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The ability to perform en bloc resection laparoscopically depends on the structure to which the tumor is adherent, as well as on the surgeon’s skill and experience. When the goal is curative resection, intraoperative discovery of a T4 lesion often requires conversion, unless the surgeon is able to effectively resect the lesion en bloc. However, en bloc resection might not be possible using either technique, and therefore, the surgeon must decide whether conversion is likely to allow curative resection. Occasionally, the laparoscopy may become diagnostic, with closure followed by re-imaging and multidisciplinary consultation prior to a definitive resection at a later date. In some situations, based on the initial laparoscopy, the goals of surgery may shift from cure to palliation. To date, there have been no randomized trials comparing laparoscopic and open approaches to T4 colonic or rectal cancers.
This video shows a laparoscopic dissection of a T4 colon cancer
A 62 year old female patient with a previous history of hypothyroidism and dyslipidemia, with a BMI of 19 Kg/m2.
The patient presented with significant anemia, weight loss and fatigue. A Colonoscopy was performed showing an ulcerative stenotic lesion 25 cm from the anal verge, which did not allow endoscope passage. To complete the study we performed an abdominal CT which showed a mass compatible with a descending colon primary neoformative process with a diameter of 5cm invading the adjacent fat and with small lymphadenopathies. There were suspicious signs of invasion of the left psoas muscle and contact with the left ureter as it crosses the iliac vessels, without dilating. Invasion of the left ovarian vein was found, but not of the ovary.
The study was completed with a Colono-CT and a PET with no other significant findings. It was decided to place a pigtail catheter in the left ureter 24 hours before surgery to help with its location and avoid injuries.
The surgery was carried out through a laparoscopic approach. The patient was placed in the supine position with open legs. The surgeon stood at the right side of the patient with one assistant on each side.
A total of 5 trocars were used. A 12mm trocar was placed in supra umbilical position for a 30° scope. A 12 mm trocar was placed at right iliac fossa and a 5 mm trocar was placed at the right flank, serving as working channels for the leading surgeon. Two 5mm trocars were placed at the epigastrium and left flank as helping channels for the assistant and for the surgeon if necessary.
We placed the patient in a right-hand position in order to make the small intestine slide into the right abdomen. Here we can see the large size of the tumor and retraction level featuring the vessels, ureter and retroperitoneal. Initial dissection started with an incision of the peritoneum in the mesentery. A cautery was used to open the peritoneum along this line, opening the plane cranially up to the origin of the inferior mesenteric artery, and caudally past the sacral promontory.
During the dissection we were able to see the edema caused by the tumor. We observed the movement of the right ureter, which should also be taken into account. We continued the medial to lateral dissection, taking care not to injure the iliac vessels or the left ureter. Blunt dissection was then used to lift the vessels away from the retroperitoneum and presacral autonomic nerves. Finally we placed a gauze to help and continue the dissection.
We tried to identify the inferior mesenteric vessels, which was very difficult due to the retraction and edema. We decided to release the descending colon from the retroperitoneum to help us identify structures. At this point we found the pancreas, which was carefully freed by the LigaSure™ using the cautery and blunt dissection.
After that we released the colon from medial to lateral and placed another gauze at this level. We continued to use a lateral approach until we identified the gauze previously placed. Dissection now continued up along the white line of Toldt, toward the splenic flexure. The surgeon's left-hand instrument should be gradually moved up along the descending colon to keep the lateral attachments under tension. In this way, the lateral and any remaining posterior attachments were freed. We opened the lesser sac to complete the mobilization of the splenic flexure. Finally the left colon was placed in a medial midline position by means of these maneuvers.
Once again the patient's position was changed to approach the distal part of the tumor and locate vessels and ureter. It is very important to perform a careful dissection to avoid unexpected injuries. At this point we performed mesocolon dissection and searched for the ureter. Here again we placed the gauze, which we would later identify across the other side. We proceeded to open the Toldt fascia on the left side to identify the gauze. A lateral dissection was performed to identify the ureter. Once located, we proceeded to its individualized dissection, signaling it with a vessel loop.
Once the ureter had been identified we were able to proceed with the lateral release of the colon tumor and its retroperitoneal area. Likewise we were also able to section the mesocolon from the medial area safely. The vessel area remained very attached to the tumor so dissection was very difficult at this level. We continued with the release of tumor at the psoas level, performing an en bloc resection. At all times we considered the ureter, which was tutored and marked with a vessel loop.
At this point we decided to perform the distal colon dissection for sectioning.The assistant grasped the rectosigmoid junction through the left flank port, and drew it up and out of the pelvis, and somewhat anteriorly. This gave the surgeon a nice view of the posterior surface of the mesorectum and the presacral space. Then we completed mesorectal dissection on both sides. An EndoGIA™ stapler was then inserted through the right iliac fossa port and used to divide the rectum with two firings.
At that point we had released the colon in the distal and proximal areas. Finally we had to remove the tumor on the left side area. Gradually we completed en bloc resection of the tumor and the encompassing psoas.
Finally we went to the mesenteric vessel area to complete the dissection at this level. We tied the inferior mesenteric artery with clips and sectioned it. Then we proceeded to release of the tumor at the ureter level, following its way, noting that it adhered to the tumor but was not invaded. For this reason it was possible to detach it. We finished the dissection with the LigaSure™ completing the resection of the tumor.
After this, the specimen was exteriorized through a Pfannenstiel incision in the hypogastrium. We cut the proximal colon, completing the sigmoidectomy. Then we made an end to end colorectal anastomosis by laparoscopic approach by an EEA stapler, completing the surgery. The anastomosis was reinforced with 3 stitches. Finally a drain was placed and the surgery was over.
The surgery took 115 minutes. Oral intake was initiated within 48 hours of the procedure.
The postoperative course was uncomplicated. The patient was discharged on postoperative day 5.
The Pathology showed a Colonic adenocarcinoma pT4aN2a. The pigtail was removed 1 month after surgery with no complications. Currently the patient is clinically stable, undergoing chemotherapy and joint monitoring by our surgery and oncology teams.
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