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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_841_Библиотеки_им_академика_М_И_Перельмана.pdf
Surgical Technique
andDicult Situations
fromAmjad Parvaiz:
Splenic Flexure Tumors
(Laparoscopic)
AmjadParvaiz andManfredOdermatt
35.1 Introduction – 274
35.2 Treatment ofSplenic Flexure Tumours
byExtended Right Colectomy – 274
35.2.1 Concept – 274
35.2.2 Mobilisation oftheRight Colon – 274
35.2.3 Mobilisation oftheLeft Colon – 275
35.2.4 Mobilisation oftheTransverse Colon – 276
35.2.5 Anastomosis – 276
35.2.6 Advantages andDisadvantages – 276
273
35
35.3 Treatment ofSplenic Flexure Tumours
byLeft Colectomy – 277
35.3.1 Concept – 277
35.3.2 Set-Up – 277
35.3.3 Mobilisation ofLeft Colon – 277
35.3.4 Mobilisation oftheMiddle Part
oftheTransverse Colon – 278
35.3.5 Mobilisation oftheHepatic Flexure – 278
35.3.6 Anastomosis – 278
35.3.7 Advantages andDisadvantages – 278
35.4 Risk Classication asRegards
Diculty Level ofLaparoscopicTME – 278
35.5 Intraoperative Problem and
Solution TME (Clinical Vignettes) – 279
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_35
274
A. Parvaiz and M. Odermatt
35.1 Introduction
Splenic exure tumours are unique as they lay
between two main arterial supply and venous
and lymphatic drainage areas. ere is no
evidence- based consensus on how to best resect
splenic exure tumours. Mainly, there are two
surgical approaches: the rst is by an extended
right colectomy and the second is by a le
extended colectomy.
Data from our unit suggest that neither
approach is superior with similar short- and
long- term outcomes for these patients. However,
the extended right colectomy seems to be preferable in obstructive splenic exure cancers
presenting as emergencies, especially when
there are no endoscopic bridge-to-surgery
options available or feasible. We will describe
both approaches according to our personal
method.
. Fig. 35.1 Extended right colectomy for splenic
exure tumours. Division points of supplying vessels and
resection lines
35
35.2 Treatment ofSplenic Flexure
Tumours byExtended Right
Colectomy
Resection of splenic exure tumours by extended
right colectomy
Step 1 Mobilisation of the right colon with
ligation of ileocolic artery and vein and
freeing of hepatic exure
Step 2 Left colon mobilisation, central division
of left colic artery
Step 3 Division of transverse mesocolon with
high ligation of middle colic artery
Step 4 Exteriorisation of mobilised bowel
segment and specimen resection
Step 5 Ileosigmoid anastomosis
35.2.1 Concept
e extent of resection as regards blood supply is
schematised in . Fig.35.1.
. Fig. 35.2 Operating theatre set-up for right colonic
mobilisation
35.2.2 Mobilisation oftheRight
Colon
e patient is positioned in a modied LloydDavies position. e operation begins on the
right side. e initial set-up of the operating
team is schematised in . Fig.35.2. e site of the
Surgical Technique andDicult Situations fromAmjad Parvaiz
. Fig. 35.3 Port sites for extended right colectomy
ports is shown in . Fig.35.3. e camera port is
at the umbilical site. Aer the usual assessment,
the patient is tilted towards the le side and
slightly head down. e greater omentum is
pushed cranially so that the transverse colon can
be identied. e small bowel is swept towards
the le side. e caecum is visualised. e mesentery in the ileo-caecal angle is grabbed by a
Johann and pulled up ventrally, laterally and
caudally. By this manoeuvre, the ileocolic artery
is brought under tension and its course visualised. Centrally, an incision of the peritoneum of
the mesentery is made below the ileocolic artery.
Aer opening the peritoneal layer, air enters and
automatically follows the embryological planes.
Dissection is continued following the air until
the mesentery can be separated from an underlying smooth shiny layer. e package containing the ileocolic artery is mobilised as centrally
as possible. ere, the ileocolic artery is circumferentially dissected and divided between two
clips. By liing up the ascending and right-sided
transverse mesocolon and supporting it by an
instrument, the separation of the planes is continued on top of the duodenum and pancreas
and from medial to lateral on top of the Gerota’s
fascia. A swab is placed on the duodenum to
facilitate the transection of the transverse
275
mesocolon from above at a later stage. e dissection between the embryologic planes is
mainly blunt and there should be no relevant
bleeding. Aer this step, the caecum and ascending colon are mobilised from lateral which actually is nothing more than dividing the
attachments of the right colon to the lateral
abdominal wall as all the rest has been mobilised
from medial to lateral in the previous steps. e
lateral mobilisation is carried out in caudo-apical direction towards the hepatic exure. en,
the hepatic exure is retracted caudally and
attachments to the gallbladder and liver are
divided. e greater omentum itself can either
be resected together with the specimen or be
detached from the transverse colon. en, the
root of the right-sided transverse colon is
divided. e swab which has been placed from
below on top of the duodenum in a previous step
is identied, while the transverse colon is
retracted caudally. e transverse mesocolon is
divided over the swab using, for example, a harmonic scalpel. e swab plays a crucial role as it
prevents damage to the duodenum. Aer an
opening of the root of the transverse mesocolon
has been created, an instrument is inserted to
support the mesocolon and protect underlying
structures. Aer this step, the entire right colon
should be completely mobilised till the right lateral aspect of the middle colic artery. At that
point, we do not advocate continuing resection
of the transverse mesocolon towards the le side
as this becomes easier when performed as the
very last step of the colonic mobilisation.
35.2.3 Mobilisation oftheLeft
35
Colon
e set-up, port sites and positioning of the
operating team are the same as described for the
le colon mobilisation in the TME chapter
(. Fig.35.4). e surgical steps and applied principles also are the same. However, when performing an extended right colectomy for a
splenic exure tumour, the inferior mesenteric
artery and the superior haemorrhoidal artery
can be preserved depending on where the ileocolic anastomosis is intended to be performed.
To achieve this, the vascular pedicle containing
276
A. Parvaiz and M. Odermatt
35
. Fig. 35.4 Operating theatre set-up for left colonic
mobilisation
the inferior mesenteric artery is mobilised as
described in the TME chapter. However, only the
le branch (le colic artery) which normally
goes o fairly centrally is divided. e inferior
mesenteric vein is not divided centrally. Its
branches will be divided when the exteriorised
specimen is resected. Medial to lateral
mobilisation, dividing the transverse mesocolon
on top of the pancreas, lateral detachment, entering the lesser sac, completing the division of the
transverse mesocolon and mobilising the splenic
exure are the next steps in analogy to its previous description. Aer this, the transverse mesocolon is still attached around the middle colic
ar t er y.
35.2.4 Mobilisation of the
Transverse Colon
e position of the surgeons is shown in
. Fig.35.5. First, the division of the gastrocolic
and hepatocolic ligament is completed or, as an
alternative, the greater omentum is detached
from the transverse colon. As the laparoscopic
central division of the median colic artery can be
challenging, we approach this vessel by dividing
the transverse mesocolon from both sides. In this
way, we always have maximal vascular control.
Even in case of inadvertent bleeding, the vascular
. Fig. 35.5 Set-up for transverse colonic mobilisation
pedicle of the middle colic artery can easily be
controlled as accessible from both sides without
risking damage of structures like the duodenum
or pancreas. Once the middle colic artery has
been isolated centrally, it is divided between
clips.
35.2.5 Anastomosis
e specimen is exteriorised by extending the
umbilical port site incision. Alternatively, an auxiliary incision of the le abdominal wall can be
made. e right, transverse and upper part of the
le colon is resected, and a handsewn or stapler
anastomosis is performed. It is important to
choose a large enough distal margin to the
tumour.
35.2.6 Advantages and
Disadvantages
Due to the mobility of the ileum, the anastomosis
can be performed on each level. e right-sided
approach for splenic exure tumours oers exibility and is technically easier than the le-sided
approach. is approach is especially useful in
obstructing splenic exure tumours presenting as
emergencies.
Surgical Technique andDicult Situations fromAmjad Parvaiz
35.3 Treatment ofSplenic Flexure
Tumours byLeft Colectomy
Resection of splenic tumours by (extended) left
colectomy
Step 1 Identication of IMA pedicle. Dividing
left colic artery centrally
Step 2 Left colon/splenic exure mobilisation
Step 3 Identication of middle colic artery and
dividing the left branch(es)
Step 4 Exteriorisation of specimen through
auxiliary incision
Step 5 Resection of the specimen
Step 6 Transverso-sigmoid anastomosis
277
35
35.3.1 Concept
e extent of resection and the transection of
blood supply are schematised in . Fig.35.6.
35.3.2 Set-Up
e set-up and port sites are the same as for the
le colon mobilisation as part of a TME (. Figs.35.4
and 35.7).
. Fig. 35.6 Resection of splenic exure tumours by
(extended) left colectomy
. Fig. 35.7 Port sites for left colectomy
35.3.3 Mobilisation ofLeft Colon
e vascular pedicle containing the IMA (inferior mesenteric artery) is mobilised as described
previously. Instead of dividing the IMA at a central point, only its le branch, the le colic artery,
is divided at its origin. is step is performed by
circumferential clearing of the IMA close to the
aorta. Following the IMA, the le colic artery can
normally be identied. ere may be anatomic
variations. Important is to stay close to the
IMA.Since the IMA remains intact, the mesentery containing the IMA cannot be lied up as
high as aer division of the IMA, and space for
blunt dissection on top of the Gerota’s fascia is
limited. Sometimes, incomplete medial to lateral
mobilisation has to be completed from lateral at a
later stage. e transverse mesocolon is incised
from below on top of the pancreas and a swap is
placed on the pancreas to facilitate completion of
this step from the lesser sac. Aer lateral mobilisation, the lesser sac is entered by dividing the
gastrocolic ligament or by detaching the greater
omentum from the transverse colon. Attachments
of the splenic exure to the spleen are divided
without applying traction on the spleen. e
transverse mesocolon is divided over the swap
which has been placed there to protect the pancreas from below. At this stage, the le colon has
278
A. Parvaiz and M. Odermatt
been fully mobilised, the le colic artery is
divided at its origin, and the inferior mesenteric
artery leading to the superior haemorrhoidal
artery and sigmoidal branches has been preserved.
35.3.4 Mobilisation oftheMiddle
Part oftheTransverse Colon
To be oncologically on the safe side, it is mandatory to divide the le branch(es) of the middle
colic artery at its origin. is step is challenging
to perform laparoscopically, especially if the
mesentery is short and fatty. e diculty is to
clearly identify the le branch(es) as there may
be anatomical variation. e bifurcation of the
middle colic artery may be centrally or more
peripherally. Sometimes, there is no le branch
but only a net of arcades. So, the best way to
proceed is to clearly identify the middle colic
artery at its origin and following its course while
dividing all branches going to the le. However,
the laparoscopic view can be misleading and
frequent reassessment of the anatomy is necessar y.
of mesentery and bowel is completed. Pulsatile
bleeding of the marginal artery is confirmed
and a handsewn or stapler anastomosis is performed. If there is a length issue, the following
suggestions may be of help. Firstly, test whether
the sigmoid colon can be mobilised further.
Secondly, consider a right colonic transposition by complete lateral mobilisation and
counterclockwise rotation of the right colon
so that the right colon is positioned below the
small bowel package. Thirdly, every left-sided
resection can be transformed to an extended
right colectomy.
35.3.7 Advantages and
Disadvantages
Advantage of this approach is the sparing of the
right-sided colon and possibly a better functional
outcome. However, the le-sided laparoscopic
approach to resect splenic exure tumours is
technically on an advanced level. Also, there may
be length problems making a tensionless anastomosis impossible.
35
35.3.5 Mobilisation oftheHepatic
Flexure
To gain length, the hepatocolic ligament and the
hepatic exure have to be fully mobilised. e
length limiting structure, however, is the middle
colic artery which can be very short. e mobilisation of the hepatic exure includes the same
steps as when performing an extended right colectomy with exception that there is no medial to
lateral mobilisation.
35.3.6 Anastomosis
The mobilised transverse and descending
colon are exteriorised by extension of the
umbilical port site incision. The transection
35.4 Risk Classication asRegards
Diculty Level of
LaparoscopicTME
Portsmouth classication of laparoscopic TME
surgery (level of intraoperative diculty)
I Female no previous abdominal surgery
upper rectal cancer BMI <26 T1 to T3
tumours tumour size <5cm
II Male upper rectal cancer BMI <28 no
previous abdominal surgery tumour
size≤5
III Any patient with upper to mid-rectal
cancer T1–T3 tumour BMI <30 previous
pelvic surgery
IV Any patient with T4 rectal cancer mid- and
low rectal cancer post-radiotherapy
previous pelvic and abdominal surgery
Surgical Technique andDicult Situations fromAmjad Parvaiz
279
35
35.5 Intraoperative Problem and
Solution TME (Clinical
Vignettes)
Case 1
Problem
In a post-radiation rectal cancer patient, the tissue
had a high uid content making the monopolar
diathermy less eective during a laparoscopic TME.
Also, the dissection produced a lot of smoke which
made the area dicult to visualise. This is a common radiation-related problem.
Solution
The solution to this problem was to constantly use
a suction device (by the assistant) and to apply dry
gauzes during the dissection.
Outcome
Although more dicult, the rectal resection could
be completed.
Case 2
Case 3
Problem
In a laparoscopic TME, there was a diculty to
apply the stapler below the tumour. This is a common problem with the laparoscopic approach particularly in obese male patients.
Solution
One of the contributory factors for this is due to
failure to completely mobilise the distal rectal tube.
In particular, the posterior median raphe has to be
released to complete the division of the rectal tube
by stapler. If in doubt, an inter-sphincteric dissection by a perineal approach in order to perform a
handsewn colo-anal anastomosis is mandatory.
Outcome
Once the posterior median raphe had been completely released, the stapler could be applied
below the tumour.
Problem
During laparoscopic rectal resection, the anterior
plane could not be visualised adequately in an
obese male patient.
Solution
The base of the urinary bladder was hitched up
to the anterior abdominal wall by a transabdominal Prolene stitch on a straight needle. We generally advocate to hitch the uterus or base of the
urinary bladder in male patients to allow for better exposure. Often a second suture is needed for
the obese male pelvis with a floppy bladder. During further dissection, counter-traction by the
assistant’s hand with a pledget held in a forceps
allows better visualisation of the plane and
therefore more precise dissection and avoidance
of bleeding.
Outcome
The dissection could be completed.
280
A. Parvaiz and M. Odermatt
Case 4
35
Problem
During a laparoscopic TME, consid-
erable bleeding from sacral veins
occurred indicating that the opera-
tor had lost the correct plane.
Solution
This is a dicult position to be in.
The Waldeyer’s fascia normally pro-
vides the landmark for the dissec-
tion of about two third of the
length of the posterior rectum and
following the correct plane avoids
injury to sacral veins. However,
once the mistake of losing the correct dorsal plane is made, there is
nothing worse than to keep on
using the energy source in an
attempt to stop the bleeding. The
best thing to do is to use either a
tonsil swab or an opened up gauze
piece and apply direct pressure on
the area for ve minutes. Also think
of an extra port in the left lower
iliac fossa so that the assistant can
continue to maintain the pressure
Case 5
Problem
During anterior dissection in a laparoscopic TME,
the back wall of the vagina was opened. This can
happen especially in patients with previous hyster-
ectomy as the back wall of the vagina is often very
adherent to the anterior rectal plane. The other
problem is the loss of the pneumoperitoneum due
to gas leakage.
Solution
A wet gauze piece was inserted into the vagina to
stop the gas leak. The gauze was held by a sponge
holding forceps (sponge stick) which additionally
allowed counter-traction in order to improve visu-
alisation of the planes. Once the dissection was
completed, the defect of the vagina was sutured
laparoscopically using absorbable sutures.
while the operator is completing
the rectal resection.
Outcome
With sustained pressure by the
assistant, the rectal resection could
be completed laparoscopically. After
removal of the specimen, it was a lot
easier to deal with the bleeding
which stopped spontaneously after
a short packing. Sometimes, bleeding from dorsal veins may require
the insertion of drawing pins.
Outcome
Normal postoperative course without complica-
tions.
281
Surgical Technique
andDicult Situations
fromThomas Schiedeck
(Laparoscopic)
omasH.K.Schiedeck andMartenSchmerer
36.1 Preparation – 282
36.2 Operation Technique – 282
36
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_36
T.H.K. Schiedeck and M. Schmerer
282
36
36.1 Preparation
5 e patient is placed on a shaped vacuum
mattress in lithotomy position.
5 Preoperatively, the operational area is rou-
tinely cleaned with an antiseptic lotion.
5 Two centimetres above the umbilicus, a longi-
tudinal skin incision about 1.5cm is performed, and the abdomen is opened under
visual control. erefore, the rectus sheet is
exposed by means of two Langenbeck hooks
and incised longitudinally.
5 Below the rectus sheet, the peritoneum is
incised and lanced about a short distance.
> Many times the peritoneum is directly
attached to the omentum majus. Especially
in obese patients, it is often dicult to
decide, whether the abdomen is completely
opened or not. Therefore, it is advisable to
lift up the Langenbeck hooks briey under
tension. The intruding air is then facilitating
the separation of the omentum and the
abdominal wall.
5 A 10mm trocar sleeve is placed through the
small incision by means of a palpation probe.
en CO2 is insuated.
5 First an explorative laparoscopy is performed.
is starts directly vertical under the rst
access to exclude injuries of the intestinal
loops and the major omentum. is is followed by an intra-abdominal 360° view. Sometimes it is useful to insert a suprapubic urine
catheter to empty the bladder and providing a
better overview in the small pelvis.
5 Following this, three trocars are placed:
5 A 12mm trocar in the right lower abdo-
men (about two ngers medial of the
superior anterior iliac spine and lateral of
the epigastric vessels)
5 A 5mm trocar in the right middle abdomen
5 A 12mm trocar in the le lower abdomen
(about two ngers medial of the superior
anterior iliac spine and lateral of the epigastric vessels)
36.2 Operation Technique
5 e operation starts with the mobilisation of
the sigmoid colon. e patient is placed in
head-down position with a slight tilt to the
right side. e small bowel is moved to the
upper abdomen to permit the view into the
small pelvis.
5 e lateral adhesions on the le side are cut
sharply with scissors using the peritoneal
reection as guideline: the incision should be
almost medially to this area. Gerota’s fascia,
which covers the retroperitoneum, should
not be injured. Retroperitoneally located
structures are identied but not routinely
exposed. ey should be le in placed covered by Gerota’s fascia. e le ureter is most
times located medial of the ovarian- respectively the testicular vessels. It is crossing the
iliac artery/vein almost at the level of the
promontory.
5 e further preparation takes place along the
descending colon heading up to the le
colonic exure. By separating the mesentery
out of its secondary embryological adhesions, the preparation still continues from
lateral to medial.
5 Mobilisation of splenic exure itself is facili-
tated with the patient in head-up position
rotated to the right side. Sometimes it may be
necessary to dissolve an adherent major
omentum from the descending colon to allow
direct view on the splenic exure.
5 Coming from lateral, the peritoneal reversal is
incised nearby the colonic mesentery which
opens the lesser sac. is step can be dicult
and confusing especially in obese patients. In
this case, it might be advisable to continue the
dissection in the middle of the transverse
colon. In case of a benign indication, the
major omentum will be placed in the upper
abdomen, grasped and lied up to bring slight
tension to the tissue. en it is mobilised from
the transverse colon and the lesser sac is
opened through this approach. To achieve
this, the grasper is inserted through the 5mm
trocar in the right upper abdomen. e dissecting tool is inserted into the 12mm trocar
in the le lower abdomen.
> Especially in very huge or obese patients, it
might be helpful to use an additional trocar
(5 mm) in the left upper abdomen.
> Not respecting the Gerota’s fascia is
dangerous by getting too deep into the
retroperitoneal space. This might lead to an
injury of the pancreas, inferior mesenteric