Laparoscopic sigmoid colectomy for cancer

This video demonstrates an uncomplicated laparoscopic sigmoid colectomy for cancer in a normal weight lady. The surgeon uses a medial approach to mesenteric mobilization and division of inferior mesenteric artery at the root. The hypogatric nerves, ureter and gonadal artery are identified. The splenic flexure is not mobilized due to the length of the bowel. The bowel is removed through a suprapubic incision and an EEA anastamosis is made. This video is a good demonstration of key anatomical landmarks and surgical approach to sigmoid colectomy for cancer through the medial approach.

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Laparoscopic sigmoid colectomy for cancer

Authors

J Leroy, J Marescaux

Abstract

This video demonstrates an uncomplicated laparoscopic sigmoid colectomy for cancer in a normal weight lady. The surgeon uses a medial approach to mesenteric mobilization and division of inferior mesenteric artery at the root. The hypogatric nerves, ureter and gonadal artery are identified. The splenic flexure is not mobilized due to the length of the bowel. The bowel is removed through a suprapubic incision and an EEA anastamosis is made.
This video is a good demonstration of key anatomical landmarks and surgical approach to sigmoid colectomy for cancer through the medial approach.

Classification

routine cases

Keywords

sigmoid cancer, laparoscopic sigmoid colectomy, medial mesenteric mobilization, EEA staples, anastomosis

Media type

Surgical video

Duration

20'00''

Publication

2006-01

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E-publication

WeBSurg.com, Jan 2006;6(01).
URL: http://www.websurg.com/doi-vd01en1874.htm

Laparoscopic sigmoid colectomy for cancer

1. Trocar position 00'11''

First, I use a mini-open technique. The step trocar is here at umbilical level, 12 mm in size, introduced just above the umbilicus. I have introduced 2 other trocars, B and C working trocars on the right mid-clavicular line, 8-10 cm lower always on the right mid-clavicular line.

2. Exploration and exposure 00'32''

We introduce my right hand with different types of instruments, particularly there is a stapler to divide the colon or rectum. In mirror of the B, this is the trocar D used to dissect the splenic flexure, to expose the sigmoid (done by the 1st assistant) with a better view posteriorly, and have a third hand to dissect and expose. Trocar E is the trocar used for incision and extraction of the specimen. It is used to better expose the root of the sigmoid mesocolon. Here you have a panoramic exploration. I have freed soft adhesions of the omentum to the anterior abdominal wall using a Ligasure device. Here you can see the liver, left lobe, right lobe and you can check that there is no metastasis in surface as it is the case for this patient. The position of the patient facilitates retraction of the small bowel; pneumoperitoneum pressure also helps. It is progressively above the promontory. It is not necessary to push the small bowel to the right above the transverse colon. I use the forceps in trocar D to slide behind the mesentery. Lateral retraction is maintained to see the duodenum, the IMA. We can see the iliac vessels, the sigmoid loop, and the tumor. We leave the sigmoid loop fall into the pelvis. We will limit the number of manipulations on the colon.

3. Medial approach 03'51''

Here you can see the promontory, right iliac vessels, aorta, origin of the IMA, IMV, and inflammatory lymph nodes. We will remove all the lymph nodes. Do you think that the choice of the approach (from caudal to cranial or vice versa) on the inferior mesenteric vein can be different with respect to the hypogastric nerve or do you think it does not make any difference? I am right-handed, so it is more logical to go from right to left, if you are left-handed it’s more logical to do the opposite. You are using monopolar diathermy more and more; it is the traction that is essential for this method. These are branches of the inter-mesenteric plexus that we are dividing; these are branches of nerves which are going on the right side of the artery. I have to change the traction by lifting atraumatically to have a better angulation. Don’t lift it too much however. To show the plexus trunk we have to stay close to the artery. The problem with the medial approach is the risk of going too posteriorly. The main danger is to do the dissection too posterior, that’s why you see the Toldt’s fascia coming here. First I want to seal and not cut the vein. I am using Ligasure as a finger, you see the retroperitoneal structures posteriorly, don’t dissect the fascia too anteriorly. This is the genital vein and the ureter moving just behind and medially to it because the ureter is moving here. If you see the ureter too close it’s because you are too posterior. You remember I did not divide the mesocolon. I change the retraction, I use forceps in the trocar D to expose better; it is not necessary. I complete exposure with another forceps, this one in the suprapubic port. This is the plane I use for TME, you see that due to the traction and counter-traction we open the plane easily.

4. Lateral mobilization 11'33''

Because we also did the medial approach, it is good to avoid injury of the retroperitoneal structures (genital vessels).

5. Colonic resection 12'35''

I don’t think mobilization of the splenic flexure is necessary in this case, for cancer we have to do a resection of a minimum of 5cm distally to the tumor and 10cm above the tumor. The only reason to mobilize would be a vascular problem, to have a better mobilization of the descending colon and to not do the anastomosis on the descending colon, this is particularly true in obese patients. We begin the dissection using the Ligasure device. We are 15cm under the cancer, it is very far, we will divide 15cm under the tumor. It is not necessary to remove the colorectal junction too because as you see it is not a sigmoiditis and it is probably better to keep this junction to avoid functional problems. Also because we have no diverticulosis in this case. The stapler is a blue cartridge 45mm Endo-GIA, it is better to have this kind of continuous staple line . Now we must remove enough colon to keep the vascularization. We will choose this limit. I ask my assistant to change the exposure and I am dissecting/dividing in the direction of this; the assistant is retracting.

6. Extraction 16'44''

I am now doing the incision, this is a plastic wound protector; I introduce a forceps in, the diameter of the hole is 7cm. I use the forceps as a retractor and my finger as another retractor. Then I pull the trocar out and I push the ring in between my finger (17;20). Automatically this is positioned. We lock the bag like this, we pull the loop and we will do the extraction through a two-layer plastic protection. I remove the complete specimen through the bag.

7. Preparation of anastomosis 18'05''

We will pull this, eventually we will free more if this is necessary. We re-use purse-string forceps.

8. Anastomosis 19'20''

The light is the circular line. The air-test is negative.