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Laparoscopic sigmoidectomy for cancer in a female patient: a gold standard technique

Authors

Abstract

This video clearly demonstrates the technical details (exposure, vascular approach, colorectal dissection and anastomosis) to correctly perform a laparoscopic sigmoidectomy for cancer in a female patient.

Classification

basic techniques

Keywords

Laparoscopic sigmoidectomy, cancer, female patient, gold standard technique

Media type

Duration

19'00''

Publication

2009-04

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E-publication

WeBSurg.com, Apr 2009;9(04).
URL: http://www.websurg.com/doi-vd01en2591.htm

Laparoscopic sigmoidectomy for cancer in a female patient: a gold standard technique

1. Introduction 00'08''

The objective of this video is to show the technique for a laparoscopic sigmoidectomy in a female patient presenting with sigmoid colon cancer. The exposure of the root of the sigmoid mesocolon is carried out after perfect shelving of small bowel loops towards the upper right lateral region of the abdomen.

2. Peritoneal incision via medial to lateral approach 00'33''

Tension placed on the root of the sigmoid mesocolon allows for the incision of the peritoneum from the anterior aspect of the sacral promontory until the lateral portion of the duodenojejunal flexure.

3. Skeletonization of the mesenteric vessels 01'06''

Dissection is continued with the skeletonization of the vascular arch formed by the inferior mesenteric vessels. The ideal place for skeletonizing it is at the anterior aspect of the promontory back to the vascular sleeve thanks to an adequate traction that open the retroperitoneal spaces. Then traction is placed on the vascular axis and the different cellular and adipose planes are opened in order to join the lateral aspect of the origin of the inferior mesenteric artery. The use of monopolar scissors is very useful since it allows for a sharp dissection of the anatomical structures. Monopolar current with a low voltage (20 to 25 Watts) is used due to the elective character of the dissection.

4. Inferior mesenteric artery division 02'02''

The inferior mesenteric artery is divided 1 to 2cm from the aorta, which will not be skeletonized. This division is performed either after application of 2 clips, or after use of the Ligasure device. When using the Ligasure, and particularly in elderly patients with arteriosclerosis, the vascular ligation can be further completed by the use of a suture’s loop. The inferior mesenteric artery is then retracted anteriorly. This induces a pneumodissection of the retroperitoneal fibrocellular spaces and allows to divide the nerves’ branches in contact with the artery coming from the superior hypogastric plexus trunk situated lateral left of the aorta.

5. Inferior mesenteric vein division 03'21''

The inferior mesenteric vein is identified but not completely skeletonized. It is ligated either by suturing as in the present case thanks to the 10mm Ligasure Atlas device, or by clip application. Then the root of the sigmoid mesocolon and of the descending mesocolon is further freed posteriorly.

6. Sigmoid colon\'s lateral freeing 03'54''

The sigmoid colon is further freed on its lateral aspect thanks to adequate blunt traction placed on the meso, which helps to place tension on the structures to be divided. To do so, monopolar cautery (either with scissors or with a spatulated electrode) is used in order to divide the fibrotic structures. Dissection is continued caudally.

7. Upper rectum dissection 04'22''

The presacral space is mobilized by staying anteriorly to the presacral fascia, and posteriorly and around the fascia propria of the upper rectum until we reach the posterior aspect of the rectosigmoid junction. It is necessary to dissect the upper rectum while respecting the dissection technique used when performing total mesorectal excisions. Once the posterior dissection has been achieved, the dissection is completed on the left lateral aspect in order to obtain a resection at least 5cm beyond the inferior pole of the tumor. This dissection within the meso should not be tronconical, but cylindrical. That’s why dissection is carried out according to the technique used for TME. Manipulation of the colon is performed without grasping the diseased area situated at the level of the colorectal junction. Here we can clearly see the disease-free area where the rectum will be divided underneath the colorectal junction.

8. Mesorectal dissection 05'33''

Division of the meso is achieved in a cylindrical fashion slightly above the Douglas’ pouch. Here we can see the division of the mesorectum perpendicular to the mesentery in order to achieve a cylindrical resection removing at least 5cm of colon or rectum, mesentery included. This technique is purely oncological. On the left portion, it would be inappropriate to perform a tronconical division. That’s why the use of articulated scissors coming from the right (since they have been introduced through the right iliac fossa port) contributes to divide the tissues perpendicularly and achieve a cylindrical resection of the mesocolon or mesorectum. In order to respect oncological principles, a ligation of the upper rectum is performed using Ethibond material as in the present case, with extracorporeal knots; the loop obtained ensures patency of the rectal stump, which will be cleansed through the anus with a Betadine solution before application of a stapler. The ligation allows to place an adequate traction on the rectal stump, which will have been previously cleared of potential tumoral cells.

9. Division of the rectum 09'27''

The rectum is divided with an Endo-GIA linear stapler, blue cartridge, 60mm in length. Once completed, the closure of the stump is controlled using an air test or a Betadine test. Division of the vascular package, and especially of the inferior mesenteric vein that had been previously ligated using the Ligasure Atlas device is undertaken. The immediate non-division was not preferred because the descending mesocolon is preserved since it maintains bowel loops above the dissection plane and helps to better visualize the operating field during posterior dissection. Vascular ligature (especially large vessels) can be doubled using either a ligation or a clip; ligature with a suture loop offers the benefit of an ‘en bloc’ grasping without sharp dissection of the vascular structure. The descending colon and the splenic flexure must then be freed. Some authors recommend freeing of the splenic flexure first, then followed by freeing of the descending colon, which necessitates a wider dissection that is inappropriate in the present case. Personally, I prefer to free as need be. I use preferably a lateral approach. Freeing is carried out using the 10mm Ligasure Atlas device. It may be completed by a medial freeing removing the vascular structures.

10. Division of the mesocolon 11'50''

Once the area to be divided has been determined, the mesocolon is divided.

11. Division of the colon 12'19''

Then the colon is stapled and divided at the level of the area to be anastomosed. Here we have a diverticular disease of the colon, which necessitates a wider dissection. The cephalad bowel resection above of a tumor should be performed at least 10cm from the superior limit.

12. Colon extraction and anastomosis preparation 12'40''

The following steps include the extraction and preparation of the anastomosis. To do so, a plastic wound protector is introduced through the suprapubic port entry. An Endo-catch II plastic bag is introduced through this plastic drape. The diseased isolated segment of bowel specimen is placed into the extraction bag, which is brought out through the plastic drape. Extraction of the colon is performed; one of its extremities has been identified thanks to the ligature thread. The colon is progressively pulled, which reduces its volume inside the bag whilst placing traction on the bag, which can be extracted easily. No contamination of the abdominal cavity was observed thanks to this double protection. The colon is then brought through the plastic drape. The colonic extremity is further prepared in order to introduce the anvil of a circular stapler. This is achieved after placement of a purse-string fashioned with a specific instrument, a purse-string device. Trimming of the excess tissue is done with scissors in order to avoid being too close to the purse-string. The anvil of the DST PCEEA circular stapler is introduced. Then the purse-string is closed on the shaft of the anvil before reintroducing it again along with the proximal colon into the abdominal cavity. We control that the anastomosis is tension-free. The stapled rectal stump had been controlled to rule out any leakage. Then the 2 parts of the stapler, the anvil and the shaft are connected by grasping of the plastic material and not the metallic part using a forceps. I prefer to use a tooth “crocodile” forceps, which allows to grasp the shaft of the anvil without any difficulty.

13. Colorectal anastomosis 15'55''

The two extremities are positioned making sure that there is no twist, that the area is well vascularized, and the stapler is performed according to the recommendations of the manufacturer. Then the two donuts are controlled. We check that they are complete and thick enough.

14. Anastomosis - Air test 16'37''

An additional air test at the anastomotic zone can be performed if need be. It is essential to control that there is no tension at the level of the meso, which is the case here, without any vascular risk at the level of the marginal arteries. It is necessary to stay at enough distance from this vascular network and ensure a perfect mobilization.

15. Mesenteric defect closure 17'25''

Regarding the mesocolic defect, it can be closed simply by using a stapler as in our case. The stapler facilitates the closure. At this level, it is preferable to divide the peritoneum fairly to the left of the duodenojejunal flexure in order to prepare for this operative step. Closure more caudally is easy to achieve. It contributes to prevent the risk of internal hernia that can still occur anyway in the pelvis. At this time of the procedure, we control that there is no leakage with an air test. Control of hemostasis is also performed. The procedure ends with aspiration of carbon dioxide and re-approximation of the different openings in the abdominal cavity, especially the suprapubic incision as well as the 10mm supraumbilical incision holes in the right iliac fossa.

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