Totally laparoscopic segmental resection of splenic flexure for cancer

In laparoscopic colectomy, intracorporeal anastomosis is technically difficult. The objective of this video is to show the technique of laparoscopic segmental resection of the splenic flecture using a medial approach with an intracorporeal manual colosigmoid anastomosis. Each step of the procedure is well explained and technical details are thoroughly analysed.

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Totally laparoscopic segmental resection of splenic flexure for cancer

Authors

J Leroy, J Marescaux

Abstract

In laparoscopic colectomy, intracorporeal anastomosis is technically difficult. The objective of this video is to show the technique of laparoscopic segmental resection of the splenic flecture using a medial approach with an intracorporeal manual colosigmoid anastomosis. Each step of the procedure is well explained and technical details are thoroughly analysed.

Classification

clinical cases

Keywords

Totally laparoscopic segmental resection of splenic flexure, cancer

Media type

Surgical video

Duration

12'00''

Publication

2009-05

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E-publication

WeBSurg.com, May 2009;9(05).
URL: http://www.websurg.com/doi-vd01en2458.htm

Totally laparoscopic segmental resection of splenic flexure for cancer

1. Introduction 00'10''

The objective of this film is to demonstrate the technique of segmental resection of the splenic flexure using a medial approach with a manual colosigmoid anastomosis under laparoscopic control. Once a few adhesions have been taken down, the inferior mesenteric artery is approached conventionally using a medial access from right to left. This helps to identify the origin of the artery.

2. Dissection of the inferior mesenteric artery 00'43''

Once the trunk of the artery has been identified, it is dissected and skeletonized. Then the left colic artery is identified. The objective is to remove all the cellular nodal tissue enveloping the vascular sheaths while preserving the vascular supply of the sigmoid colon and rectum.

3. Division of the left colic artery 01'18''

The trunk of the left colic artery is divided using the Ligasure Atlas device as close to the inferior mesenteric artery as possible.

4. Medial approach dissection 01'30''

Then the dissection is continued using the medial approach on the posterior aspect of the mesocolon anterior to Gerota’s fascia. Here the anterior aspect of the kidney can be seen. Laterally to the duodenojejunal flexure, the transverse mesocolon is opened anterior to the pancreas sufficiently distal from the duodenojejunal flexure in order to avoid any injury to the duodenum and keep a bit of peritoneum for closure of the mesocolic defect at the end of the procedure in better conditions. Once the pancreas has been identified, the root of the left transverse mesocolon is divided on the anterior aspect of the pancreas until the posterior aspect of the splenic flexure. Here the inferior mesenteric vessels and the ureter protected by Gerota’s fascia are clearly visible. Dissection is continued on the posterior aspect of the descending mesocolon and the lateral portion of the mesocolon is reached at the posterior aspect of the descending colon. The descending mesocolon can now be divided until the colon is reached at the junction between the descending colon and the sigmoid colon.

5. Division of the descending colon 03'34''

The colon is then divided using the 60mm linear Endo-GIA stapler, blue cartridge in order to preserve the vascularization of the colonic wall. The transverse colon still needs to be divided. It will be divided once the transverse mesocolon has been divided until the left portion of the transverse colon.

6. Division of the transverse mesocolon 04'04''

Division is carried out using the 60mm Endo-GIA linear stapler, blue cartridge, perpendicular to the colon; the splenic flexure which has been resected is left towards the left hypochondrium. We must check that there is no tension and that the two extremities of the transverse and sigmoid colon are well vascularized.

7. Isoperistaltic approximation of the transverse and sigmoid colon 04'29''

These two extremities are positioned one against another in an isoperistaltic position, which helps to evaluate the anastomotic possibilities without tension. Two stitches for identification and fixation are carried out laparoscopically using Ethibond 2/0 extracorporeal sutures. These sutures allow for the correct positioning of the two colonic segments. They also enable to check the limits of the anastomotic area. They will be very useful as landmarks to expose the suture and division area.

8. Opening the colonic wall 05'30''

The sigmoid wall is opened, preferably on one of the anterior taenia until the colonic mucosa is opened. Scissors with monopolar electrodes can be used to achieve gentle and elective coagulation of the submucosal vessels. This division is completed with control of the correct vascularization and staining of the mucosa. The same technique is applied on the transverse colon that is opened on the anterior taenia. The seromuscular plane is opened first. Then the mucosa is opened using scissors with monopolar electrode, roticulator mini-shears.

9. Intracorporeal manual anastomosis 06'18''

Once the mucosa and the wall of the transverse and sigmoid colon have been opened, the posterior suturing can be started using monofilament absorbable Maxon or PDS sutures 2/0 or 3/0. Intracorporeal knots are tied. The first stitch is made cephalad or to the left. Then the different stitches are made extramucosally. The anastomosis is performed using a running suture. There is no need to pull on the suture since the monofilament thread enables to perfectly advance through the tissues. Here we can see the extramucosal passage of the thread. Once the thread has been passed, it can be pulled in order to tighten and approximate the margins of the anastomosis. The posterior suturing can be completed using final stitches and the final suturing and last stitch can be achieved using intracorporeal knots so that the next to last loop will serve as a second thread to perform the knot. The anastomosis of the anterior margin still needs to be performed laparoscopically. Two half-running sutures will be used. They will be joined together on the middle of the anastomotic area. A manual suture is used through extramucosal stitches. Several stitches are passed and traction is then achieved, which saves time. This is possible thanks to the use of monofilament sutures. Stitches of the running suture will be performed from caudad to cephalad to start with, and from cephalad to caudad for the other half-running suture. This is achieved so that the 2 threads are brought together facing each other in order to obtain a flat knot and terminate the running suture at its medial anterior part. Once the anastomosis has been carried out, we must check that there is no-tension and that there is no mesenteric defect that would let the small bowel go through and induce obstruction.

10. Mesenteric defect closure 10'30''

This defect must be perfectly closed from the duodenojejunal flexure even above it using either manual sutures or staples. The closure can be performed either by a medial approach or by a lateral approach. Once the defect has been thoroughly closed in order to prevent any obstruction, the operative specimen has to be extracted. The specimen has been shelved in the left hypochondrium.

11. Specimen extraction 10'56''

An Endo-Catch II extraction bag is introduced through the suprapubic port. It is introduced through a suprapubic plastic drape with a ring that protects a suprapubic mini-incision. Then the specimen is brought through this incision and extracted.