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Cancer of the descending colon: laparoscopic left colectomy

Authors

J Leroy, J Marescaux

Abstract

This video clearly demonstrates the laparoscopic performance of left hemicolectomy for cancer.

Keywords

cancer, descending colon, laparoscopy, left colectomy

Media type

Duration

27'00''

Publication

2008-05

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Audio

Subtitles

E-publication

WeBSurg.com, May 2008;8(05).
URL: http://www.websurg.com/doi-vd01en2336.htm

Cancer of the descending colon: laparoscopic left colectomy

1. Operative set-up and trocar positioning 00'25''

This is the case of an elderly male patient, with a tumor of the descending colon at the junction between the descending colon and the sigmoid loop. We will do a resection adapted to the patient’s age and to the pathology because it is an adenocarcinoma. 12mm supraumbilical trocar for the optic on the midline just above the umbilicus, two working trocars B and C on the right mid-clavicular line at the level of the umbilicus for the left hand and right iliac fossa for the right hand, a 12mm to introduce a stapler. Two other trocars to dissect and retract, trocar D mirror to trocar B, and trocar E just above the pubis where we will do the extraction and it is the trocar that will be used to expose and retract. At the end of the procedure, we will increase the incision to extract the specimen.

2. Operation commences with adhesiolysis for exposure 01'36''

We have the small bowel and the sigmoid, a very long and vertical sigmoid, it is not stuck to the left. There is a long loop. Before I have pushed the omentum. We see the sigmoid finishing in the pelvis and going all the way here, and here is the descending colon. This position is due to fixations, this is the duodenojejunal junction. We have exposed with a limited Trendelenburg, we don’t remove the loop from the pelvis, first we will free the adhesions of the sigmoid loop. First, we have to understand the anatomy before freeing the adhesions. Do you always start by mobilizing the sigmoid or do you free up the splenic flexure first? I never begin with the mobilization of the splenic flexure. In this case, it is different because the tumor is very high but it is not always necessary to mobilize largely the sigmoid to have a good resection and a tension-free anastomosis. When we do the mobilization, it is to have a tension-free anastomosis, it’s not to do an oncologic resection. We have now freed the sigmoid loop, we have the duodenojejunal junction, we have the descending colon. I think it is good to do a left colectomy in this case because we have a very long and flexible colon. We will expose some more by increasing the Trendelenburg angle. Where do you think this tumor is because in these very long colons? The tumor is at the junction between the descending colon and the beginning of the sigmoid loop. The clips which have been placed endoscopically, will it make any difference for the surgeon? It is mainly the position of the clip and the X-ray and the anatomy of the patient concerning the sigmoid loop. We now begin the procedure.

3. Medial dissection to begin operation proper 06'02''

We incise the peritoneum from the anterior part of the promontory to the duodenojejunal junction in the direction of the junction. This is the aorta, we are stretching the tissues more anteriorly to be sure that we will find the IMA, I have it. The danger is to get confused between the left iliac and IMA. To be sure, slide back to the vascular sheet of the sigmoid colon like this, you will be sure that you are not on the iliac vessels.

4. Vascular skeletonization and division 07'25''

We have the division with the left colic or sigmoid trunk. This is the origin of the IMA. This is to close from the aorta, we will do the division but I have a duct with a small branch there that is why I will do it in two goes. First I do the division there, I will use the Ligasure but will put the loop just behind. The danger of using the Ligasure particularly in older patients and in cases of atherosclerosis is to break the vessels and not have a good sealing, but I have enough possibilities to control, it is only to gain time. We place a loop behind. This is the left colic artery, this is an unusual anatomy. We’ll complete the dissection. This is a medial approach, I don’t touch the colon. The problem with this colon is to manipulate it, it is very long and if we do the posterior and lateral freeing using the lateral approach, it becomes more difficult. This is a vein coming, this is the right plane, I use the Ligasure like a finger to complete the dissection as you can see, anterior to Toldt’s fascia. A very good demonstration of the fascia there. This is the kidney, we continue lower. When you do a medial to lateral approach, at what point do you identify the ureter? If I stay anterior to the fascia, I am sure that the ureter is behind, the ureter is there.

5. Identification of left ureter 11'04''

Slowly I am reaching the lateral attachments of the mesentery; until now the loop is not a handicap except at the very beginning. I am staying anterior to the fascia, preserving the plexuses that are more posterior. I will free the lateral attachment. What you don’t see is my left hand, it is doing all the work by applying good traction to do this dissection. I am dividing the mesentery.

6. Preparation and transection of distal resection margin 13'10''

Is this the site of your anastomosis? Approximately yes, we have to be on the rectum because if we are on the sigmoid, we will have ischemia. This is a 60mm stapler. For the colorectal junction, we can, lower we cannot if you see the size of the cartridge and the size of the pelvis and it is a large pelvis. OK, we have finished this, we now have to free the transverse colon, we will do the medial approach.

7. Proximal colonic mobilization 14'36''

First, we have to open the lesser sac quickly. This is a trick, this is the lesser sac and behind we have the pancreas. Two tractions and we have to free the attachment of the root of the transverse mesocolon. I am lateral to the IMV, the risk is to have vessels going or coming from the splenic flexure so I will divide the vessels. The lesser sac is here. The tail of the pancreas is here, the kidney. We can continue there but the best is to stop the medial dissection and to finish laterally. I have freed the posterior attachment, now we can go for the lateral freeing. We have the posterior plane we have freed and I want to find the colonic plane. I am freeing the lateral attachment, colo-omental attachment. We will continue the dissection. We can use Harmonic too but the field is not so clean. The other possibility when freeing this way is to divide the gastro-omental attachment, it is easier but riskier for the spleen. My assistant is putting traction on the transverse colon. I am close to the spleen, you see it behind. Can you show us where you think the tumor is? We will do a palpation, I usually place a stitch but I have forgotten. We will do the anastomosis around there, we will complete outside.

8. Proximal transection (intracorporeal) 20'00''

I will do a division of the colon inside and we will complete outside if we don’t have enough distance. I am on the transverse colon, on the splenic flexure at least. That is the trocar incision I did in the suprapubic region, looks like that is about 2.5cm above the pubic bone. I open the incision some more, introduce the bag, open it, we will push the specimen inside. We close the bag like this, and pulling it, there’s no risk of contamination or squeezing.

9. Extracorporeal delivery of specimen and proximal bowel 21'55''

The tumor is there, we will check. The tumor is at around 20cm of distance proximally. Now we will do the anastomosis; to do that, we will pull the colon through the suprapubic incision. The colon has got a good pink color.

10. Preparation for re-anastomosis 23'08''

We placed beforehand a Babcock forceps to make sure that the colon stays out. Which liquid do they use to clean the lens? Hot water and sterile soap. We warm the scope with hot water. We have to check that we have enough mobilized.

11. Intracorporeal re-anastomosis 25'08''

You see it is coming very easily. We have to check that the rings are complete and look for the doughnuts. We will do an air test now. We have to close the gap because you see bowel obstruction is a real danger in this kind of procedure. To close the gap, you can use staples, running sutures; in this case, I will use running sutures.

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