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Leroy J, Marescaux J. Laparoscopic total colectomy for T4N0M0 right colonic cancer and Lynch syndrome. Epublication: WeBSurg.com, Jan 2013;13(1). URL: http://www.websurg.com/ref/doi-vd01en3804.htm

J Leroy (France), J Marescaux (France)

English - 27'07''
January 2013

The authors demonstrate their technique of laparoscopic total colectomy indicated for T3 tumors of the right transverse colon in a 40-year-old man with a family history of Lynch syndrome. Colonoscopy performed 3 years earlier ruled out the presence of polyps. Due to the tumor's invasiveness and the necessity to perform repeated endoscopic monitoring, it was decided to perform a total colectomy. The intervention is begun to the right and is completed to the left making sure to avoid any tumor manipulation. The different steps of the procedure are clearly outlined with images of outstanding quality. The vascular approach, especially to the right along the superior mesenteric axis, is beautifully exposed.

Palabras clave: Laparoscopic total colectomy, T4N0M0 right colonic cancer, Lynch syndrome


00'15'' Introduction
The objective of this film is to demonstrate a total colectomy technique in a male patient in his forties, presenting with a T3 right colonic tumor and with hereditary non-polyposis colorectal cancer (Lynch syndrome). Considering the context, a total colectomy was decided upon. Total colectomy is initiated from the right side of the colon, seat of the tumor, with an oncological approach at this level.
00'43'' Oncologic right colectomy by medial posterior approach
Exposure is achieved with the patient placed in a reverse Trendelenburg position and by retracting the transverse colon cranially in order to expose the junction between the right mesocolon and the mesentery.
01'21'' Primary vascular approach
The superior mesenteric axis is freed and the ileocolic vessels are divided, which allows for a correct identification of the third portion of the duodenum, the second portion of the duodenum and the head of the pancreas medially. A vascular approach is used according to the complete mesocolon resection technique in order to be as oncological as possible.

Here, dissection in contact with the pancreatic head, close to the second duodenum, is clearly visible and dissection of the planes is performed using a strictly medial approach without any manipulation of the colon.

Dissection is continued on the anterior aspect of the superior mesenteric vein, and the different venous branches are divided paying attention to preserve pancreatic vessels more particularly. Only the right colic vessels will be divided and here the right colic vein is visible: it is divided by means of the 5mm Blunt-Tip Ligasure™ vessel-sealing device. Another right colic branch is also divided as it drains into Henle’s gastrocolic trunk. Here, the omental vein can be seen along with the dissection performed anteriorly to the pancreas.

Dissection is pursued to the left with the identification of the colica media, which will be dissected, skeletonized, and divided proximal to the superior mesenteric vein, namely close to its origin on the superior mesenteric artery. Dissection on the anterior aspect of the pancreas is continued, still by staying within the embryological planes, just in contact with the posterior layers of the ascending mesocolon. Here, the progressive freeing of such planes is clearly visible by exerting adequate traction and counter-traction. The genu superius as well as the right side of the superior layer of the transverse mesocolon are reached. Here, the planes are clearly visible.
04'23'' Freeing of the attachments of the right colon
The procedure is carried on more medially by following the first duodenum, which represents a landmark providing us the insertion zone of the greater omentum. Here, the attachments of the transverse mesocolon on the right side of the duodenum are well visible. Division of such attachments is carried out using a posterior medial approach. As soon as the transverse mesocolon has been opened at this level, the gallbladder comes into sight through the defect made within the transverse mesocolon. Dissection is carried on to the left, paying attention not to manipulate the colon where the tumor is seated.

Division is achieved by opening the lesser sac and by staying anterior to the pancreas. One should avoid landing onto the posterior aspect of the pancreas and to find oneself posterior to it with the subsequent risk of injuring the pancreas. As can be seen here, the pancreas is clearly visible, mobile, and the risk is to pass behind it. The inferior border should be identified absolutely and traction on the transverse mesocolon may sometimes be adjusted to avoid too posterior a dissection.

Dissection of this zone is continued by opening the lesser sac. The opening zone can be searched for more laterally to the left as this zone is much more detachable to the left than posteriorly to the antrum.

Here, division of the attachments on the inferior border of the stomach is well visible. Freeing of the greater omentum is continued. The greater omentum is removed ‘en bloc’ along with the colon in order to allow for a complete lymph node examination and especially to avoid being in contact with the tumor.

The greater omentum is detached in contact with the stomach as can be seen here. The division is achieved without changing the position of instruments, still be retracting the stomach, the greater omentum and the transverse colon cranially. Here, the interest of using the Ligasure® vessel-sealing device is demonstrated as it allows for a perfect hemostasis as well as division after hemostasis—these operative steps are much longer if bipolar cautery is used, and above all, the operative field would be much foggier with any other type of energy device.

Mobilization and freeing of the colon is carried out at the transverse part. The ascending colon still needs to be freed from its posterior attachments. This operative step is begun by a posterior freeing and one can feel that the tumoral mass is not very far. It is important to perform the dissection away from the mass and maneuvers are pursued on the distal part of the ileum. Posterior attachments are divided at the level of the caecum in order to pursue laterally onto the ascending colon once anatomical landmarks such as iliac vessels, the ureter and genital vessels have been controlled.

The last bowel loop is grasped and divided paying attention not to free too much of the terminal small bowel, which will facilitate its identification later on.

The dissection can be continued on the posterior aspect of the caecum by means of the Sonicision™ cordless ultrasonic dissection device. This instrument equals to ultrasonic scissors, and is much more ergonomic as there is no cable that connects it to an external generator.

Freeing of the transverse colon is achieved using a posterior approach. One is faced with a few difficulties in identifying the structures and it is essential to be careful at this stage during manipulation. It is essential to find the plane that lies more posteriorly. In order to dissect properly, atraumatic traction is performed paying attention not to perforate the digestive tract which is slightly dilated.

Here, one can see that dissection is slightly tricky as there are posterior fixation zones and it might be more prudent to understand the anatomy using a superior approach to try and free the adhesions from the tumoral mass which is clearly visible to the left in the present case. This mass looks much more fixed posteriorly than anteriorly.

Once the medial approach has been completed, one can rapidly understand the benefit of using such an approach to free the area where the tumor lies.
A distal, then proximal and posterior approach has been used and the freeing of the tumoral area is completed.

Here, a small adhesion to the duodenum is taken down and the last posterior attachments of the ascending colon and of the right transverse colon are freed. Here, the tumor mass is clearly visible and care must be taken not to touch it. A few adhesions on the posterior aspect of the caecum are taken down and one can clearly see that the whole of the right colon has been mobilized.
13'11'' Left colectomy with oncologic approach
The following step consists in the freeing of the left colon. Total colectomy has been decided upon given the context and the fact that this patient required regular monitoring. It is easier to control a rectal stump than to perform complete monitoring of the colon. Indeed, this patient developed a tumor in 2 to 3 years’ time as he was screened for endoscopically 3 years earlier.
13'51'' Primary vascular approach and medial posterior dissection
Here, the freeing of the inferior mesenteric artery is visible. The plexuses are respected and parietalized on the anterior and lateral aspect of the rectum. The ureter is well identified. To perform this operative step, the surgeon moved from a position between the patient’s legs to stand to the patient’s right with the possibility of completely dissecting the left colon as conventionally performed using a medial approach. Here, the ureter, the psoas muscle, a few lymphatic rami - or a vein coursing on the external part of the ureter, are clearly visible.
Here, the splenic flexure of the colon is fixed quite cephalad. The inferior mesenteric vein is exposed. Dissection is carried on by respecting the nerve plexuses. The use of the Ligasure™ vessel-sealing device is extremely important as it ensures a perfect closure of the lymphatic ducts, hence avoiding any sero-lymphatic effusion that could induce a risk of cancer cell dissemination. This instrument also allows for a perfect hemostasis, hence avoiding any postoperative lymphorrhea.

Here, the embryological dissection plane can be observed between Gerota’s fascia posteriorly and Toldt’s fascia anteriorly. A more cranial plane must then be found, anterior to the pancreas, and the root of the left transverse mesocolon can then be detached towards the pancreatic tail. Here, one can see that the plane at the medial part of the transverse colon and at the posterior aspect of the stomach has been found again. The root of the left transverse mesocolon will be divided until the posterior aspect of the splenic flexure, staying anterior to the pancreas. At this time in the procedure, the difficulty is to carry on with the freeing of the greater omentum. Much can be done without changing the position, namely using a medial transmesocolic approach. This will however be insufficient as detachment will have to be extended towards the splenic region as well as on the left part of the greater curvature.

Dissection is carried on still using a medial posterior approach. The interest is to avoid any time-consuming colonic manipulation as changing positions constantly forces the surgeon to reposition himself/herself. Consequently, the medial posterior approach is highly valuable. Indeed, as soon as the anatomy has been well understood, some operative time is definitely saved. Lateral mobilization which starts here at the level of the sigmoid colon is the easiest maneuver. In our opinion, it would be wrong to sta rt with this time of lateral mobilization, and especially in obese patients.

Here, the splenic region can be seen along with the colo-splenic ligament and the phrenicocolic ligament that have just been divided. Division must be continued by detaching the greater omentum even if it does not look so important at this level. Here, the left omental vein is divided and one can see that the pancreatic tail not very far. Therefore, caution is the rule of the procedure at this time. Division of the greater omentum can be completed. At this moment, division on the greater curvature, left side of the colon, is completed.
The whole of the right colon, of the transverse colon, of the descending colon have been mobilized. Dissection is continued towards the colorectal junction and one can see that the division is pursued smoothly at this level in this patient with a relatively normal anatomy.

When performing a total colectomy, one must bear in mind that the surgical strategy is paramount and the following surgical step must always be anticipated to avoid multiple manipulations and reduce operative length.

Here, the colorectal junction comes into sight as it starts to be freed on its posterior aspect. Laterally, and to the left, attachments of the distal sigmoid colon and of the upper rectum will be taken down. Control is essential prior to any division and one must make sure that the space is free. Here, attachments are well visible. In case of doubt, the lateral approach is recommended. Everything relies on exposure. Here is the colorectal junction. Once again, the 5mm Blunt-Tip Ligasure™ vessel-sealing system is used. In obese patients, the 10mm Ligasure™ vessel-sealing system is preferably used; it is more rapid and effective than a larger one. A stapler with Tri-Staple™ Technology, 60mm long purple cartridge, is then introduced through a 12mm port.
21'59'' Ileorectal side-to-end anastomosis
Once the colon has been divided, our attention is turned towards the distal small bowel that had been divided without being freed in order to check for lowering possibilities. The colon will be exteriorized through a suprapubic incision. The anvil of a 28mm DST PCEEA™ circular stapler will then be introduced. At other times, a 25mm DST PCEEA stapler may be used as the small bowel has a smaller diameter.

A side-to-end anastomosis is performed and a re-cut is made 2cm away. Here, the 28mm DST PCEEA™ circular stapler is visible. It can be introduced easily into the lumen of the small bowel as can be seen here. The small bowel is perforated on the anti-mesenteric border perpendicularly using a white cartridge. The anti-mesenteric border is made shorter than the mesenteric border.

The purse-string is used only to secure the zone to avoid any enlargement of the defect during tightening and stapling.

Here, one can clearly see that the small bowel is perfectly vascularized. The whole is reintroduced into the abdominal cavity. The plastic sheath introduced into the suprapubic incision will be used as a temporary port. It is a Vi-Drape® 7cm in diameter. The rectal stump is then cleansed using a betadine solution.
The rectal stump is then perforated by means of the DST PCEEA™ circular stapler. It is essential to avoid making 2 ears and perforate close to an angle in order to use as much staple line as possible. This single staple line has been made in a circular fashion. This represents the racket-handle technique that prevents any ischemia in case of stapling astride the staple line.

Control must be made to rule out the absence of twist and the doughnuts must be checked to make sure that they are complete and thick as can be seen in these pictures. This is proof that doughnuts have been divided adequately.
The defect needs to be closed now in order to avoid any small bowel loop incarceration. Usually, staples are used. A simple running suture can also be used. Here, a self-blocking V-Loc™ running suture is used. The suture can be made by fixing the stapled area and prevent any potential internal hernia.
This suture will be used to completely close the defect. A lavage is merely used to cleanse the abdominal cavity, which will be closed at the level of the ports. A pelvic drainage with a Blake suction drain was positioned laterally in the left pelvis. For 12mm ports, closure will also include the aponeurosis. For 5mm ports, only the skin will be re-approximated. No protective stomy is necessary as it is not an emergency procedure. There is no danger at anastomotic level. The 2 bowel segments are perfectly vascularized.
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Joël Leroy 
   

Jacques Marescaux