Laparoscopic approach for a T3 cancer of the colorectal junction

This video shows a standard oncological laparoscopic approach for T3 cancer of the colorectal junction. In this case, the patient presents a big tumor with a clinical sub-occlusion. A low anterior resection is performed by a medial to lateral approach, with a primary inferior mesenteric artery control. Splenic flexure mobilization was not necessary in this case. An end-to-end colo-anal anastomosis ends the procedure.

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Laparoscopic approach for a T3 cancer of the colorectal junction

Authors

J Leroy, J Marescaux

Abstract

This video shows a standard oncological laparoscopic approach for T3 cancer of the colorectal junction. In this case, the patient presents a big tumor with a clinical sub-occlusion. A low anterior resection is performed by a medial to lateral approach, with a primary inferior mesenteric artery control. Splenic flexure mobilization was not necessary in this case. An end-to-end colo-anal anastomosis ends the procedure.

Classification

basic techniques

Keywords

Laparoscopy, T3 cancer, colorectal junction

Media type

Surgical video

Duration

18'50''

Publication

2008-11

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E-publication

WeBSurg.com, Nov 2008;8(11).
URL: http://www.websurg.com/doi-vd01en2442.htm

Laparoscopic approach for a T3 cancer of the colorectal junction

1. Laparoscopy and exposure 00'15''

I’m doing a dissection. I am inside of the abdominal cavity. I have opened the peritoneum and I will introduce. I have seen the bowel. There are no adhesions. I have a view inside the abdomen and I introduce the sleeve and will introduce the trocars immediately. We enter the abdominal cavity. We check that we are really inside the abdominal cavity and we begin the insufflation. I will complete the exposure. You can see the sigmoid with adhesions, then the omentum, and we will now expose the pelvis.

2. Access to the IMA and vascular control 01'35''

To do so, we will use good muscle relaxation. Here’s the suprapubic trocar and we will do the extraction suprapubically so we don’t hesitate to put one more trocar. This patient had a previous ovariectomy on the left. And here we can see a very big tumor. We use traction and counter-traction. You can see the sacral promontory there. And we go slowly in a stepwise manner in order to find the big nodes. We have skeletonized the artery. We will seal it. We can clip. Don’t be too close from the aorta. Keep minimum distance and we will achieve the ligation using a loop.

3. Medial posterior mobilization 04'05''

Don’t tighten too much because you will break the vessels. We slide at the back of the vessels, of the vascular sheet to keep the nerve intact. I’m doing a medial approach for the vessels but I’ll complete the dissection also using a medial posterior dissection. You dissect the artery as you have seen, you do a skeletonization so you dissect close to the vessel, close to the vascular sheet on the back, and later use traction and counter-traction and stay anterior to the Toldt’s fascia. I am sealing the IMV. There are 2 possibilities: you can seal but it is not necessary to cut immediately. Why? I will keep this curtain to maintain the small bowel upwards as a retractor. We use the same technique as for a rectum, we hope that there is no in-vision, normally there isn’t but I don’t know for the ureter, there is no dilatation up. It is coming using the instrument as a finger.

4. Lateral mobilization 06'05''

We have just opened laterally. We find the medial plane, we have begun opening posteriorly. We have to consider this for the anastomosis and the quality of the vascularization too. It is a very low tumor in the mesentery, I don’t know in the sigmoid, but in the meso, it is very low because it is fixed. We are at a larger distance to the rectal tumor.

5. Division of distal rectum and proximal colon 09'15''

We will ligate under the tumor, wash under the tumor, we will wash the rectal stump with betadine; this is to respect oncological principles to avoid trapping cancerous cells inside a stapling line. What is the distal margin that you need before cutting the colon and how do you know where the margin is? Normally, it is around 2cm as a minimum, for the lateral margin it is minimum 1 to 2mm but you see that we have respected the propria fascia of the rectum so we have removed all of the fascia. It’s a cylindrical dissection of the meso, not a conical dissection. You see the edema on the rectal stump, this is a sequella of the radiation therapy in my opinion, it is not due to the tumor. Because we know that in open surgery we are used to palpating the tumor and estimating the distal margin. We will verify it but I am sure that we are 2cm underneath, so now we have to mobilize the colon, the color is perfect there. When you look at the colon, do you feel that it is quite dilated? Yes, there was bowel obstruction in this case, stenosis and that is why we have to operate on the patient. What is you attitude today when you have a patient presenting with bowel occlusion or sub-occlusion on a tumor? Do the stent if it is a good indication without a complete stenosis and to do the procedure in one time if you have a complete exploration of the colon. If it is not the case, you can have a laparoscopic exploration and check that there is no carcinomatosis, resection or Hartmann’s or stoma depending on the site and I would say the bowel dilatation: if there is a huge dilatation, it is impossible, so you will probably do a colostomy using a local approach on the right transverse colon for example, for sigmoid. We will choose the segment of colon where we will do the anastomosis, probably there. You have recently published a paper on difficulties in laparoscopic colectomy looking at the different steps of the operation. In your study, what was the most difficult part of the operation? Exposure is the first step of a procedure but the main difficulty is that for the sigmoid.

6. Extraction 13'50''

But you see there is coprostasis inside, it is a colonic cancer, you will see how I proceed to remove colonic cancer. I don’t do that for diverticulitis. This is to put the bowel inside a plastic bag to avoid contact. So we are inside the aponeurosis, it is a huge tumor, and to remove that out of the rectum without danger would be difficult. We might injure the rectal stump that is fragile, it is not a good indication. We have performed a sigmoidectomy with only one trocar and trans-anal with extraction through the anus, but it wasn’t for a huge tumor. You see that I have placed a plastic drape.

7. Extracorporeal anvil insertion 15'25''

We have to keep a segment of proximal bowel, we can put a loop in, we close, and we will remove and pull through a plastic drape; this is a double protection. The colon is coming, the tumor is there at a minimum of 5cm. We will move through the Babcock, well-coloured, so we complete the bowel preparation like this. You can go on the Internet and see other techniques, especially for obese patients. See it is bleeding.

8. Mechanical anastomosis 16'30''

So we will re-introduce now in the abdomen. We evaluate the possibilities, place the anvil and without traction, it is close to the rectal stump. We perforate like this. Move up because you see that the sacral promontory will not facilitate the introduction. This conflicts with the sacral promontory, push. You stop, we check that there are no twists.

9. Closure of the peritoneal window 17'50''

We fire, and verify the doughnuts, I think they are complete, this is the proximal and this is the distal part with the purse-string. We will do an air-test now, now we clamp, we will close the gap now, we can make a running suture but we will place staples to go faster.