Introduction

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Ростовский Государственный Медицинский Университет

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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_861_Библиотеки_им_академика_М_И_Перельмана.pdf

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YamamotoS,InomataM,KatayamaH,etal.Short-termsurgicaloutcomesfromarandomized

controlledtrialtoevaluatelaparoscopicandopenD3dissectionforstageII/IIIcoloncancer:

JapanClinicalOncologyGroupStudyJCOG0404.AnnSurg2014;260(1):23–30.

Chapter10

LaparoscopicLateral-toMedialColectomy

RobertD.BennettandJorgeE.Marcet

INTRODUCTION

FirstdescribedbyJacobsetal.,laparoscopiccolectomyhasprovedtobea safeandfeasibleapproachforbothbenignandmalignantsurgical conditionsofthecolon.Infact,thelaparoscopicapproachhasbecome standardforcolonresectionsinmostcircumstances.Numerousstudies haveconfirmedadvantagesofthelaparoscopicapproachwhencompared toanopenprocedure,includingdecreasedpostoperativepain,reduced incidenceofileus,enhancedrecoveryofpulmonaryfunction,reduced immunosuppression,decreasedlengthofhospitalstay,improved cosmesis,andearlierreturntoworkandnormalactivities.Inaddition, laparoscopiccolonresectionhasshownequalorimprovedsurvivalinthe settingofmalignancy.Laparoscopictechniquescanbeemployedforthe entiretyofanoperationorforspecificportions.Itistheauthors’ preferencetoperformalaparoscopic-assistedprocedureinmost circumstances.Thedissectioniscompletedinalaparoscopicmanner, includingdivisionofthemesenteryandcompletemobilizationofthe affectedcolon,andtheanastomosisbeingperformedextracorporeal. Usingthistechnique,thespecimenisdeliveredthroughasmall abdominalincision.Ahand-sewnorstapledextracorporealanastomosis canthenbeperformed,ortheanvilofacircularstaplersecuredinplace intheproximalbowelinpreparationforanintracorporealanastomosis.

Laparoscopicleftcolondissectionhasbeendescribedinbothlateralto-medialandmedial-to-lateralmanner.Openleftcolonresectionswere traditionallyperformedinalateral-to-medialdirection,andinitial descriptionsoflaparoscopicleftcolonresectionsalsoinvolvedlateral-tomedialdissection.Medial-to-lateraldissectionwasfirstdescribedin1994 byMilsometal.,andassurgeonshavebecomemorecomfortableand

adeptwithlaparoscopictechniques,amedial-to-lateraldissectionhas becomepreferredinmanysituations.Theadvantageofamedial-tolateralapproachisthatthenaturalperitonealattachmentsoftheright andleftcolonareleftintactduringcentraldivisionofthevascular structuresandmesenteryneartheiroriginandthusservetokeepthe colonretractedlaterallyduringthemedialdissection.Althougha statementissuedbytheEuropeanAssociationofEndoscopicSurgeons (EAES)in2004endorsedamedial-to-lateralapproachaspreferred,it wasbasedonlevel5evidenceandwasagradeDrecommendation. Despitethisconclusion,thelateral-to-medialdissectioncontinuesto haveutilityandprovidesthesurgeonflexibilityindeterminingthe optimalapproachtoagivenclinicalscenario.

Thischapterhasbeenwrittentodiscussandillustratetechnicaltips employedbytheauthorstoperformalaparoscopiclateral-to-medialleft colondissection,andindicationsforusingthesetechniques.

INDICATIONSANDPATIENTSELECTION

Laparoscopiccolonresectionissuperiortoopenresectionandhas becomethecurrentstandardofcareincolonresectionforappropriately trainedsurgeons.Prospectiverandomizedtrialshavealsoshownthat laparoscopiccolonresectionyieldsatleastequivalentoncologicresults whencomparedtotheopenapproach.Assuch,thelaparoscopic approachisindicatedinbenignandmalignantconditionsalike.

Therearenoabsoluteindicationsorcontraindicationstoalateral-tomedialapproach.Oneofthestrongestindicationstoproceedwitha laparoscopiclateral-to-medialdissectionissurgeonfamiliarityand comfortwiththistechnique.Thislogiccannotbeoverstated,because laparoscopicleftcolonresectionisacomplexprocedurewitha demonstratedsteeplearningcurve.

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Thesurgeonshouldalwaysstrivetoobtainabroadareaofmesenteric dissectiontoensureanadequatelymphadenectomy(≥12lymphnodes) duringtheresectionofacoloncancer.Arecentsystematicreviewand meta-analysissuggeststhatthetwoapproachesarenodifferentinterms ofnumberoflymphnodesharvestedorcancerrecurrencerates, suggestingthatmalignancyisnotnecessarilyacontraindicationto performingalateral-to-medialdissection.

Benignconditionsofthecolonareideallysuitedforalateral-to-medial dissectionbecauselymphnodeharvestisnotaconsideration.Exceptions tothisstatementwouldbesurgeryforendoscopicallyunresectablepolyps orincaseofinflammatoryboweldiseasewithprovenorsuspected dysplasia.Diverticulardiseaseisthemostcommonindicationforaleftsidedcolonresection.Diverticularpathologyoftheleftcoloncanalsobe approachedwithalateral-to-medialormedial-to-lateraldissection.In thesettingofrecurrentdiverticulitis,thechronicinflammatoryprocess surroundingthesigmoidcolonoftenmakesdissectionverydifficult.In thiscase,ifalateral-to-medialdissectionpresentsitselfassaferoreasier, itshouldbetakenratherthanadheringtoarigidstandardofmedial-tolateraldissection.

Anothersituationinwhichamedial-to-lateralapproachmaybe preferrediswhentheoperationisbeingdoneforinflammatorybowel diseasewherethebaseofmesenteryisinvolvedbytheinflammatory process,encasingthevesselsandobliteratingtheembryological dissectionplane.Thisapproachofferstheadvantageofavoidinginjuryto

vesselsorretroperitonealstructures.

PREOPERATIVEPLANNING

Whethertheindicationforlaparoscopicleftcolectomyisabenignora malignantcondition,properpreoperativeplanningisessential.Axial, contrast-enhancedimagingstudiesareoftenobtainedfordiagnosisof diverticulitisormalignancybeforeanoperationisundertaken.These imagingmodalitiescanbeinvaluableinsurgicalplanningtoassistthe surgeoninanticipatingpotentialintraoperativedifficulties.Althoughthe uretershouldideallybeintraoperativelyvisualizedduringallleftcolon resections,thelocationoftheureterrelativetoaplannedresectionmay beascertainedbyintravenouscontrast-enhancedcomputedtomography scanallowingthesurgeontoreviewspecificanatomicdetailsbefore embarkingonapotentiallydifficultdissection.Oralcontrasthelps identifyloopsofthesmallintestineandcanhelpdistinguishbetween bowelandotherstructures,suchasatumormass,bloodvessel,orafluid collection.Becauseoralcontrastrarelyreachestheleftcolonandrectum, rectalcontrastisparticularlyusefulindefiningthelowergastrointestinal anatomyinpatientsundergoingleftcolonresection.

Accuratepreoperativetumorlocalizationisanimportantconsideration whenplanningasuccessfullaparoscopicleft-sidedcolectomyfor malignancy.Inthissetting,patientslikelyhaveundergonecolonoscopic evaluationwhichledtothediagnosis.Ifendoscopywasperformed remotely,itcanbevaluabletoperformrepeatcolonoscopyorflexible sigmoidoscopy,whenpossible,thedaybeforesurgery,thusobviatingthe needfortwoseparatebowelpreparations.Inpreparationforresectionfor acolontumor,thelesionshouldbemarkedwithtattooinktoaidin localizationduringsurgery.Indiainkandothercarbon-basedinksarethe mostcommonlyusedagents.Althoughendoscopiclocalizationofrightsidedtumorsmaybefacilitatedifthelesionisvisualizedclosetothe appendicealorificeandileocecalvalve,thereexistnocomparable landmarksinthetransverse,descendingorsigmoidcolon.Ifunableto visualizetattooinkfrompreviousendoscopictumorlocalization, intraoperativecolonoscopycanbeperformedifthesiteofthelesionis notobviousoninspectionoftheserosalsurface.

Alternatively,orcomplementarily,preoperativecontrastenemacanbe usedtohelplocalizecoloniclesions.

SURGERY

Positioning

Thepatientshouldbesecurelystrappedontheoperatingtableinlow lithotomyonanon-slippadorwithshoulderpadsinplacetoallowfor safeuseofsteepTrendelenburgandleftsideuppositions.Usingthese positionsallowsformovementofthesmallboweloutoftheoperative fieldandfornaturalgravitationalretractionoftheleftcolonfromits abdominalandpelvicsidewallattachments,facilitatingthelateral-tomedialdissection.Lowlithotomypositionallowsforaccesstothepelvis andeventualcolorectalanastomosisifappropriate.Thispositionalso allowsforthesurgeonorassistanttostandbetweenthepatient’slegsand maybemoreergonomicallycomfortablefordissectionoftheleftupper quadrantandmobilizationofthesplenicflexure.

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Theoperatingsurgeonwillstandtothepatient’srightsideformostor alloftheoperation.Duringportplacement,theassistantmaystandto thepatient’sleft,butwillmovetothepatient’sright,cephaladtothe operatingsurgeon,forthemajorityofthecase.Laparoscopicmonitors shouldbeplacedatthepatient’sleftandatthefootoftheoperatingtable, atthesurgeon’seyelevel.Afterobtaininglaparoscopicaccess(see subsequenttext)andpositioningthepatientinTrendelenburgwithleft sideup,thetableheightshouldbeadjustedtotheoperatingsurgeon’s preferencetomaximizeergonomicbenefit.

PortPlacement

Laparoscopicleftcolonresectionistypicallyperformedviaathree-port technique.Peritonealaccessisobtainedinthemidabdomenthrougha cutdowntechniqueattheumbilicalstalk.Theumbilicalstalkisgrasped anddirectlyincisedatitsbase.Fascialstaysuturesmaybeplaced, dependingonsurgeonpreference,anda5-or10-mmportinserted.Our preferenceistousea10-mmportforthecameraport,becausealarger portsizewillaccommodatethelinearcuttingstapler.The5-or10-mm, 30-degreelaparoscopiccameraisintroducedandtheremainingports,5 mmindiameter,arethenplacedunderdirectlaparoscopicvisualization.

Therearemanydifferentportsitearrangementsdescribedfor laparoscopicleftandsigmoidcolectomy.Asaprincipleofalllaparoscopic

surgery,workingportsshouldbetriangulatedtofacilitatetwo-handed dissection,maximizeergonomics,andtoavoidswordfightingofworking instruments.Thepatient’sbodymassindexandabdominalbreadth shouldbetakenintoconsiderationaswellwhenchoosingportlocations. Whenplacingthesuprapubicorrightlowerquadrantportto accommodatetheendoscopicstapler,onemustconsidertheanglethat thestaplerwillachievecomingacrosstherectosigmoid.Instruments introducedthroughtherightupperquadrantworkingportshouldbeable toreachtothesplenicflexureandalsoallowretractionofthesigmoid colonmesenterydeepinthepelvis.Dependingontheavailabilityofand theneedforasecondassistanttoholdthelaparoscope,afour-orfiveportsetupcanbeutilized,butthreeportsareusuallyadequate.Onceport placementiscompleted,theoperationmayproceed;uretericcatheters maybeuseful.

SurgicalTechnique

Ageneralsurveyoftheabdominalandpelviccavityisperformed evaluatingallfourquadrants.Inthesettingofmalignancy,special attentionshouldbepaidtotheliverandperitonealsurfacestoinvestigate foroccultmetastases,bowelinjuryfromtrocarplacement,andthetumor siteintheleftcolon.

Theinitialstepinlaparoscopiclefthemicolectomyorsigmoid colectomyismobilizationoftheleftcolonorsigmoidcolonwithearly identificationofthelefturetersoastoavoidinjury.Tofacilitate dissection,thepatient’sleftsideisrotatedupward.Trendelenburgor reverseTrendelenburgpositionisusedasnecessarytofacilitateaccessto thepelvisorsplenicflexure,respectively.Thismaneuverallowsfor movementofthesmallboweloutoftheoperativefieldandforeaseof retractionoftheleftandsigmoidcolon.

Incisingtheattachmentsofthevisceralandparietalperitoneumatthe junctionoftheproximalsigmoidanddescendingcolonallowsthecolon anditsmesenterytoberetractedmediallywhilegentlypushingthe retroperitoneumposteriorly.Theperitoneumisfirstincisedclosetothe lateralborderofthecolon,maintainingthepericolicfatintact,atthelevel oftheproximalsigmoid.Thepneumoperitoneumwilloftenhelpestablish thisoptimaldissectionplane.Acombinationofsharpandblunt dissection,withoccasionaluseofbipolarenergy,isusedtodissectinthis mostlyavascularplane.Asthedissectionprogressesfromlateralto medial,theleftgonadalvesselsareusuallyidentifiedfirst,followedbythe leftureter.Thesestructuresaregentlypushedawayfromthemesentery posteriortotheplaneofdissection(Fig.10-1).

FIGURE10-1Incisionbetweenvisceraland

parietalperitoneumalongtheedgeofthemesocolon.

Somesurgeonsprefertoidentifytheureterearlyonintheprocedure throughanincisionintherectosigmoidmesentery.Thiscanbedoneby holdingthesigmoidcolononanteriorstretchandincisingthroughthe medialaspectofthemesentery,throughtheavascularareasuperiorto thesigmoidalvessels.Thiscreatesawindowintotheretroperitoneum throughtherectosigmoidmesenterythroughwhichtheuretermaybe identified.Onceidentifiedandsweptdownandawayfromtheplaneof dissection,thelateral-to-medialdissectionisthenundertaken.Once again,uretericcathetersmayhelpfacilitateandexpediteureteric identification.

Acombinationofsharpdissectionandmonopolarenergyareusedto dissectalongthelineofToldtcontinuingcephaladalongthedescending colontowardthesplenicflexure.Gerota’sfasciaisidentifiedandthe mesocolonisseparatedfromtheretroperitoneumatthislevel.Holding gentleretractionwithabowelgrasperinonehand,theotherhand utilizesacombinationofbluntandsharpdissectiontodevelopan avascular,areolartissueplanebetweenthecolonmesenteryandthe retroperitoneum(Fig.10-2).Atraumaticgraspinginstrumentsareused andthetissuesaremovedwithgentletractionproducedbypushingwith theinstrument.Thus,grabbingandpullingthetissuewithaninstrument isminimized,resultinginlesspotentialtrauma.

FIGURE10-2Colonmesenteryisseparatedfrom

Gerota’sfasciaandretroperitonealplane.

p.73

p.74

Theremainingperitonealattachmentsareincisedandeffortismadeto continueinthesameplaneofdissectionstayinganteriortothe retroperitonealtissues(Fig.10-3).Dissectioniscarriedcaudallytothe leveloftheupperrectum,enteringthepre-sacralspacewhileretracting thesigmoidcoloninacephaladandmedialdirection.Themesenteryon themedialaspectoftherectosigmoidisthenincisedadjacenttothe bowelattheanticipatedlevelofdistalboweltransection(Fig.10-4).The perpendicularincisioniscarriedlaterallytojointhelateraldissection plane.Thiscreatesawindowfordistalboweltransection.

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