Laparoscopic total colectomy with partial proctectomy

This video demonstrates the performance of a total colectomy performed laparoscopically that included resection of the cephalad portion of the rectum. This approach involves resection of the proximal portion of the rectum. The authors divide the ileum near the ileocecal junction. With the ureter identified and secured, they move to dissect anterior to the fascia. The duodenum comes into view, then progressively the colon and attachments are freed. After they complete freeing the right colon, they move to the patient’s left side to carry out a left colectomy.

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Laparoscopic total colectomy with partial proctectomy

Authors

J Leroy, J Marescaux, F Costantino

Abstract

This video demonstrates the performance of a total colectomy performed laparoscopically that included resection of the cephalad portion of the rectum.
This approach involves resection of the proximal portion of the rectum. The authors divide the ileum near the ileocecal junction. With the ureter identified and secured, they move to dissect anterior to the fascia. The duodenum comes into view, then progressively the colon and attachments are freed. After they complete freeing the right colon, they move to the patient’s left side to carry out a left colectomy.

Keywords

laparoscopy, total colectomy, partial proctectomy

Media type

Surgical video

Duration

18'00''

Publication

2008-02

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E-publication

WeBSurg.com, Feb 2008;8(02).
URL: http://www.websurg.com/doi-vd01en2261.htm

Laparoscopic total colectomy with partial proctectomy

1. Case presentation 00'30''

We will do a total colectomy with a small extension on the rectum.

2. Vascular approach of the right and transverse colon 00'39''

First, we will begin on the right side as in for a right colectomy. The goal is to limit the size of the incision to perform minimally invasive surgery. I’m exposing the root of the transverse colon. It is not a carcinomatosis that we usually have on the right side, but we will do a colectomy as for a limited cancer. The transverse colon is retracted anteriorly; the right colon with the hepatic flexure, the liver, and the ileo-caecum. This is probably the axis of the superior mesenteric vessels. These are the ileocolic vessels. I’m dividing the peritoneum. We have to go slowly to open the plane. This is the beginning of the plane and we will see rapidly the duodenum as you see here. I’ve just finished the division. Here is the duodenum in sight, the pancreas. I have to free from medial to lateral the attachments of the ascending colon, and I’m freeing the root of the transverse mesocolon. First I have to open the peritoneum, and we will enter the lesser sac. Big colic vessels are there. I will divide them. We will enter the lesser sac now. The best place to enter the lesser sac is more to the left. You remember the duodenojejunal junction not far going slowly to the other landmark to the root of the mesentery. That is the duodenojejunal junction. We stay anterior to it. We want to open the lesser sac, anterior to the pancreas. This is the lesser sac. There are adhesions to the stomach as you see. The lesser sac is opened. I’m dividing the root of the transverse mesocolon. This is a medial approach for colectomies. The advantage of this approach is first a primary vascular approach, secondly, we are not changing the position of the bowel and we have a constant exposure of the operative field, so it’s not time-consuming. What are the major risks of this approach? The difficulty to recognize the anatomy, I think is the main risk, because it’s not a usual approach, and we first discover the vessels, and in laparoscopy we also change the traction and the technique for exposure; for example, in the transverse colon we’re lifting anteriorly and working from caudad to cephalad, it’s not usual, so we have to imagine the anatomy and recognize it intraoperatively to avoid errors. I’m dividing far from the pancreas, and you see close to the stomach, we enter the lesser sac further. Normally I have divided the attachments of the root of the transverse mesocolon.

3. Right colon mobilisation 06'08''

We will now divide the ileum not far from the ileocaecal junction. Do you usually look for the ureter or not? Well, we don’t try to dissect it; usually the ureter is more medial. Perhaps we will see it through. It’s not really a danger. There is another danger yet, it is to dissect higher, if you have a wrong plane. You have to dissect anterior to the fascia. You see the duodenum, then progressively the colon and attachments freed for the right colon. I will ask my assistant to grasp the omentum. Here you see the ischemia not pushing but pulling anterior. To ensure a good division, it’s necessary to exert traction. Freeing of the right colon is now complete. Now we will go to the right side of the patient and we will be doing a left colectomy.

4. Left colon mobilisation 08'29''

We have to expose. To do so, the patient is placed in a Trendelenburg position. Here is the duodenojejunal junction. Can you explain your strategy? Why do you start at this level? My strategy is to divide the meso at mid-distance of the aorta to divide the sigmoid branches. I have to divide the vessels not at the origin of the IMA because its not a cancer here but a diffuse and disseminated polyposis. The best thing here is to free laterally. So here you don’t do a complete medial approach. You have a mix of lateral and medial approach. As soon as I’ve finished with the medial approach, I am not far from the lateral attachments and lateral side of the mesocolon. Here I carry on with the lateral division. The best way is to stay anterior to Toldt’s fascia that you can see there. This is the IMV that runs behind the pancreas. Normally we divide, in this case we keep the vascular supply of the rectum and we will divide the peritoneum only. This approach appears logical, even if it’s not easy at the beginning to find the correct plane to go here ahead because the identification of the orientation of the grasper is really a question of experience. Again it’s very clear that the danger is the tail of the pancreas because it can be really close to the colon and it can be pulled anteriorly due to the traction that is exerted on the mesentery. I have freed completely the attachments of the transverse mesocolon. Now I have the lateral attachments and we see that we can do the division using a medial approach. We have difficulties to cut because it’s necessary to have a good traction to ensure a good cutting. Now back. I want to see the attachments of the omentum. This is the final attachment of the splenic flexure.

5. Rectal dissection with tattoo of the distal polyp 11'31''

We will now perform an endoscopy and a tattoo of the inferior limit of the polyp to resect not too much. We want to keep a rectal stump for better functional results. Bowel clamp now. We have just located the polyp. It’s lower here. So we will do the division of the mesorectum. I’m doing the division close to the bowel as previously said to keep the vascularization of the rectum, and because it is an elderly patient, we’re dividing the mesorectum till we reach the limit. We have finished to dissect the rectal stump. There is no tumor in the stump. We have finished to divide the colon.

6. Small bowel ileal mobilisation 13'56''

So now we will do the extraction of the colon using a suprapubic incision.

7. Specimen extraction 14'05''

We have to perform a large incision, enough to have no traction on the small bowel and mesentery. We will remove the colon. Here is the caecum.

8. Ileo-rectal anastomosis and closure of the mesenteric defect 15'57''

Now we do the anastomosis about 10cm away from the anal margin. We now verify the ring. We do an air test. We are now closing the gap. We can use sutures, staples. We will put a drain in the pelvis, but no diverting stoma.