Three-trocar laparoscopic sigmoidectomy with transanal extraction for diverticulitis and endometriosis

This case is for beginners in which Professor Joel Leroy explains all steps showing patient, trocars and surgical team position.

This video demonstrates a three trocar technique for mobilization and resection of the left colon for malignancy despite some considerable technical difficulty due to the patient’s body habitus. It concentrates in most detail on how to obtain the exposure necessary for radical oncology resection using this technique.

Complete mesocolic excision (CME) with central vascular ligation (CVL) is a potentially superior oncological technique in colon cancer surgery. The tenets of high vascular ligation at the origin and mesocolic dissection facilitate a greater lymph node yield. We present the case of a 70-year-old lady with chronic right iliac fossa discomfort. Computer tomographic scans showed a bulky ascending colon cancer with a 2.6cm right mesocolic lymph node. She underwent laparoscopic CME right hemicolectomy with CVL. Three operative trocars were used (a 12mm trocar in the left iliac fossa, 5mm ports in the left flank and right iliac fossa). Dissection begins in an inferior to superior approach, starting with mobilization of the ileocolic mesentery off the right common iliac vessels, then progressing to separate the mesentery off the duodenum and Gerota's fascia, exposing the head of the pancreas and the duodenal loop. CVL begins with the identification of the superior mesenteric vein (SMV). The vascular structures are isolated individually and ligated high at the level of the SMV, removing the metastatic right mesocolic node ‘en bloc’. Following proximal and distal transections, an intracorporeal ileo-transverse anastomosis is performed. Histology findings demonstrate the presence of a pT4a N2a M0 mucinous adenocarcinoma with 5 out of 17 lymph nodes (including the large mesocolic lymph node) positive for metastasis.

Single port operations are usually presented for appendectomies and cholecystectomies. We present the case of an 84-year-old man who presented recently to our department with Iron Deficiency Anemia (IDA).
A CT-colonography identified a caecal tumor, which was proven malignant by biopsies taken at a subsequent colonoscopy. Radiologically, this appeared to be an early T3 N0 tumor.
Because of his favorable body habitus and well-localized lesion, we elected to perform his laparoscopic-assisted right hemicolectomy by a single port technique.

Laparoscopic colorectal surgery is currently a well-established approach. The robotic approach is emerging. In this lecture, Dr. Melani presents his early experience.

Introduction:
We present the case of a 54-year-old male with a 5cm villous adenoma at the ileocaecal valve with a focus of invasive carcinoma. Previous attempts at endoscopic mucosal resection were unsuccessful.

Methods:
The set-up consisted of two 10/12mm ports (sub-umbilical and left iliac fossa) and three 5mm ports (right iliac fossa, supra-umbilical and epigastric). The primary vascular approach initially consists of identification, ligation and division of the vessels (ileocolic, right colic and right branch of the middle colic) at their origin, retroperitoneal mobilization of the mesocolon, taking down of the hepatic flexure and completion of the mobilization of the caecum and lateral attachments.

Conclusion:
The primary vascular approach to laparoscopic right hemi-colectomy is achievable.