Medial approach for segmental resection of the splenic flexure in colonic cancer

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Medial   approach   for   segmental   resection   of   the   splenic   flexure   in   colonic   cancer

Authors
J Leroy, J Marescaux
Keywords
colon cancer,segmental resection,splenic flexure
Media type
Duration
06'00''
Publication
2004-04
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Apr 2004;4(04).
URL: http://www.websurg.com/doi-vd01en1554e.htm

Medial   approach   for   segmental   resection   of   the   splenic   flexure   in   colonic   cancer

1. Case presentation 00'08''
This is a video presentation demonstrating the use of the medial approach in segmental resection of the splenic flexure for a colonic tumor. These trocars are used with a zero degree camera. The case is that of a 47 year-old male patient with a colonic tumor requiring resection. The diagnosis was made during colonoscopy. The decision was made to perform a laparoscopic segmental resection of the splenic flexure. The operation is started by obtaining the correct exposure. These are the images from the colonoscopy showing the intraluminal tumor. Intralesional blue dye injection facilitated the intraoperative detection of the tumor shown here in the laparoscopic view. We start by stretching the transverse mesocolon and incising the peritoneum in this area. We use this approach at our institute for mobilization of the splenic flexure during sigmoid colectomy. We now see the aorta. The peritoneum is further divided in this area in an attempt to isolate the vascular structures. This is the inferior mesenteric artery, which is now being skeletonized. This is the left colic artery branching off the IMA. Following isolation, this vessel is divided at its origin using the Ligasure coagulation device. We continue more laterally onto the venous structures, which are also divided. This is the IMV, which is also being skeletonized and will be preserved. The medial approach is ideal for laparoscopy due to the good surgical access obtained facilitating careful vascular and lymphatic dissection, which are important oncological principles. Once the IMV is isolated, we move cephalad and laterally to look for the plane in front of Toldt’s fascia. The dissection is continued cephalad to the base of the transverse mesocolon, which is being stretched here. To the left of the screen, we see the pancreas coming into view and the dissection is continued anterior to this in order to avoid injury to the splenic vessels. Here access has been gained into the lesser sac. The transverse mesocolon is divided from right to left at its base. It is evident how the medial approach enables better surgical access to the posterior attachments of the splenic flexure. This is better than the conventionally used lateral approach. A blue dye of the tumor can now be seen as the dissection is continued laterally. Another advantage of this approach is that there is minimal manipulation of the tumor during resection, which is an oncological principle. This procedure is considered by experts as the most technically demanding laparoscopic procedure. It is evident how the medial approach may offer some technical advantages facilitating the mobilization of the splenic flexure. Once the medial side is free, we move on to the opposite side. Here the greater omentum, which is the superior attachment of the transverse colon, is divided using the Ligasure device. Now to the lateral attachments of the descending colon, which are freed using monopolar scissors. The lateral mobilization is made easier by the fact that the medial mobilization has already been performed. Now the mobilized colon is prepared for division. An appropriate position is chosen with an adequate resection margin and the surrounding fat is divided. The bowel is divided using the Endo-GIA. The same is done with the proximal end. Once the bowel is resected, it is placed in an Endo-catch bag and retrieved from the body doubly protected with a wound protector. The primary anastomosis is then performed using a circular stapling device. The device is fired to complete the anastomosis. This procedure demonstrates how the medial approach facilitates laparoscopic segmental resection of the splenic flexure and how principles of oncological resection can be respected using this approach. This is the end of the operation.