a counterclockwise approach, to allow for the correct triangulation of surgical instruments especially during the mobilization of the hepatic flexure, which is often the most critical phase of the operation. Starting from the mobilization of the transverse colon and proceeding towards the caecum we take advantage of gravity in handling the right colon. The operative time was 90 minutes. The patient recovered with no complications and was discharged on postoperative day 6. His symptoms disappeared completely.
Laparoscopic right hemicolectomy with complete mesocolic excision for advanced ascending colon cancer
Complete mesocolic excision (CME) with central vascular ligation (CVL) is a potentially superior oncological technique in colon cancer surgery. The tenets of high vascular ligation at the origin and mesocolic dissection facilitate a greater lymph node yield. We present the case of a 70-year-old lady with chronic right iliac fossa discomfort. Computer tomographic scans showed a bulky ascending colon cancer with a 2.6cm right mesocolic lymph node. She underwent laparoscopic CME right hemicolectomy with CVL. Three operative trocars were used (a 12mm trocar in the left iliac fossa, 5mm ports in the left flank and right iliac fossa). Dissection begins in an inferior to superior approach, starting with mobilization of the ileocolic mesentery off the right common iliac vessels, then progressing to separate the mesentery off the duodenum and Gerota's fascia, exposing the head of the pancreas and the duodenal loop. CVL begins with the identification of the superior mesenteric vein (SMV). The vascular structures are isolated individually and ligated high at the level of the SMV, removing the metastatic right mesocolic node ‘en bloc’. Following proximal and distal transections, an intracorporeal ileo-transverse anastomosis is performed. Histology findings demonstrate the presence of a pT4a N2a M0 mucinous adenocarcinoma with 5 out of 17 lymph nodes (including the large mesocolic lymph node) positive for metastasis.
JL Ng, SAE Yeo
Surgical intervention
1 year ago
13551 views
1175 likes
0 comments
05:37
Laparoscopic right hemicolectomy with complete mesocolic excision for advanced ascending colon cancer
Complete mesocolic excision (CME) with central vascular ligation (CVL) is a potentially superior oncological technique in colon cancer surgery. The tenets of high vascular ligation at the origin and mesocolic dissection facilitate a greater lymph node yield. We present the case of a 70-year-old lady with chronic right iliac fossa discomfort. Computer tomographic scans showed a bulky ascending colon cancer with a 2.6cm right mesocolic lymph node. She underwent laparoscopic CME right hemicolectomy with CVL. Three operative trocars were used (a 12mm trocar in the left iliac fossa, 5mm ports in the left flank and right iliac fossa). Dissection begins in an inferior to superior approach, starting with mobilization of the ileocolic mesentery off the right common iliac vessels, then progressing to separate the mesentery off the duodenum and Gerota's fascia, exposing the head of the pancreas and the duodenal loop. CVL begins with the identification of the superior mesenteric vein (SMV). The vascular structures are isolated individually and ligated high at the level of the SMV, removing the metastatic right mesocolic node ‘en bloc’. Following proximal and distal transections, an intracorporeal ileo-transverse anastomosis is performed. Histology findings demonstrate the presence of a pT4a N2a M0 mucinous adenocarcinoma with 5 out of 17 lymph nodes (including the large mesocolic lymph node) positive for metastasis.
Laparoscopic left complete mesocolic excision for stented descending colon cancer
Complete mesocolic excision (CME) with central vessel ligation (CVL) was first introduced with the aim to preserve an intact layer of mesocolon, containing all blood vessels, lymphatic vessels, lymph nodes, and surrounding soft tissue during colorectal cancer resection. The supplying vessels are also transected at their origin for optimal oncological outcomes. This method has been extensively studied in right colonic cancers with improvement in local recurrence and survival rates when compared to the conventional approach. Its excellent results are attributed to the superior lymph node harvest and removal of disseminated cancer cells in the surrounding soft tissue. Similarly, such advantages can be translated to left hemicolectomy with the use of CME with a CVL approach. Additionally, in left hemicolectomy, the vessels ligated (left branch of middle colic and left colic) are branches of vessels from the aorta rather than from the aorta directly, often limiting lymph node harvest. CME with CVL can help to overcome this limitation in left hemicolectomy. We present a video of a laparoscopic CME and CVL in a 48-year-old Chinese male with large bowel obstruction secondary to a descending colonic tumor which was successfully stented one week before.
SAE Yeo, MH Chang
Surgical intervention
2 years ago
3136 views
316 likes
0 comments
08:47
Laparoscopic left complete mesocolic excision for stented descending colon cancer
Complete mesocolic excision (CME) with central vessel ligation (CVL) was first introduced with the aim to preserve an intact layer of mesocolon, containing all blood vessels, lymphatic vessels, lymph nodes, and surrounding soft tissue during colorectal cancer resection. The supplying vessels are also transected at their origin for optimal oncological outcomes. This method has been extensively studied in right colonic cancers with improvement in local recurrence and survival rates when compared to the conventional approach. Its excellent results are attributed to the superior lymph node harvest and removal of disseminated cancer cells in the surrounding soft tissue. Similarly, such advantages can be translated to left hemicolectomy with the use of CME with a CVL approach. Additionally, in left hemicolectomy, the vessels ligated (left branch of middle colic and left colic) are branches of vessels from the aorta rather than from the aorta directly, often limiting lymph node harvest. CME with CVL can help to overcome this limitation in left hemicolectomy. We present a video of a laparoscopic CME and CVL in a 48-year-old Chinese male with large bowel obstruction secondary to a descending colonic tumor which was successfully stented one week before.
Laparoscopic resection of endometriotic fibrotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels and adherent to the mid-sigmoid colon
Deep endometriosis is one of the most complex and risky surgeries. Its laparoscopic management requires a systematic approach, a good anatomical knowledge, and a high level of surgical competency.
This is the case of a 37-year-old lady presenting with a complex deep pelvic endometriosis. She had a long history of severe dysmenorrhea, colicky abdominal pain, back pain, and constipation. Imaging studies (MR) showed a large fibrotic endometriotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels, nerves, and adherent to a 4cm segment of the mid-sigmoid colon.
This patient has a complicated past history of left ureter ligation during a caesarean section (in 2011), which resulted in a left-sided nephrectomy in 2012. She got a pneumothorax complication, lung drainage, right-side thoracotomy in 2013, and finally a total pleurectomy in 2014.
A Wattiez, R Nasir, I Argay
Surgical intervention
2 years ago
5172 views
311 likes
0 comments
42:42
Laparoscopic resection of endometriotic fibrotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels and adherent to the mid-sigmoid colon
Deep endometriosis is one of the most complex and risky surgeries. Its laparoscopic management requires a systematic approach, a good anatomical knowledge, and a high level of surgical competency.
This is the case of a 37-year-old lady presenting with a complex deep pelvic endometriosis. She had a long history of severe dysmenorrhea, colicky abdominal pain, back pain, and constipation. Imaging studies (MR) showed a large fibrotic endometriotic nodule extending from the posterior lateral aspect of the uterus to the left pelvic sidewall, encasing the internal iliac vessels, nerves, and adherent to a 4cm segment of the mid-sigmoid colon.
This patient has a complicated past history of left ureter ligation during a caesarean section (in 2011), which resulted in a left-sided nephrectomy in 2012. She got a pneumothorax complication, lung drainage, right-side thoracotomy in 2013, and finally a total pleurectomy in 2014.
Laparoscopic right colectomy for caecal cancer with prophylactic lighted ureteral stenting (LUS)
Identifying the ureter during colorectal surgery (CRS) is one of the most critical steps of the operation. Iatrogenic ureteral injury occurs very rarely, with an incidence ranging from 0.28 to 7.6%. However, this complication has the potential to be devastating and its prevention is a priority. Laparoscopic approach in CRS reduces the tactile feedback of the surgeon who has to rely only on visual identification to prevent iatrogenic injury. As a result, lighted ureteral stents (LUS) were devised to improve visual identification of ureters throughout the dissection.
This video presents the case of a 70-year-old woman presenting with a caecal adenocarcinoma. She underwent a laparoscopic right colectomy with intracorporeal anastomosis. A LUS (IRIS U-kit®, Stryker) was placed under general anesthesia, just before the beginning of the surgical procedure, requiring about 15 minutes to be accomplished. The stent was removed after the operation, before the end of anesthesia, with no postoperative sequelas.
In order to prevent any potential iatrogenic injury, the selective or routine use of LUS during laparoscopic CRS could well improve the identification of the ureter, with a negligible increase in the operative time.
E Soricelli, E Facchiano, L Leuratti, G Quartararo, N Console, P Tonelli, M Lucchese
Surgical intervention
1 month ago
1672 views
2 likes
0 comments
09:10
Laparoscopic right colectomy for caecal cancer with prophylactic lighted ureteral stenting (LUS)
Identifying the ureter during colorectal surgery (CRS) is one of the most critical steps of the operation. Iatrogenic ureteral injury occurs very rarely, with an incidence ranging from 0.28 to 7.6%. However, this complication has the potential to be devastating and its prevention is a priority. Laparoscopic approach in CRS reduces the tactile feedback of the surgeon who has to rely only on visual identification to prevent iatrogenic injury. As a result, lighted ureteral stents (LUS) were devised to improve visual identification of ureters throughout the dissection.
This video presents the case of a 70-year-old woman presenting with a caecal adenocarcinoma. She underwent a laparoscopic right colectomy with intracorporeal anastomosis. A LUS (IRIS U-kit®, Stryker) was placed under general anesthesia, just before the beginning of the surgical procedure, requiring about 15 minutes to be accomplished. The stent was removed after the operation, before the end of anesthesia, with no postoperative sequelas.
In order to prevent any potential iatrogenic injury, the selective or routine use of LUS during laparoscopic CRS could well improve the identification of the ureter, with a negligible increase in the operative time.
Endoscopic full-thickness colonic resection for malignant polyp excision
This is the case of an 83-year-old woman who presented with per rectal bleeding. She had flexible sigmoidoscopy, which showed a 1.5 to 2cm flat polyp with central depression and non-lifting sign. CT-scan of the chest, abdomen, and pelvis was performed and showed no metastasis. The case was discussed with the multidisciplinary team and decision was made to perform an endoscopic full-thickness colonic resection. The case was performed using the colonic FTRD® set (OVESCO™). The procedure was completed successfully and the patient was discharged on postoperative day 1. During the postoperative follow-up, the resection margin was clear. This is the first case performed in the North-East of England to our knowledge. Since this case, we have performed another case.
Y Aawsaj, K Khan, M Hayat
Surgical intervention
1 month ago
487 views
1 like
1 comment
05:30
Endoscopic full-thickness colonic resection for malignant polyp excision
This is the case of an 83-year-old woman who presented with per rectal bleeding. She had flexible sigmoidoscopy, which showed a 1.5 to 2cm flat polyp with central depression and non-lifting sign. CT-scan of the chest, abdomen, and pelvis was performed and showed no metastasis. The case was discussed with the multidisciplinary team and decision was made to perform an endoscopic full-thickness colonic resection. The case was performed using the colonic FTRD® set (OVESCO™). The procedure was completed successfully and the patient was discharged on postoperative day 1. During the postoperative follow-up, the resection margin was clear. This is the first case performed in the North-East of England to our knowledge. Since this case, we have performed another case.
LIVE INTERACTIVE SURGERY: Colonoscopy and resection of large pedunculated sigmoid colon polyp
An intestinal polyp is a mass of tissue, which arises from the bowel wall and protrudes into the lumen. Polyps may be sessile or pedunculated. The incidence of polyps ranges from 7 to 50%. Polyps are most commonly found in the rectum and sigmoid colon and decrease in frequency towards the caecum.
Symptoms and signs:
Polyps are usually asymptomatic. The most frequent complaint is rectal bleeding, which is usually occult. Abdominal pain and obstruction occur with large polyps. The main concern with polyps is the risk of malignant transformation.
Complications of polypectomy: Common complications following polypectomy are bleeding and infection. The risk of bleeding ranges from 0.2 to 1.2%. When patients are on blood thinners, the risk of bleeding increases to 6.8%.
Advantages and disadvantages of use of prophylactic clips:
Clips can be applied during the procedure itself. They are easy to deploy. No scarring can be observed.
Disadvantages:
They are expensive, and present a risk of perforation and further bleeding.
R Dumas, S Leblanc
Surgical intervention
3 years ago
1095 views
39 likes
0 comments
11:52
LIVE INTERACTIVE SURGERY: Colonoscopy and resection of large pedunculated sigmoid colon polyp
An intestinal polyp is a mass of tissue, which arises from the bowel wall and protrudes into the lumen. Polyps may be sessile or pedunculated. The incidence of polyps ranges from 7 to 50%. Polyps are most commonly found in the rectum and sigmoid colon and decrease in frequency towards the caecum.
Symptoms and signs:
Polyps are usually asymptomatic. The most frequent complaint is rectal bleeding, which is usually occult. Abdominal pain and obstruction occur with large polyps. The main concern with polyps is the risk of malignant transformation.
Complications of polypectomy: Common complications following polypectomy are bleeding and infection. The risk of bleeding ranges from 0.2 to 1.2%. When patients are on blood thinners, the risk of bleeding increases to 6.8%.
Advantages and disadvantages of use of prophylactic clips:
Clips can be applied during the procedure itself. They are easy to deploy. No scarring can be observed.
Disadvantages:
They are expensive, and present a risk of perforation and further bleeding.
Video case: colon cancer
Endoscopic mucosal resection (EMR) is a method for treating early gastrointestinal mucosal lesions. The procedure of EMR involves submucosal injection of normal saline or saline with a mix of methylene blue to separate the lesion from the underlying muscle layers. The raised lesions can be completely removed with a snare. EMR is a simple and safe procedure with a small learning curve.
The risk of serious complications such as perforation and bleeding is rare.
The invasion depth of the tumor can be assessed after resection using pathological examination. The recurrence rate is very low (0-3.6%) after resection. EMR is not an appropriate choice for gastrointestinal tumors (size >20mm) as the complete recurrence rate is very low and recurrence after resection is very high.
R Dumas
Lecture
3 years ago
1070 views
41 likes
0 comments
11:03
Video case: colon cancer
Endoscopic mucosal resection (EMR) is a method for treating early gastrointestinal mucosal lesions. The procedure of EMR involves submucosal injection of normal saline or saline with a mix of methylene blue to separate the lesion from the underlying muscle layers. The raised lesions can be completely removed with a snare. EMR is a simple and safe procedure with a small learning curve.
The risk of serious complications such as perforation and bleeding is rare.
The invasion depth of the tumor can be assessed after resection using pathological examination. The recurrence rate is very low (0-3.6%) after resection. EMR is not an appropriate choice for gastrointestinal tumors (size >20mm) as the complete recurrence rate is very low and recurrence after resection is very high.
Totally laparoscopic splenic flexure resection for cancer
The objective of this video is to demonstrate a laparoscopic segmental oncological splenic flexure colonic resection for cancer. Splenic flexure carcinoma is a rare condition, as it represents 3 to 8% of all colon cancers. It is associated with a high risk of obstruction and a poor prognosis. The surgical approach is challenging and not fully standardized. The resected area must include the mesocolon with major vessels ligation at their origin, in order to reduce local recurrence via the complete removal of potentially involved lymph node stations.
The oncological effectiveness of a segmental resection could be determined by the peculiar lymphatic spread of splenic flexure cancers. Different studies showed that the majority of positive lymph nodes among patients with splenic flexure carcinoma are distributed along the paracolic arcade and the left colic artery. As a result, a segmental resection associated with a medial-to-lateral approach could be safe and effective. The experience with a totally laparoscopic approach with intracorporeal anastomosis is well described in the current literature. Additionally, an intracorporeal anastomosis minimizes the risk of bowel twisting, preventing the exteriorization of the stumps, and reducing bowel traction, which can affect anastomotic irrigation, especially in obese patients. In a setting of surgeons experienced with laparoscopic colorectal surgery, the outcomes of laparoscopic segmental resection of splenic flexure are similar to those of laparoscopic resections for cancer in other locations.
G Basili, D Pietrasanta, N Romano, AF Costa
Surgical intervention
6 months ago
2451 views
8 likes
0 comments
10:12
Totally laparoscopic splenic flexure resection for cancer
The objective of this video is to demonstrate a laparoscopic segmental oncological splenic flexure colonic resection for cancer. Splenic flexure carcinoma is a rare condition, as it represents 3 to 8% of all colon cancers. It is associated with a high risk of obstruction and a poor prognosis. The surgical approach is challenging and not fully standardized. The resected area must include the mesocolon with major vessels ligation at their origin, in order to reduce local recurrence via the complete removal of potentially involved lymph node stations.
The oncological effectiveness of a segmental resection could be determined by the peculiar lymphatic spread of splenic flexure cancers. Different studies showed that the majority of positive lymph nodes among patients with splenic flexure carcinoma are distributed along the paracolic arcade and the left colic artery. As a result, a segmental resection associated with a medial-to-lateral approach could be safe and effective. The experience with a totally laparoscopic approach with intracorporeal anastomosis is well described in the current literature. Additionally, an intracorporeal anastomosis minimizes the risk of bowel twisting, preventing the exteriorization of the stumps, and reducing bowel traction, which can affect anastomotic irrigation, especially in obese patients. In a setting of surgeons experienced with laparoscopic colorectal surgery, the outcomes of laparoscopic segmental resection of splenic flexure are similar to those of laparoscopic resections for cancer in other locations.
Laparoscopic right colectomy: bottom-to-up approach with intracorporeal anastomosis
Introduction
Laparoscopic right colectomy (LRC) has become a well-established technique in colon cancer treatment achieving the same degree of radicality as open colectomy with the advantages of minimal invasion. A medial-to-lateral approach is the standard technique, but the bottom-to-up approach, with intracorporeal anastomosis (BTU), has recently gained popularity among surgeons.
Clinical case
The authors report the case of a 70-year-old male patient with persistent abdominal discomfort and a change in bowel habits. Preoperative staging revealed an adenocarcinoma at the hepatic flexure of the colon with no metastatic disease. The patient was proposed for a laparoscopic right colectomy.
A bottom-to-up approach was performed by opening an avascular plane posterior to the right mesocolon, creating a mesenteric route cranially along Gerota’s fascia until the duodenum and liver have been exposed. A side-to-side ileocolic intracorporeal stapled anastomosis was fashioned. The procedure and postoperative recovery were uneventful.
Discussion/Conclusion
LRC using a BTU approach is a feasible and safe alternative to the conventional medial-to-lateral approach. The main advantages are a short learning curve and an easy access to the retroperitoneal space with direct visualization and protection of retroperitoneal structures. The performance of an intracorporeal anastomosis offers the advantage of a smaller extraction incision, lower wound-related complications, and fast recovery.
J Magalhães, L Matos, J Costa, J Costa Pereira, G Gonçalves, M Nora
Surgical intervention
7 months ago
2311 views
11 likes
2 comments
10:31
Laparoscopic right colectomy: bottom-to-up approach with intracorporeal anastomosis
Introduction
Laparoscopic right colectomy (LRC) has become a well-established technique in colon cancer treatment achieving the same degree of radicality as open colectomy with the advantages of minimal invasion. A medial-to-lateral approach is the standard technique, but the bottom-to-up approach, with intracorporeal anastomosis (BTU), has recently gained popularity among surgeons.
Clinical case
The authors report the case of a 70-year-old male patient with persistent abdominal discomfort and a change in bowel habits. Preoperative staging revealed an adenocarcinoma at the hepatic flexure of the colon with no metastatic disease. The patient was proposed for a laparoscopic right colectomy.
A bottom-to-up approach was performed by opening an avascular plane posterior to the right mesocolon, creating a mesenteric route cranially along Gerota’s fascia until the duodenum and liver have been exposed. A side-to-side ileocolic intracorporeal stapled anastomosis was fashioned. The procedure and postoperative recovery were uneventful.
Discussion/Conclusion
LRC using a BTU approach is a feasible and safe alternative to the conventional medial-to-lateral approach. The main advantages are a short learning curve and an easy access to the retroperitoneal space with direct visualization and protection of retroperitoneal structures. The performance of an intracorporeal anastomosis offers the advantage of a smaller extraction incision, lower wound-related complications, and fast recovery.
Laparoscopic left hemicolectomy in a thin patient, including anastomotic control using intraoperative fluorescence
Usually, Body Mass Index (BMI) is correlated to the difficulty in performing the surgery. Obesity is associated with a more complex surgery and a longer operative time due to difficulties in finding the right plane of dissection and identifying the structures. However, treating a thin patient may also be dangerous because the planes of dissection are more adherent, which makes it harder to identify the real embryological dissection plane.
This video shows the danger of dissection when the mesocolon is very thin and adherent to Toldt’s fascia or Gerota’s fascia.

The nightmare of colon and rectum surgery is the leak of the anastomosis. It may occur also with all precaution: no anastomotic tension, the evaluation of the vascularization may be difficult because macroscopic lesion, when there is an ischemia, would appear after some hours; the use of the ICG test is a good tool to control the poor vascularization of the anastomosis earlier and to correct it, hence avoiding the drama of the leak.
S Rua
Surgical intervention
9 months ago
3355 views
11 likes
0 comments
13:14
Laparoscopic left hemicolectomy in a thin patient, including anastomotic control using intraoperative fluorescence
Usually, Body Mass Index (BMI) is correlated to the difficulty in performing the surgery. Obesity is associated with a more complex surgery and a longer operative time due to difficulties in finding the right plane of dissection and identifying the structures. However, treating a thin patient may also be dangerous because the planes of dissection are more adherent, which makes it harder to identify the real embryological dissection plane.
This video shows the danger of dissection when the mesocolon is very thin and adherent to Toldt’s fascia or Gerota’s fascia.

The nightmare of colon and rectum surgery is the leak of the anastomosis. It may occur also with all precaution: no anastomotic tension, the evaluation of the vascularization may be difficult because macroscopic lesion, when there is an ischemia, would appear after some hours; the use of the ICG test is a good tool to control the poor vascularization of the anastomosis earlier and to correct it, hence avoiding the drama of the leak.
Robotic triple docking ultralow anterior resection with intersphincteric resection and coloanal anastomosis
The da Vinci™ surgical robotic system with its increased instrument stability, magnified tridimensional view, and dexterity with 7 degrees of wristed motion of its instruments offers a distinct surgical advantage over traditional laparoscopic instruments. This is especially true in the deep pelvis, where the limited space and visibility make it extremely challenging to perform distal rectal dissection. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.
For very low rectal tumors close to the anorectal junction, if a sphincter-saving procedure is to be attempted, surgeons will frequently perform an intersphincteric resection (ISR) with a handsewn coloanal anastomosis. If successful, the patient will be able to avoid an abdominoperineal resection and its resulting permanent stoma.
ISR is a technically challenging procedure to perform, especially in male and obese patients. It is because the approach to the intersphincteric plane from the abdominal approach is deep within the pelvis and frequently curves anteriorly, which makes the intersphincteric plane challenging to approach laparoscopically. In addition, ISR from the perineum is also difficult as the anus has a small opening; as a result, when the surgeon sits directly in front of the perineum, assistants will be unable to adequately visualize the operating field, making it very challenging to properly assist for the dissection. It may potentially result in some blind dissection, which may lead to entry into the wrong plane and a poor oncological specimen.
With the da Vinci™ surgical robotic system, this problem can potentially be minimized. First, via the transabdominal approach, the robotic system is able to access deep into the pelvic cavity and dissect down to the intersphincteric plane beyond the puborectalis sling. Secondly, docking the robot and approaching the ISR perineally, the robotic system can also provide a magnified vision, a fine dissection and allow the assistant a good viewing position sitting in front of the perineum to assist in a more productive manner. These advantages of the robotic system will facilitate ISR dissection and retrieval of a superior oncological specimen.
This video features a totally robotic triple docking approach for an ultralow anterior resection with intersphincteric resection and handsewn coloanal anastomosis in a male patient with a low rectal cancer.
SAE Yeo
Surgical intervention
9 months ago
1671 views
5 likes
0 comments
15:36
Robotic triple docking ultralow anterior resection with intersphincteric resection and coloanal anastomosis
The da Vinci™ surgical robotic system with its increased instrument stability, magnified tridimensional view, and dexterity with 7 degrees of wristed motion of its instruments offers a distinct surgical advantage over traditional laparoscopic instruments. This is especially true in the deep pelvis, where the limited space and visibility make it extremely challenging to perform distal rectal dissection. Additionally, the complete control of the surgeon over the stable surgical platform allows fine and accurate dissection in this area.
For very low rectal tumors close to the anorectal junction, if a sphincter-saving procedure is to be attempted, surgeons will frequently perform an intersphincteric resection (ISR) with a handsewn coloanal anastomosis. If successful, the patient will be able to avoid an abdominoperineal resection and its resulting permanent stoma.
ISR is a technically challenging procedure to perform, especially in male and obese patients. It is because the approach to the intersphincteric plane from the abdominal approach is deep within the pelvis and frequently curves anteriorly, which makes the intersphincteric plane challenging to approach laparoscopically. In addition, ISR from the perineum is also difficult as the anus has a small opening; as a result, when the surgeon sits directly in front of the perineum, assistants will be unable to adequately visualize the operating field, making it very challenging to properly assist for the dissection. It may potentially result in some blind dissection, which may lead to entry into the wrong plane and a poor oncological specimen.
With the da Vinci™ surgical robotic system, this problem can potentially be minimized. First, via the transabdominal approach, the robotic system is able to access deep into the pelvic cavity and dissect down to the intersphincteric plane beyond the puborectalis sling. Secondly, docking the robot and approaching the ISR perineally, the robotic system can also provide a magnified vision, a fine dissection and allow the assistant a good viewing position sitting in front of the perineum to assist in a more productive manner. These advantages of the robotic system will facilitate ISR dissection and retrieval of a superior oncological specimen.
This video features a totally robotic triple docking approach for an ultralow anterior resection with intersphincteric resection and handsewn coloanal anastomosis in a male patient with a low rectal cancer.
Laparoscopic complete mesocolic excision (CME) right hemicolectomy with intracorporeal anastomosis
Complete mesocolic excision (CME) in colon cancer surgery has recently gained popularity as increasing evidence points to improved oncological clearance with superior lymph node yield, bigger tumor clearance margins, and higher quality surgical specimens. There are also some indications that it may lead to improved oncological outcomes. The tenets of CME include high vascular ligation at the root of the vessel, dissection along the embryological planes of the colonic mesentery, and adequate margins of bowel from the tumor.
Although the technique was initially described and achieved via a laparotomy, laparoscopic CME was also performed, although it was noted to be technically challenging. The right colon and the variability of vascular anatomy add to the difficulty of the procedure.
Extracorporeal anastomosis is commonly performed for right hemicolectomy in most centers. There are some reported advantages to the intracorporeal anastomosis, namely a potentially higher lymph node yield, a smaller skin incision, and the ability to extract the specimen via a Pfannenstiel’s incision, which has lower rates of incisional hernia.
This video features a laparoscopic CME right hemicolectomy with intracorporeal anastomosis for a malignant polyp.
SAE Yeo
Surgical intervention
1 year ago
11686 views
1080 likes
0 comments
13:33
Laparoscopic complete mesocolic excision (CME) right hemicolectomy with intracorporeal anastomosis
Complete mesocolic excision (CME) in colon cancer surgery has recently gained popularity as increasing evidence points to improved oncological clearance with superior lymph node yield, bigger tumor clearance margins, and higher quality surgical specimens. There are also some indications that it may lead to improved oncological outcomes. The tenets of CME include high vascular ligation at the root of the vessel, dissection along the embryological planes of the colonic mesentery, and adequate margins of bowel from the tumor.
Although the technique was initially described and achieved via a laparotomy, laparoscopic CME was also performed, although it was noted to be technically challenging. The right colon and the variability of vascular anatomy add to the difficulty of the procedure.
Extracorporeal anastomosis is commonly performed for right hemicolectomy in most centers. There are some reported advantages to the intracorporeal anastomosis, namely a potentially higher lymph node yield, a smaller skin incision, and the ability to extract the specimen via a Pfannenstiel’s incision, which has lower rates of incisional hernia.
This video features a laparoscopic CME right hemicolectomy with intracorporeal anastomosis for a malignant polyp.
Segmental left colectomy: a modified caudal-to-cranial approach
Note from the WeBSurg-IRCAD Scientific Committee:
This video entitled “Segmental left colectomy: a modified caudal-to-cranial approach" shows an original technique of segmental colonic resection for benign conditions. Although, in the present case, the indication is not specified, there seems to be a tattooing on a lesion, which would not correspond to the initial indication of benign conditions. The indication might be a polyp. Such indications remain rare. The given approach is difficult to perform for inflammatory pathologies generating significant adhesions. However, although the video quality is not ideal, it was decided to publish this film with a special mention “case for debate” stating that this is not the IRCAD position, but the technique can be discussed.
Note from the authors of the video:
We have designed a modified caudal-to-cranial approach to perform a laparoscopic left colectomy preserving the inferior mesenteric artery for benign colorectal diseases.
A dissection is performed to separate the descending mesocolon from the plane of Gerota's fascia from the medial aspect to the peritoneal lining to the left parietal gutter. The peritoneal layer is incised parallel to the vessel and close to the colonic wall. The dissection is continued anteriorly up to reach the resected parietal gutter. A passage into the mesentery of the upper rectum is created for the use of the stapler and the dissection of the rectum. These maneuvers allow to straighten the mesentery simplifying the identification and division of the sigmoid arteries. A caudal-to-cranial dissection of the mesentery is performed from the divided rectum to the proximal descending colon using a sealed envelope device. It can be very useful to mobilize the colon in any direction: laterally, medially, or upward. The dissection is performed along the course of the vessel up to the proximal colon, with progressive division of the sigmoid arterial branches. The specimen is extracted through a Pfannenstiel incision. The anastomosis is performed transanally with a circular stapler according to the Knight-Griffen technique.
M Milone, P Anoldo, M Manigrasso, F Milone
Surgical intervention
1 year ago
3676 views
504 likes
0 comments
09:27
Segmental left colectomy: a modified caudal-to-cranial approach
Note from the WeBSurg-IRCAD Scientific Committee:
This video entitled “Segmental left colectomy: a modified caudal-to-cranial approach" shows an original technique of segmental colonic resection for benign conditions. Although, in the present case, the indication is not specified, there seems to be a tattooing on a lesion, which would not correspond to the initial indication of benign conditions. The indication might be a polyp. Such indications remain rare. The given approach is difficult to perform for inflammatory pathologies generating significant adhesions. However, although the video quality is not ideal, it was decided to publish this film with a special mention “case for debate” stating that this is not the IRCAD position, but the technique can be discussed.
Note from the authors of the video:
We have designed a modified caudal-to-cranial approach to perform a laparoscopic left colectomy preserving the inferior mesenteric artery for benign colorectal diseases.
A dissection is performed to separate the descending mesocolon from the plane of Gerota's fascia from the medial aspect to the peritoneal lining to the left parietal gutter. The peritoneal layer is incised parallel to the vessel and close to the colonic wall. The dissection is continued anteriorly up to reach the resected parietal gutter. A passage into the mesentery of the upper rectum is created for the use of the stapler and the dissection of the rectum. These maneuvers allow to straighten the mesentery simplifying the identification and division of the sigmoid arteries. A caudal-to-cranial dissection of the mesentery is performed from the divided rectum to the proximal descending colon using a sealed envelope device. It can be very useful to mobilize the colon in any direction: laterally, medially, or upward. The dissection is performed along the course of the vessel up to the proximal colon, with progressive division of the sigmoid arterial branches. The specimen is extracted through a Pfannenstiel incision. The anastomosis is performed transanally with a circular stapler according to the Knight-Griffen technique.