with Dr. Gabriel Diaz Del Gobbo
The laparoscopic approach to right colectomy has now been proven to be safe in oncological terms. Most surgeons perform an extracorporeal anastomosis after the resection. Current literature seems to regard the intracorporeal approach a better strategy, but the learning curve is steeper and may prolong surgical time in the first cases. An intracorporeal anastomosis after a right colectomy is ideal for patients with morbid obesity or a bulky mesentery. This strategy makes it possible to make a smaller incision in the abdominal wall and prevents increased traction to the mesentery during the exteriorization of the specimen.
The descending colon must be prepared after a sigmoid resection. A well vascularized colon must be selected and a correct pursestring made to attach the anvil. This video was produced to show several safety maneuvers such as the supervision of an untwisted mesocolon and a tension free anastomosis
The selection of an optimal site for anastomosis so far has been dependent on subjective clinical indicators of intestinal viability: color of the bowel wall, bleeding edges of resected margins, and palpable pulsations.
Indocyanine green fluorescence is a relatively new technique. Its intensity is correlated to tissue perfusion and bright fluorescence indicates good perfusion. The ICG may lead us to change the colonic site to perform the anastomosis. The green arrow distinguishes the well vascularized colon from the poorly vascularized one.
Patients with an indication of proctocolectomy require a reservoir to achieve bowel transit restoration. The J Pouch is the most popular option due to a favorable balance between postoperative complications and quality of life. We have produced a video with the main steps to build a J pouch through mechanical anastomosis.
TaTME involves different situations, which require different surgical steps and instruments. Each procedure needs a different type of anastomosis such as: hand sewn colo-anal anastomosis which is indicated in very low rectal cancer, an end to end mechanical anastomosis can be used if we have a sufficient distal margin to use a stapler.
A side to end anastomosis is indicated when we have sufficient proximal colon to exteriorize the specimen through a Pfannenstiel incision or through the anus. With this kind of anastomosis we are looking for better functional outcomes.
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