Laparoscopic right colectomy for villous tumor

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Laparoscopic right colectomy for villous tumor

Authors

J Leroy, J Marescaux

Media type

Surgical video

Duration

15'33''

Publication

2005-05

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E-publication

WeBSurg.com, May 2005;5(05).
URL: http://www.websurg.com/doi-vd01en1689e.htm

Laparoscopic right colectomy for villous tumor

1. Trocar placement 00'20''

Here’s the umbilical line, subcostal line, the incision. I have introduced a 12mm trocar using a mini-open approach to free the adhesions around the right subcostal area; so I have introduced the scope in this trocar to free adhesions with the instrument introduced in the supra-umbilical area. There is a 12mm trocar in the suprapubic midline at the level of the anterior iliac spine after insufflation as I normally do. Finally I put a 5mm trocar in the right iliac fossa. If I introduce it more medially, I’ll have my instrument in conflict with my scope. We place the patient in a supine position, head up. The surgeon stands between the patient’s legs. Now to the exposure. This is the transverse colon. I have freed the adhesions of the omentum and we’ll expose using a forceps introduced in the left hypochondrium trocar. This is the adhesion between the ascending colon and transverse colon. We will use a left lateral tilt to push the small bowel to the left side. The duodenojejunal junction is not far from here. We won’t see it completely. The ileocolic limit is here so the root of the mesentery is at this level. Now we want to have the ileocecal vessels so I’ll incise vertically. I don’t touch the colon. I’ll incise this way.

2. Ileocaecal dissection 02'42''

I don’t mobilize the colon first. I use a medial approach with Harmonic scissors, for example. The transverse mesocolon is here and the colon is higher. I’ll separate the right from the left. I have the ileocolic vessels here. The duodenum is coming. I will first divide the ileocolic vessels and just behind normally you have the duodenum. I don’t want to go too medially. It’s enough in this case. How would you change the approach if it was a younger patient with a frank cancer? I’ll do the dissection anteriorly to the superior mesenteric vein, and find all the vessels. This is the duodenum. I’m progressively completing my dissection. There’s a diverticulum of the duodenum. We know that some so-called high-grade dysplastic polyps are finally T4-T3 cancer sometimes. I think that is a good procedure for cancer too. I completely agree. For a fatty patient with a BMI of 32 is not so easy. The danger is to have the stomach coming. I’m dividing the mesocolon. I’m normally on the colon. Here’s the omentum fixed and this is not due to carcinologic problems but to the laparotomic cholecystectomy. Do you intend to keep the wall of the greater omentum? Normally I remove it but I want to be sure that I’ll have a place to divide pushing my stapler not in the fatty tissue but around the colon.

3. Division of transverse colon 06'12''

I divide the ileocolic vessels and the transverse mesocolon. Is there any specific danger at this stage of the operation? Always there is but you see I don’t change my position and so I’m gaining time. Now I’m dividing the omentum. So I separate right from left. The danger is to injure the duodenum, the bladder when you have the gallbladder behind, the stomach but we have to understand the anatomy with this inferior view.

4. Division of omentum 07'18''

Now I have divided the omentum. I can continue to free the attachments of the colon this way. I keep this position to begin the lateral freeing because I don’t want to free the colon completely at this moment. I will ask the assistant to catch the mesentery like this. We do the posterior freeing using a medial approach, anterior to Toldt’s fascia. We have the duodenum on the right side of the screen. Now I want to divide the ileum but sometimes I have difficulty since there are adhesions due to appendectomy and I ask my assistant to pull towards the left hypochondrium. More medially you have the ureter, not posterior to the cecum but medially.

5. Mobilization of caecum 09'30''

Can you show us again from the medial side to see where you are exactly in relation to the Toldt’s fascia or the ureter? I will divide the ileum like this. Once you have applied staples, you won’t have the possibility to use the Ligasure because there’s a contact with metallic staples.

6. Division of ileum 10'15''

Don’t lock the system but use it like this without closure. I have finished the right colectomy. I have to do the anastomosis now. I have separated right from left. This is the ileum. This is the duodenum, and the diverticulum is here; here’s the mesentery. Here’s the transverse colon coming; we can free more dividing the adhesions of the omentum to this. I’ll ask my assistant to maintain the transverse colon this position. This is the small bowel, the ileum. I want to find the loop that I have divided and I’ll fix together. There’s a small hematoma as you see here. And I want to do a new resection that I can do outside. Normally surgeons do a side-to-side anisoperistaltic anastomosis. I do extracorporeal knots. This is an isoperistaltic anastomosis in this case, before it was anisoperistaltic. We do the exteriorization outside. What about an end-to-side anastomosis? We can do it too in a bypass procedure for example. I’ll now introduce an Endocatch bag after a 2nd one here. You first push the distal part in and progressively the proximal part. I have a forceps on my sutures ready. I have now to remove this. I will use a double protection. This is the removal of the ileum. We have the bowel outside and the anastomosis ready to be done. And we will close using hand-made sutures.

7. Extraction of colon and anastomosis 13'58''

Was it a 60mm length cartridge? No it’s a 45. We can use 60, it’s not only 4.5cm, it’s more if we consider the manual sutures. We insufflate. Have you already observed internal incarcerations of the small bowel because of no closure of this defect? On the left, yes. The procedure is now over.