with Dr. Antonio M. Lacy
A 65-year-old female with no relevant medical record presented altered bowel movements and underwent a colonoscopy that revealed a proliferative lesion at 14cm from the anal verge. A CT scan ruled out metastasis. A T4 tumor was suspected due to infiltration of the uterus.
Surgical treatment with minimal invasive surgery was provided. The patient was placed in the supine position with open legs. The leading surgeon and the camera stood on the right side of the patient and the other assistant stood on the left.
A total of 6 trocars were used. A 12-mm port just above the umbilicus for a 30° scope; a 12-mm trocar at the right iliac fossa, and three 5-mm ports, one at each flank and the final one placed very low at the hypogastrium.
The goal of the surgery is to evaluate the feasibility of an oncological resection. The IMV were sectioned using the LigaSure™ and the left colon was mobilized from medial to lateral.
Careful examination of the pelvis revealed a redundant sigma with a large tumor that involved the posterior aspect of the uterus. The surgeon decided to mobilize the posterior wall of the sigma and the proximal rectum in order to facilitate the exposure maneuvers.
The hook was used to perform sharp dissection. Exposure was laborious due to the size and weight of the tumor. To achieve lateral mobilization, the peritoneal reflection was pulled up while the colon was pulled away from the pelvis. Avascular planes must be identified and followed to ensure R0 resection.
The posterior dissection was carried very low into the pelvis to ensure a disease-free distal margin. At this stage the dissection was performed from posterior to lateral, going from a clear plane to a more difficult one.
This case required an en block hysterectomy. The LigaSure™ was used to section the Fallopian tubes. As a clear posterior dissection was performed, the left lateral is evident and can be mobilized using the hook
To dissect the anterior aspect, the uterus was mobilized so as to ensure a disease-free margin. Digital examination of the vagina and the rectum were performed to help delimit the distal margin.
The uterus was divided from the vaginal stump using the energy devices in combination. The LigaSure™ was used when the surgeon had to release the posterior aspect of the uterus to avoid accidentally opening the colon.
In these cases the oncological resection is the most important aspect for the patient. If it cannot be accomplished by means of a laparoscopy, the surgeon must change to an open approach.
The ureter must be kept in mind during this part of the dissection. The left lateral was more difficult due to triangulation. Synchronized triangulation, traction and exposure are crucial.
The posterior approach allows the surgeon to reach more easily the plane to be mobilized. Now the uterus was mobilized and the surgeon assessed the colon in order to section it using mechanical sutures.
This is one of the issues of the laparoscopic approach: sectioning the rectum down into the pelvis may require several firings and may lead to an increased leakage rate.
The vaginal stump was tested to assessed whether it should be closed, but it was sealed using the LigaSure™.
It is important to perform lavage with an iodine solution to try and diminish the risk of collections. Medial to lateral mobilization of the descending colon was performed to ensure a tension-free anastomosis.
As can be seen, the left ureter was respected. The left colic artery is also left, if possible. The lateral detachment was made. It was not necessary to perform splenic flexure mobilization.
A Pfannenstiel incision was performed and a protective bag was placed to protect the wound. The proximal margin was sectioned extra corporeally and the colon was prepared for anastomosis using a pursestring suture to tighten the anvil.
The colon and uterus were resected en bloc with macroscopic free margins.
A mechanical side-to-end anastomosis was performed under direct laparoscopic supervision. Before firing the surgeon checked that the colon was not twisted. A trans anal Foley catheter was placed for decompression of the anastomosis and a protective ileostomy was created, as the anastomosis was very low into the pelvis.
A drain was left for postoperative surveillance. The surgeon plicated the peritoneum over the vaginal stump. Revision for hemostasis and lavage were the last steps of the procedure.
Surgical time was 120 minutes and there were no vascular or urological lesions. The patient started oral intake two days after the procedure and was discharged five days after the procedure.
Pathological examination revealed an R0 resection of a pT4N1 tumor and the patient received adjuvant therapy, with good tolerance to FOLFOX4. Five years after surgery she remains disease-free.
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