monthly focus

surgical intervention video

This is the case of a 53-year-old female patient with no relevant medical history. The clinical symptoms began 3 months prior to rectal bleeding and loss of weight. Upon physical examination, a 4cm indurated bleeding mass was found from the anal margin. The colonoscopy showed a friable exophytic-looking tumor lesion, which ranged from 3 to 7cm from the anal verge, covering 50% of the circumference. The histopathological exam found a moderately differentiated adenocarcinoma. Magnetic resonance imaging showed an inferior rectal neoplasm located 3.78cm from the anal margin with an extension to the middle rectum. This neoplasm was in contact with the right internal anal sphincter pulling it. Suspicious mesorectal and left internal iliac chain lymph nodes were observed, conclusive for a rectal T3a, N1, M0 neoplasm. A carcinoembryonic antigen test was also performed, which was at 16.8ng/mL. The case was presented at an oncological board meeting where it was decided to give total neoadjuvant treatment (TNT). After TNT was finished, studies showed a partial response to treatment. As a result, it was decided to schedule the patient for surgical management. Surgeons performed a robotic assisted ultra-low anterior resection with a manual coloanal anastomosis and a covering ileostomy. Postoperative outcomes were uneventful. Oral intake resumed the next day. The patient was discharged on postoperative day 7. Histopathological findings demonstrated surgical margins negative for neoplasia and lymph nodes negative for dysplasia.



Bibliography:

1. Gilmore B, Adam MA, Rhodin K, Turner MC, Ezekian B, Mantyh CR, et al. Evolution of minimally invasive surgery for rectal cancer: update from the national cancer database. Surg Endosc. 2021 Jan 28;35(1):275–90.  DOI: 10.1007/s00464-020-07393-y https://pubmed.ncbi.nlm.nih.gov/32112255/

2. Kethman WC, Bingmer KE, Ofshteyn A, Charles R, Stein SL, Dietz D, et al. Effects of surgical approach on short- and long-term outcomes in early-stage rectal cancer: a multicenter, propensity score-weighted cohort study. Surg Endosc. 2022 Aug 4;36(8):5833–9. DOI: 10.1007/s00464-022-09033-z https://pubmed.ncbi.nlm.nih.gov/35122149/

3. Chapman BC, Edgcomb M, Gleisner A, Vogel JD. Outcomes in rectal cancer patients undergoing laparoscopic or robotic low anterior resection compared to open: a propensity-matched analysis of the NCDB (2010–2015). Surg Endosc. 2020 Nov 14;34(11):4754–71. DOI: 10.1007/s00464-019-07252-5 https://pubmed.ncbi.nlm.nih.gov/31728754/

4. Tang B, Lei X, Ai J, Huang Z, Shi J, Li T. Comparison of robotic and laparoscopic rectal cancer surgery: a meta-analysis of randomized controlled trials. World J Surg Oncol. 2021 Dec 3;19(1):38. DOI: 10.1186/s12957-021-02128-2 https://pubmed.ncbi.nlm.nih.gov/33536032/

Robotic ultra-low anterior resection for low rectal cancer

The authors present the case of an 80-year-old female patient who underwent a laparoscopic ‘en bloc’ upper rectum resection and total hysterectomy for upper rectal carcinoma. The patient was admitted to our hospital with a diagnosis of colon cancer located in the upper rectum. The preoperative staging revealed a T4b tumor invading the myometrium. The surgical procedure was completed successfully with no intraoperative complications. The patient was discharged on postoperative day 5 without any complication. Follow-up examination at 6 and 12 months showed no evidence of disease recurrence. 

This minimally invasive procedure allows a faster recovery with good oncologic outcomes. Laparoscopic surgeons with experience in pelvic surgery should consider this approach in some cases. 

Bibliography:

1. Miyo M, Kato T, Takahashi Y, Miyake M, Toshiyama R, Hamakawa T, Sakai K, Nishikawa K, Miyamoto A, Hirao M. Short-term and long-term outcomes of laparoscopic colectomy with multivisceral resection for surgical T4b colon cancer: Comparison with open colectomy. Ann Gastroenterol Surg. 2020 Jul 20;4(6):676-683. doi: 10.1002/ags3.12372. PMID: 33319158; PMCID: PMC7726680. Link: https://pubmed.ncbi.nlm.nih.gov/33319158/

2. Miyake Y, Nishimura J, Takahashi H, Haraguchi N, Hata T, Takemasa I, Mizushima T, Yamamoto H, Doki Y, Mori M. The short-term outcomes of laparoscopic multivisceral resection for locally advanced colorectal cancer: our experience of 39 cases. Surg Today. 2017 May;47(5):575-580. doi: 10.1007/s00595-016-1429-y. Epub 2016 Oct 21. PMID: 27770208. 	Link: https://pubmed.ncbi.nlm.nih.gov/27770208/

3. Ishiyama Y, Tachimori Y, Harada T, Mochizuki I, Tomizawa Y, Ito S, Oneyama M, Amiki M, Hara Y, Narita K, Goto M, Sekikawa K, Hirano Y. Oncologic outcomes after laparoscopic versus open multivisceral resection for local advanced colorectal cancer: A meta-analysis. Asian J Surg. 2023 Jan;46(1):6-12. doi: 10.1016/j.asjsur.2022.02.047. Epub 2022 May 12. PMID: 35568616. Link: https://pubmed.ncbi.nlm.nih.gov/35568616/

4. Zhang J, Sun J, Liu J, Mei S, Quan J, Hu G, Li B, Zhuang M, Wang X, Tang J. Comparison of short- and long-term outcomes between laparoscopic and open multivisceral resection for clinical T4b colorectal cancer: A multicentre retrospective cohort study in China. Eur J Surg Oncol. 2023 Dec 7;50(1):107316. doi: 10.1016/j.ejso.2023.107316. Epub ahead of print. PMID: 38086316 Link: https://pubmed.ncbi.nlm.nih.gov/38086316/

Laparoscopic ‘en bloc’ upper rectum resection and total hysterectomy for upper rectal carcinoma 

Résection laparoscopique "en bloc" du haut rectum et hystérectomie totale pour carcinome du haut rectum

Colectomie droite laparoscopique avec dissection du ganglion lymphatique D3 pour adénocarcinome colique

In this educational video, the authors present the case of a 58-year-old female patient who was diagnosed with an obstructing lesion in the proximal transverse colon, 98cm away from the anal verge, in December 2022. Biopsies revealed an adenocarcinoma. The patient was in a good general condition, without any comorbidities. A CT-scan and a virtual colonoscopy confirmed the presence of a 4cm long lesion, with a diameter of 5cm. Multiple perivisceral lymph nodes were detected. The multidisciplinary team decided to perform surgery. In January 2023, a laparoscopic extended right colectomy with a complete excision of the mesocolon, a D3 lymphadenectomy with central vascular ligation (CVL), and an intracorporeal mechanical isoperistaltic ileocolic anastomosis, were performed. An indocyanine green (ICG) test was performed after vascular ligation to assess the vascularization of the ileum and the transverse colon. In the video, the authors also demonstrate the anatomical landmarks to perform a D3 dissection, as well as a middle colic pedicle ligation. The patient was discharged on postoperative day 5. The histological exam revealed an adenocarcinoma stage pT4a N2b M1.

Take-home messages: 

Correct traction on the ileocolic pedicles allows adequate preparation of the anatomical planes. 

A large separation of Toldt’s fascia from Gerota’s fascia should be performed in a medial-lateral and caudo-cranial direction until the duodenum is well exposed. 

Fredet’s area should also be completely freed to access the posterior face of the superior mesenteric vein (SMV). 

Positioning between the legs of the first operator is critical for an adequate lymphadenectomy of the SMV. Exposure of Henle’s trunk and dissection at the origin of the vessels are also essential key steps. 



Bibliography:

1. Proposal of a new classification system for complete mesocolic excison in right-sided colon cancer - S Benz, A Tannapfel, Y Tam, A Grünenwald, S Vollmer, I Stricker - Affiliations expand PMID: 30838463 DOI: 10.1007/s10151-019-01949-4 - https://pubmed.ncbi.nlm.nih.gov/30838463/A -

2. Proposal for Novel Standards of Histopathology Reporting for D3 Lymphadenectomy in Right Colon Cancer: The Mesocolic Sail and Superior Right Colic Vein Landmarks - Alvaro Garcia-Granero, M.D., Ph.D.• Gianluca Pellino, M.D., Ph.D.  & Co PMID: 31996584 DOI: 10.1097/DCR.0000000000001589 - https://pubmed.ncbi.nlm.nih.gov/31996584/

3. The Medial Border of Laparoscopic D3 Lymphadenectomy for Right Colon Cancer: Results from an Exploratory Pilot Study - Leqi Zhou, M.D., Dechang Diao, Ph.D. (…) - PMID: 34310517 DOI: 10.1097/DCR.0000000000002046   - https://pubmed.ncbi.nlm.nih.gov/34310517/

4. 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 - Seiichiro Yamamoto, MD, PhD, Masafumi Inomata & Co - PMID: 24509190 DOI: 10.1097/SLA.0000000000000499 - https://pubmed.ncbi.nlm.nih.gov/24509190/

Laparoscopic right colectomy with D3 lymph node dissection for colonic adenocarcinoma

This is the case of a 46-year-old female patient with a history of endometriosis that did not respond to medical treatment. In 2013, she underwent an exploratory laparotomy which revealed a frozen pelvis and endometriotic foci without treatment during the procedure. 

She was evaluated due to chronic pelvic pain characterized by dyschezia and dyspareunia, transrectal bleeding, and disabling dysmenorrhea. There were no relevant findings during the physical examination. 

Diagnostic tests were performed. MRI of the pelvis showed multiple adenomyomas, adenomyosis, deep implantation of the endometrium approximately 3.5cm in the rectum, compromise of the anterior, middle, and posterior compartments.

Considering these findings, the patient underwent a laparoscopy for deep endometriosis resection.

A multidisciplinary team, made up by a gynecologist and a colorectal surgeon, performed a total excision of deep endometriosis, a linear resection of the rectum with intracorporeal anastomosis, and an extraction of surgical specimens through natural orifices.

The postoperative period was uneventful. Oral intake started on the first postoperative day and the patient was discharged on postoperative day 3.

During the 34-week follow-up, the patient was pain-free, with no changes in defecation or disease recurrence. 

Bibliography:

Charatsi D, Koukoura O, Ntavela IG, Chintziou F, Gkorila G, Tsagkoulis M, Mikos T, Pistofidis G, Hajiioannou J, Daponte A. Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis. Adv Med. 2018 Sep 26;2018:3461209. doi: 10.1155/2018/3461209. PMID: 30363647; PMCID: PMC6180923.

Pontrelli G, Huscher C, Scioscia M, Brusca F, Tedeschi U, Greco P, Mancarella M, Biglia N, Novara L. End-to-end versus side-to-end anastomosis after bowel resection for deep infiltrating endometriosis: A retrospective study. J Gynecol Obstet Hum Reprod. 2022 Dec;51(10):102472. doi: 10.1016/j.jogoh.2022.102472. Epub 2022 Sep 7. PMID: 36087927.

Intracorporeal colorectal anastomosis with natural orifice extraction for deep bowel endometriosis

Anastomose colorectale intracorporelle avec extraction par les voies naturelles pour endométriose intestinale profonde

Anastomotic leak is still a complication of colorectal surgery that can seriously compromise the postoperative course. Preservation of the main vascularization may play a protective role for anastomotic perfusion. In addition, it may reduce the risk of edema. The aim of this technique is to reduce anastomotic leaks in laparoscopic left hemicolectomy for oncological patients with complete vascular preservation of the inferior mesenteric artery. 



This is the case of a 54-year-old female patient with cancer of the descending colon. It was decided to perform a laparoscopic left hemicolectomy. During the procedure, the inferior mesenteric artery (IMA) was identified, and arterial lymphatic tissue was dissected. The IMA peeling allowed to isolate the left colic artery (LCA), and the tributary artery of the splenic flexure (SFA). The LCA was skeletonized down to its terminal branches until the identification of the right branch (RbLCA), which was preserved. The left branch (LbLCA) was also identified and selectively ligated, hence preserving the IMA, the LCA with its right branch, and the SFA. The preservation of the arterial vascularization may reduce the risks of anastomotic leaks using a radically oncological approach.



Bibliography:

1. Kryzauskas, M., Poskus, E., Dulskas, A., Bausys, A., Jakubauskas, M., Imbrasaite, U., Makunaite, G., Kuliavas, J., Bausys, R., Stratilatovas, E., Strupas, K., & Poskus, T. (2020). The problem of colorectal anastomosis safety. Medicine, 99(2), e18560. https://doi.org/10.1097/MD.0000000000018560

2. Liu, Q., & Li, X. (2018). [Evolution and prospect of colorectal anastomosis]. Zhonghua Wei Chang Wai Ke Za Zhi = Chinese Journal of Gastrointestinal Surgery, 21(4), 470‑475.

3. Westerduin, E., Klaver, C. E. L., van Geloven, A. A. W., Westerterp, M., Bemelman, W. A., & Tanis, P. J. (2018). Outcome after redo surgery for complicated colorectal and coloanal anastomosis : A systematic review. Diseases of the Colon and Rectum, 61(8), 988‑998. https://doi.org/10.1097/DCR.0000000000001129



Extreme vascular preservation in laparoscopic left colectomy for colon cancer

Chirurgie extensive de préservation vasculaire lors d'une colectomie laparoscopique gauche pour cancer colique

video lecture

In this authoritative lecture, Dr. Steele outlines new endo-laparoscopic methods of oncological resection and anastomosis for colorectal cancer.

Focus on colorectal surgery

Robotic ultra-low anterior resection for low rectal cancer

Laparoscopic ‘en bloc’ upper rectum resection and total hysterectomy for upper rectal carcinoma

Laparoscopic right colectomy with D3 lymph node dissection for colonic adenocarcinoma

Extreme vascular preservation in laparoscopic left colectomy for colon cancer

Intracorporeal colorectal anastomosis with natural orifice extraction for deep bowel endometriosis

New endo-laparoscopic methods of oncological resection and anastomosis for colorectal cancer