Laparoscopic total colectomy for colonic polyposis

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Laparoscopic total colectomy for colonic polyposis

Authors

J Leroy, J Marescaux

Keywords

colonic polyposis, total coletomy, laparoscopy

Media type

Surgical video

Duration

10'00''

Publication

2004-12

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E-publication

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1609.htm

Laparoscopic total colectomy for colonic polyposis

1. Trocar position 00'09''

This is the case history of a patient with colonic polyposis. After discussion with the patient, laparoscopic total colectomy will be performed. Five ports are utilized. The optical port is placed in a supra-umbilical site. It is a 10mm port. The other 4 trocars are placed in both the right and left mid-clavicular lines as shown here.

2. Dissection of right colon 00'25''

We begin the operation with the exposure of the transverse colon mesentery. The inherent nature of the total colectomy procedure dictates that the surgeon changes position during the procedure to maintain optimum exposure during dissection. We feel that this port placement is in line with this plane. The surgeon stands between the patient’s legs as they are in a lithotomy position. The assistants stand on either side of the patient during this part of the procedure to aid in retraction of the mesocolon. With the Ligasure 10mm Atlas device, we proceed to open the mesocolon and coagulate and cut the middle colic vessels. We maintain a close distance to the colon so as to decrease the incidence of injury to the surrounding structures. We move to the right mesocolon and complete this dissection. Currently, the patient is in the reverse Trendelenburg position to aid in the mobilization of the small bowel out of the operative field. The superior mesenteric artery is seen here. The lateral attachments of the right and left colon aid in retraction during this step. We feel the strategy saves significant time during the procedure. After the mesenteric dissection of the right and transverse colon is completed, we begin the dissection of the greater omentum from the colon. As you can see the 2 additional ports are utilized in retraction of the omentum during this part of the procedure. We continue our dissection towards the hepatic flexure. The duodenum is visualized here. We complete the lateral mobilization of the ascending colon as shown here. We now begin mobilization of the splenic flexure. As we have gained entrance into the lesser sac during the transverse mesocolon dissection, we can safely dissect the vascular supply of the splenic flexure as well as the surrounding structures such as the gastrum. Although you see the small bowel in the operative field, the medial dissection of the mesentery is adjacent to the colon keeping the small bowel out of the way. Here we view the splenic flexure as it leads on down to the sigmoid colon.

3. Dissection of left colon 03'45''

The proximal left colon dissection is nearly complete. At this time, the surgeon has changed his position to the right of the patient to utilize the 2 ports noted in the right mid-clavicular line. The first assistant will man the optical port next to the surgeon on the right side of the patient and the 2nd assistant is now between the legs of the patient. The ports on the left side of the patient are utilized for retraction. The patient’s reverse Trendelenburg position is also changed at this time as well to a left lateral tilt with Trendelenburg to aid in the retraction of the small bowel. The sigmoid mesentery is well exposed. We will begin the dissection of its vascular supply at this time. The surgeon stays adjacent to the colon, once again to avoid injury to the surrounding structures. The remainder of the lateral attachments of the proximal left colon are taken down. We do the same for the sigmoid colon. The sigmoid colon is now retracted and the remainder of its vascular supply is dissected. The ureter is seen here well out of harm’s way. The remainder of the proximal rectal dissection is continued. Note again the minimal time required for exposure of the operative field although this video is edited with minimal time spent in exposure for the procedure to complete in each of its phases. We are now at the rectum, and with the roticulating Endo-GIA, we are able to fire across the rectal stump.

4. Rectal dissection and division 06'44''

We aid in the mobilization of the rectal stump prior to its anastomosis with the terminal ileum. A 5mm incisional access is completed in the suprapubic region and a wound protector is placed. The colon is then retracted up and the distal ileum is then transected. With the specimen out of the patient, the pneumoperitoneum is regained and the distal ileum is then mobilized in preparation for the anastomosis with the rectal stump. To prevent an internal hernia, the mesenteric defect is then approximated with the stapling device.

5. Extraction and ileal division 08'32''

The approximation of the terminal ileum with the rectal stump is then done, and to decrease tension along the anastomosis, further dissection is then done. The mesenteric defect is approximated with the stapler.

6. Anastomosis 09'00''

This completes our procedure.