Laparoscopic sigmoidectomy for T3N2M1 sigmoid cancer
Epublication WebSurg.com, Dec 2011;11(12). URL: http://websurg.com/doi/vd01en3540
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.