WSHIMA: - Case 14: Colectomy
PREOPERATIVE DIAGNOSIS: Left colon cancer.
POSTOPERATIVE DIAGNOSIS:Same
PROCEDURE PERFORMED: Laparoscopic extended left hemicolectomy.
INDICATIONS: The patient is a 61-year-old male with a biopsy proven adenocarcinoma in the left colon with no evidence for distant metastatic disease. He is brought to the operating room for resection.
DETAILS OF THE PROCEDURE: With the patient in the supine position, after induction of adequate general endotracheal anesthesia, the abdomen was prepped with Betadine and draped in the usual sterile fashion. Through a 1 cm supraumbilical incision using a cut-down technique, a 10 mm trocar was inserted in the peritoneal cavity through the large umbilical hernia defect. Entering the peritoneal cavity under direct visualization, a pneumoperitoneum was established and maintained to 15 mmHg with CO2 gas throughout the remainder of the case. A reticulating trocar was placed and the peritoneal cavity was visualized there. No significant abnormal findings noted in the abdominal cavity other than the India ink tumor in the mid left colon. Inspection of the liver revealed some small cysts on the surface of the liver but no evidence for metastatic disease. Three more ports were placed, one in the left upper quadrant, one in the right upper quadrant, one in the left lower quadrant and using these the sigmoid colon which is quite long and redundant and the left colon were mobilized from their lateral attachments. The splenic flexure was then taken down completely using harmonic scalpel and blunt dissection entering the lesser sac and a site for proximal resection was identified in the mid transverse colon. The lesser sac was entered at this location by dividing the gastrocolicomentum entering the lesser sac and dividing the omentum distal to this point from the gastrocolicomentum leaving the omentum attached to the colon. This was carried out past the splenic flexure. The left colic artery and vein were identified at the take-off of the superior rectal and sigmoid vessels from the left colic artery. This was isolated circumferentially and divided using an endovascular GI stapling device. The mesentery out to the wall of the mid sigmoid colon was divided with harmonic scalpel for later resection at a distal resection margin. The mesentery out to the mid transverse colon was divided with harmonic scalpel staying well off the retroperitoneum taking care to identify the pancreas, the duodenum, the left ureter and keeping them out of the plane of dissection.
At this point the left upper quadrant site was opened to allow 3 to 4 cm through which the colon was delivered. The proximal resection margin site was identified. The bowel was isolated circumferentially and divided using a GIA stapling device. The remaining portion of omentum was divided with harmonic scalpel and a small amount of remaining mesentery was divided with harmonic scalpel. Attention was then turned after retracting this out of the abdominal cavity to the distal resection margin at the mid sigmoid colon. The colon was isolated circumferentially and divided with a GIA stapling device. The remaining mesentery was divided with a harmonic scalpel and the specimen was removed and sent for pathologic evaluation.
Attention was then turned to the anastomosis. This was created in a side-to-side functional end-to-end fashion between the mid transverse colon and the mid sigmoid colon with the open end of the bowel closed using a separate firing of the GIA stapling device. The staple lines were oversewn using interrupted 3-0 Vicryl sutures. The anastomosis was oversewn with interrupted 3-0 Vicryl sutures. The mesenteric defect was not approximated but the bowel was placed back adjacent to the retroperitoneum with the omentum secured over the anastomosis.The umbilical hernia was approximated by approximating the fascia from beneath through the left upper quadrant incision using a series of interrupted 0 Prolene sutures. The fascia at the left upper quadrant site was then closed in 2 layers of running 0 PDS suture. The fascia at the other trocar sites was closed using interrupted 0 Vicryl suture and all sites were closed using 4-0 Vicryl subcuticular suture with Steri-Strips and sterile dressings applied to the wound.