Laparoscopic right colectomy with Ligasure Advance® for ileocaecal mass in a young male patient

Endoscopic polypectomy still remains the cornerstone of therapy for colorectal polyps and adenomas. However, if colorectal polyps are too large or not accessible for endoscopic ablation or cannot be removed without an increased risk of perforation, operative procedures are required. In such circumstances, laparoscopic resection represents a minimally invasive alternative. The purpose of this film is to demonstrate our right colectomy technique, which respects oncological principles. The case is performed in a male patient with a BMI of 22 and presenting with a voluminous caecal mass with a lipoma found on biopsy. Because of its volume, a right colectomy has been decided upon.

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Laparoscopic right colectomy with Ligasure Advance® for ileocaecal mass in a young male patient

Authors

J Leroy, J Marescaux

Abstract

Endoscopic polypectomy still remains the cornerstone of therapy for colorectal polyps and adenomas. However, if colorectal polyps are too large or not accessible for endoscopic ablation or cannot be removed without an increased risk of perforation, operative procedures are required. In such circumstances, laparoscopic resection represents a minimally invasive alternative. The purpose of this film is to demonstrate our right colectomy technique, which respects oncological principles. The case is performed in a male patient with a BMI of 22 and presenting with a voluminous caecal mass with a lipoma found on biopsy. Because of its volume, a right colectomy has been decided upon.

Classification

basic techniques

Keywords

Laparoscopic right colectomy, LigaSure Advance, ileocaecal mass, young male patient

Media type

Surgical video

Duration

17'30''

Publication

2009-07

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E-publication

WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2466.htm

Laparoscopic right colectomy with Ligasure Advance® for ileocaecal mass in a young male patient

1. Introduction 00'02''

The purpose of this film is to demonstrate our right colectomy technique, which respects oncological principles. The case is performed in a male patient with a BMI of 22 and presenting with a voluminous caecal mass with a lipoma found on biopsy. Because of its volume, a right colectomy has been decided. The patient is placed in a reverse Trendelenburg position with a cushion under his right flank, thus allowing for a slight tilt to the left of the operating table. The patient’s legs are spread apart. The number of trocars used will depend upon the difficulties faced during the operation. On average, 5 trocars are used including one optical trocar placed half-way between the umbilicus and the xiphoid process. A second optical port will be placed on the midline, at the level of the anterior superior iliac spines. Then an operative trocar, trocar C, is placed in the right iliac fossa, trocar D is placed on the left subcostal mid-clavicular line in order to expose the operative area, and eventually trocar E in the left iliac fossa within the epigastric vessels.

2. Exposure of surgical field 01'45''

The first step of the procedure is to expose the surgical field. This is managed thanks to graspers introduced in the left subcostal trocar, allowing to retract the greater omentum above the transverse colon, and then allowing to exert some anterior traction on the transverse mesocolon. It is necessary to see the duodenojejunal and ileocolic junction that delimit the root of the mesentery. We begin by dividing the ileocolic vessels. To do so, we incise the peritoneum at the limit between the mesentery and the ascending mesocolon, which allows to free the retroperitoneal space and to rapidly uncover the third duodenum. The third duodenum can be found underneath the ileocolic vessels. The view of the operative field is obtained thanks to a 0 degree optic introduced through the midline trocar, at the level of the anterior superior iliac spines. Soon afterwards, we detach the retroperitoneal space and find the third duodenum. We continue the procedure by opening the peritoneum anterior to the superior mesenteric vein. Using the Ligasure Advance® facilitates this step and makes it more accurate. We can therefore use the monopolar cautery electrode to divide the fibrous tracts, and the Ligasure device to dissect the vascular elements. The division is then carried out with the help of a scalpel. The plane of dissection that carries on anterior to the superior mesenteric vein can be seen very clearly. During all this, the assistant keeps the root of the transverse mesocolon retracted anteriorly. Slowly, the anterior aspect of the pancreas is uncovered. Traction and counter-traction on the tissues allows to open the embryological planes, and in particular the plane situated anterior to the pancreas. Here a lymph node is resected and isolated before being sent for analysis. The lymph node alone is placed in a plastic bag introduced through the trocars. For the time being, this plastic bag is left in the supra-hepatic region. We continue the dissection by keeping lateral to the superior mesenteric vessel and in particular to the vein, which is more often situated to the right of the superior mesenteric artery. We continue the maneuver by identifying the right colic vessels that, contrarily to the right branches of the colica media artery, are not always there.

3. Division of right colic vessels 06'24''

These right colic vessels, and in particular the vein, are divided with the Ligasure Advance®. The dissection is continued in the same direction in order to get closer to the marginal vessels and find the right branches of the medial colic vessels. Here the head of the pancreas can be seen very clearly, as well as the second duodenum. The following step is the dissection of the transverse mesocolon and the division of the right branches of the ileocolic vessels. We also begin to undo the root of the transverse mesocolon from the anterior aspect of the pancreas, but we also divide the insertion of the greater omentum on the first duodenum. The transverse mesocolon is divided in a stepwise manner. During this, the exposure of the transverse colon has not changed, which avoids having to modify the anatomical landmarks.

4. Division of transverse colon 08'06''

The transverse colon can then be divided with the help of a 60mm blue cartridge Endo-GIA linear stapler introduced in the supra-umbilical trocar A. This division is done perpendicularly to the colon while preserving the vascular supply of the remnant colon, i.e. the left transverse colon. Once the colon has been divided, the division of the greater omentum is continued. Once the greater omentum has been divided, generally by using the Ligasure device only, the dissection of the transverse mesocolon from medial to lateral can be continued. The next step is the division of the terminal small bowel close to the ileocaecal valve; this is done in order to completely separate the ascending colon and the right colon from the left colon.

5. Division of small bowel 09'33''

We grasp the terminal small bowel and introduce a 60mm white cartridge linear stapler via the supra-umbilical trocar, as is often recommended by bariatric surgeons due to improved hemostasis. The division of the persistent mesenteric bridge is continued with the Ligasure Advance® while avoiding the division of the staples with the scalpel as it would weaken it and render the tool unusable. The division of the mesenteric bridge is continued here again with the Ligasure Advance® in order to ensure perfect hemostasis. The right colon is then separated from the left colon. Now the right colon is completely freed from its attachments. We must see the ureter here moving through the peritoneum. We begin by placing some traction on the ileocaecum thanks to a grasper introduced through the left subcostal port that is maintained by the assistant, but also by the grasper that is held by the surgeon’s left hand and that itself has been introduced through the right iliac fossa. The aim is to find the plane between the primitive posterior peritoneum, with Toldt’s fascia, Gerota’s fascia, and the ascending mesocolon. Thanks to traction, but also thanks to the Ligasure Advance®’s monopolar dissection, we can divide this posterior plane from the anterior plane from caudad to cephalad. We finish by division of the insertion of the transverse mesocolon at the level of the diaphragm.

6. Preparation of anastomosis 12'11''

The following step is the preparation of the anastomosis, which will be done intra-abdominally: indeed, this avoids traction on the mesenteries. To do so, we fix the terminal small bowel segment and the transverse colon with two Ethibond 2/0 sutures in order to perform a side-to-side isoperistaltic anastomosis. The opening in the colon is performed with the Ligasure advance’s monopolar cautery and completed with the help of a grasper.

7. Mechanical anastomosis 12'52''

We then introduce a 60mm blue cartridge Endo-GIA stapler in order to do the largest possible anastomosis. We check that there is no hemorrhage at the level of the stapling line, then close the orifice by making sure to not forget the posterior part of the incision that is closed with an absorbable monofilament, here the PDS 3/0, by performing two extramucosal half running sutures that meet in the middle. The monofilament’s advantage is that multiple stitches can be placed before having to tighten the suture, and this in an atraumatic way. The second suture is prepared, again with absorbable monofilament. The two running sutures will meet in the middle and the knot will be tied after checking the tightness of the two running sutures.

8. Closure of mesenteric defect 14'35''

The problem of the breach’s closure remains, as it may induce an occlusive syndrome. The breach’s closure can be completed either via a medial approach, via stapling, via a running suture or interrupted stitches of absorbable suture, or as is done here via a lateral approach. The advantage is that it is not necessary to manipulate the bowel during the closure as this one is quite simply kept in the left part of the abdomen. Thanks to gravity, the bowel will remain perfectly exposed during the closure without having to apply some traction on the intestine. This closure is performed with the help of absorbable monofilament suture. The closure must be perfect as even an incomplete closure is more dangerous than leaving it completely open. Once the breach has been closed, the operative specimen is extracted. As the specimen is generally quite large, it is interesting to place on one of its extremities, and mostly the transverse colon, a thread with the help of a buckle; this thread will serve as a landmark for the extraction of the specimen.

9. Specimen extraction 16'51''

The colon is placed in a very voluminous Endo-catch II bag introduced through the suprapubic incision. The bag is then extracted through the incision and thanks to the landmark thread, we can pull very rapidly on the colon. The different incisions are closed without drainage after a last laparoscopic control of the abdominal cavity.