What is the place of laparoscopy in colorectal surgery in China and also in your own practice?

This video demonstrates a right hemicolectomy for a large cancer at the hepatic flexure. The patient has had a cholecystectomy and an appendectomy in the past and the adhesions make the case more difficult. The surgeon uses a medial approach to mobilize and divide the ileocolic vessels and the right branch of the middle colic. After full mobilization of the right colon, it is exteriorized through a small transverse incision at the umbilicus and an end-to-side anastomosis is made with an EEA stapler. The mesenteric window is not closed.

In this key lecture, Dr. Barry Salky highlights laparoscopic right colectomy and describes intracorporeal vs. extracorporeal anastomosis.

Introduction
Laparoscopic right colectomy (LRC) has become a well-established technique in colon cancer treatment achieving the same degree of radicality as open colectomy with the advantages of minimal invasion. A medial-to-lateral approach is the standard technique, but the bottom-to-up approach, with intracorporeal anastomosis (BTU), has recently gained popularity among surgeons.
Clinical case
The authors report the case of a 70-year-old male patient with persistent abdominal discomfort and a change in bowel habits. Preoperative staging revealed an adenocarcinoma at the hepatic flexure of the colon with no metastatic disease. The patient was proposed for a laparoscopic right colectomy.
A bottom-to-up approach was performed by opening an avascular plane posterior to the right mesocolon, creating a mesenteric route cranially along Gerota’s fascia until the duodenum and liver have been exposed. A side-to-side ileocolic intracorporeal stapled anastomosis was fashioned. The procedure and postoperative recovery were uneventful.
Discussion/Conclusion
LRC using a BTU approach is a feasible and safe alternative to the conventional medial-to-lateral approach. The main advantages are a short learning curve and an easy access to the retroperitoneal space with direct visualization and protection of retroperitoneal structures. The performance of an intracorporeal anastomosis offers the advantage of a smaller extraction incision, lower wound-related complications, and fast recovery.

Reversal of Hartmann's procedure is a major undertaking and due to its associated morbidity and mortality, many patients are left with permanent colostomy and many others elect not to have the reversal. The advances in laparoscopy and stapler anastomosis have made the reversal simpler and easier. The objective of this film is to show how to carry out a laparoscopic re-intervention of a stenosis of a colorectal anastomosis performed some months before for the restoration of the colorectal continuity after a laparoscopic reversal of Hartmann’s procedure that was performed to manage a perforated sigmoid diverticulitis.

The video entitled "Transanal sigmoidectomy with TEO™ platform for adenocarcinoma", authored by J Leroy, A D'Urso, D Mutter, and J Marescaux is analyzed by Richard Whelan, MD (St. Luke's-Roosevelt Hospital Center, New York, NY, United States), sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Introduction:
This is the case of a 65-year-old gentleman who presented with blood per rectum (PR) and symptoms of subacute obstruction. He was diagnosed with a stenotic invasive adenocarcinoma at 15cm from the anal verge and with liver metastases. After discussion at our multidisclipinary meeting, he was recommended to undergo palliative chemotherapy in the form of FOLFIRI and Avastin. Unfortunately, his symptoms of subacute obstruction worsened and it was recommended that he undergo a palliative resection.

Methods:
He underwent a palliative Laparoscopic Anterior Resection (LAR). Professor Armondo Melani utilized a 4-port technique with a 10mm umbilical optical port and 3 by 5mm working ports (2 on the right-hand side and one on the left). He used a medial to lateral approach starting with the splenic flexure takedown. This was achieved by entering the retroperitoneal plane cephalad to the inferior mesenteric artery (IMA) and inferior to the inferior mesenteric vein (IMV). Once the correct plane has been entered, the IMV was skeletonized and divided with a Ligasure® vessel-sealing device. The lesser sac was then entered superior and cephalad to the IMV, superior to the pancreas and to the left of the middle colic vessels. This novel approach allowed for easy identification of the pancreas and retroperitoneal mobilization of the mesocolon from the pancreas. The lesser sac was then entered above the transverse colon, the omental attachments divided and splenic flexure mobilization completed. The retroperitoneal plane was then entered caudally to the IMA, which was subsequently skeletonized and divided after identification of the left ureter and gonadal vessels. The rectum was then mobilized to >5cm below the tumor, the mesorectum divided, the rectum transected with an articulating linear stapling device. The specimen was delivered through a Pfannenstiel incision (with a wound protector). The specimen was transected and the anvil of a circular stapler inserted into the proximal colon with a purse-string suture. The colon was returned to the abdomen and the colorectal anastomosis was completed with the insertion of the circular stapler transanally.

This video shows a laparoscopic right colectomy performed during an IRCAD course.

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.