What are the risks of laparoscopic colorectal surgery?

In this lecture, Prof. Corcione uses his experience in left laparoscopic colectomy to present some tips and tricks.

Laparoscopic resection of carcinoma of the colon is associated with a long-term outcome no different from that of open colectomy. Laparoscopic approach offers short-term benefits to patients; however, concerns about oncological radicality and long-term outcome has limited the adoption of laparoscopic surgery for colorectal cancer.

Total mesorectal excision (TME) was described 20 years ago and is now recognized as the therapeutic gold standard for middle and lower third rectal cancers.
This is the case of a 70-year-old man with a BMI of 24 presenting with multiple polyps of the sigmoid colon larger than 3cm at 10 to 30cm from the anal verge. He has no past surgical history and colonoscopy revealed 3 sessile polyps at 15, 20, and 30cm from the anal verge as well as a flat polyp at 10cm from the anal verge. The histological examination concluded in one adenomatous, one adenovillous with high-grade dysplasia and one hyperplastic lesion. A laparoscopic partial TME with intraoperative endoscopic control is performed.

Diverticulosis of the left colon is an inflammatory benign disease associated with unpleasant morbidity which lead to pneumaturia and repetitive urinary infection. Computed tomography and colonoscopy may suggest the diagnosis but histology confirms it. The differential diagnosis evokes a malignant lesion and so it is mandatory to perform surgery with an oncological plane. This clinical case is that of a young man with a mass, which includes the left colon, the bladder, and the ileocaecal appendix. A ureteral stent was placed to make surgery safer and a sigmoidectomy with an ileocaecal appendectomy is performed.

The objective of this video is to demonstrate a laparoscopic segmental oncological splenic flexure colonic resection for cancer. Splenic flexure carcinoma is a rare condition, as it represents 3 to 8% of all colon cancers. It is associated with a high risk of obstruction and a poor prognosis. The surgical approach is challenging and not fully standardized. The resected area must include the mesocolon with major vessels ligation at their origin, in order to reduce local recurrence via the complete removal of potentially involved lymph node stations.
The oncological effectiveness of a segmental resection could be determined by the peculiar lymphatic spread of splenic flexure cancers. Different studies showed that the majority of positive lymph nodes among patients with splenic flexure carcinoma are distributed along the paracolic arcade and the left colic artery. As a result, a segmental resection associated with a medial-to-lateral approach could be safe and effective. The experience with a totally laparoscopic approach with intracorporeal anastomosis is well described in the current literature. Additionally, an intracorporeal anastomosis minimizes the risk of bowel twisting, preventing the exteriorization of the stumps, and reducing bowel traction, which can affect anastomotic irrigation, especially in obese patients. In a setting of surgeons experienced with laparoscopic colorectal surgery, the outcomes of laparoscopic segmental resection of splenic flexure are similar to those of laparoscopic resections for cancer in other locations.

In this video, we show the case of a 70-year-old male patient who had several attacks during the last weeks, abdominal pain, and fever. After CT-scan, he was diagnosed a perisigmoid abscess. We diagnosed a lot of diverticula and we made a diagnosis of sigmoiditis with perisigmoid abscess. So this is the Hinchey II two pelvic abscess. We began the medical treatment and finally we had several attacks and did a new examination, a new CT-scan, and an endoscopy and not a sigmoid abscess, but a voluminous diverticulum with an abscess, was diagnosed. So it was decided to operate on the patient.

This live video from a recent course at IRCAD demonstrates clearly the performance of a laparoscopic approach for sigmoid colectomy that commences with mobilisation of the splenic flexure.

Laparoscopic coloproctectomy for ulcerative colitis is a safe procedure and is associated with short-term benefits such as faster recovery and less pain. In this live video shot during the IRCAD Advanced Course in Laparoscopic Colorectal Surgery in November 2009, Prof. Cristiano Huscher shows a laparoscopic coloproctectomy for ulcerative colitis in a female patient.