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surgical intervention video

The best surgical approach for splenic flexure tumors is not well defined yet. 

The distal third of the transverse colon has an embryological origin in the hindgut, and the splenic flexure classically shows a dual lymphatic drainage, the proximal retropancreatic and the distal to the lymphatic pedicle of both the inferior mesenteric artery (IMA) and the inferior mesenteric vein (IMV). Nakagoe et al. showed that the majority of positive nodes have distal lymphatic spread to the paracolic archway and up to the origin of the left colic artery. Lymph nodes of the middle colic artery and its left branch are positive in a small percentage (0 and 4.2% respectively). 

As a result, a left segmental colectomy is a valid option for splenic flexure and distal transverse colon tumors because it allows vascular ligation at the root of the vessels, dissection along the embryological planes, and adequate bowel margins from the tumor. The preservation of the IMV should reduce impaired venous drainage of the sigmoid colon, which can be associated with anastomotic leakage, without compromising complete mesocolic excision. 

An intracorporeal anastomosis for left colonic resection may have the same advantages as for a right hemicolectomy, but can be technically more challenging. 

This video shows a laparoscopic left hemicolectomy with manual intracorporeal anastomosis and preservation of the IMV for a tumor of the distal transverse colon. 

The authors of the video do not have any conflicts of interest or financial ties to disclose.

Laparoscopic left hemicolectomy with manual intracorporeal anastomosis

Hémicolectomie gauche laparoscopique avec anastomose intracorporelle manuelle

Лапароскопическая гемиколэктомия слева с ручным анастомозом

Excision mésorectale totale transanale par laparoscopie (taTME) pour cancer du rectum moyen

This is the case of a 55-year-old man who presented with rectal bleeding. Colonoscopy detected a mass in the middle rectum, 6cm from the anal verge (AV). Biopsy results revealed the presence of an adenocarcinoma. Pelvic MRI and abdominal CT-scan showed no distant metastases, a T3N1M0 tumor 6cm from the anal verge, and an intact mesorectal fascia. 

After 8 weeks of neoadjuvant chemoradiation therapy (CRT), a minimally invasive low anterior resection with transanal total mesolectal excision was performed. 

A one-team abdomen-first approach is performed.

Laparoscopic transanal total mesorectal excision (taTME) for middle rectal cancer

Pancreatic neuroendocrine tumors (pNETs) are rare neoplasms, which account for less than 5% of all pancreatic tumors, with an incidence of 0.48 cases/100,000. They may be benign or malignant and tend to grow slower than exocrine tumors. They develop from the abnormal growth of endocrine cells in the pancreas and are either functional or nonfunctional, and may or may not cause signs or symptoms. Pancreatic NETs that have not spread outside the pancreas should be completely removed, if possible, because these tumors are more likely to be cured with surgery. This video shows a case of a pNET of the uncinate process, discovered in the study of a right colon cancer. Because of the small size of the pNET and its location, the association of a right laparoscopic hemicolectomy with a pancreatic tumor excision was deemed feasible. The mobilization of the mesenteric root allowed to identify the uncinate process and to prepare for the pNET excision. After the exposure of the duodenum and the retroperitoneal plane, the surgery continued with a right hemicolectomy and a complete mesocolic excision. An intracorporeal anastomosis was constructed and the surgical specimen was retrieved through a suprapubic incision. The pathological report revealed a T2N1 caecal adenocarcinoma and a G2 pNET. 

Laparoscopic right hemicolectomy with excision of a pancreatic neuroendocrine tumor (pNET)

Hémicolectomie droite laparoscopique avec excision d'une tumeur neuroendocrine du pancréas

Colectomie droite robotique avec excision mésocolique complète guidée par fluorescence ICG

In robotic right hemicolectomy for cancer, appropriate lymphadenectomy and anastomotic leak prevention are critical. Visualization of draining lymph nodes, of primary tumor site and blood flow using the near-infrared (NIR) fluorescence da Vinci® imaging system is a recent development. 

We present the technique of robotic right colectomy with complete mesocolic excision (CME) and D3 lymphadenectomy using Indocyanine Green (ICG) fluorescence. 

The day before surgery, a colonoscopy was performed and ICG was injected around the tumor in the submucosa. 

Robotic right hemicolectomy was performed with suprapubic trocars layout and bottom to up dissection, with CME, central vessel ligation, and D3 lymphadenectomy. 

ICG was intraoperatively administered intravenously to assess bowel perfusion before anastomosis. The identification of the primary tumor site and of bowel stumps perfusion were possible and the accuracy in identifying the D3 lymphatic basin was high, allowing for an image-guided radical lymphadenectomy. Fluorescent technology represents a valuable innovation to improve colon cancer surgery. 

Robotically assisted right colectomy with fluorescence-guided complete mesocolon excision

Colectomie droite entièrement laparoscopique pour tumeur cæcale avec approche "vaisseaux en premier"

Over the last few years, laparoscopic colorectal surgery has increased exponentially worldwide. When combined with an enhanced recovery program, a significant reduction in the length of hospital stay can be achieved, coupled with an early return to normal activities for the patient. 

This is the case of a 68-year-old obese woman with a BMI of 30 presenting with a caecal tumor. Her major co-morbidities are chronic obstructive pulmonary disease (COPD) and high blood pressure. The patient complained of chronic abdominal pain and presented a positive fecal occult blood test. Colonoscopy showed a caecal tumor. Biopsy confirmed an adenocarcinoma. CT-scan did not show any distant metastasis. A full laparoscopic approach with a medial-to-lateral and ‘vessels first’ approach is shown. 

The authors of the video do not have any conflicts of interest or financial ties to disclose.

Fully laparoscopic right colectomy for caecal tumor with 'vessels first’ approach

video lecture

In this key lecture, Professor Eric Rullier, MD, PhD, FASCRS describes a clear 6-step approach to perform a laparoscopic total mesorectal excision (TME).

The first step is posterior dissection of the TME plane in the presacral space. Hereafter, a right lateral dissection is performed with sparing of the hypogastric nerves followed by anterior dissection and identification of the seminal vesicles and pelvic plexus. A left lateral dissection is then performed whereafter the planes are connected. 

In this procedure, the 6 essential landmarks are the following: ''the presacral space, hypogastric nerves, seminal vesicles, pelvic plexus, levator ani muscles, and Denonvilliers' fascia and the prostate.’

Dr. Eric Rullier, MD, PhD, FASCRS does not have any conflicts of interest or financial ties to disclose.



Laparoscopic TME - The 6-step procedure

Excision totale du mésorectum par laparoscopie - procédure en 6 étapes

Professor Heald teaches us the importance of learning from our mistakes and from other people so as not to commit them again, he emphasizes lessons to learn where he tells us not only about the challenges of pelvic, oncological surgery, and possible mistakes to be made. We advise you to feel free to say what we think in the surgery room, you can help in difficult situations and proper planning prior to all surgeries. 

Beautiful lesson of the day: to fail to prepare is to prepare to fail.

In this outstanding didactic lecture, Professor Heald explains part of his great experience and the experiences of a career of more than 50 years, truly amazing! and life lessons he now shares with us, where he shows a clear example that “we must be our own sternest critics” and have the “courage to fail”. 

in conclusion: beware of Panic Factor, and you can always call a friend, talk to patients, forget your own pride, learn to apologize. 

Remember: there are things under your control and others that are not!

Thank you Professor Heald for these great teachings.

Skeletons in the cupboard: MY mistakes

Cadavres dans le placard : MES erreurs

In this key lecture, Dr. Armando Melani, MD, MSC, FACSexplains how transverse colectomy with total mesocolic excision for cancer is a doable and safe surgery, in his opinion and according to his experience.

Dr. Melani  outlines the recommendations for a safe transverse colectomy and teaches us how to avoid lesions in the superior mesenteric vessels, shows laparoscopic mobilization for resection of the transverse colon due to cancer, and demonstrates an excellent vascular approach.

Finally, Dr. Melani provides the rationale of the extension of the LND for right colon cancer and gives a didactic demonstration in this video.

In conclusion, transverse colectomy with total mesocolic excision for cancer is relatively difficult. The reasons for this are the anatomical variations of middle colic vessels, transverse mesocolon attachments with the pancreatic head, and venous communications. In this authoritative lecture, Dr. Melani demonstrates the laparoscopic approach and provides all recommendations to achieve a successful surgery. 

Dr. Melani, MD, MSC, FACS  does not have any conflicts of interest or financial ties to disclose.

Transverse colectomy with total mesocolic excision for cancer - Safe Transverse

Colectomie transverse avec excision mésocolique totale pour le cancer - abord transverse en sécurité

In this key lecture, Dr. Marks, explains why transanal Total Mesorectal Excision (taTME) is the best procedure for distal rectal cancer surgery, in his opinion. With this approach, it is possible to see a clear distal margin, there is an expanded sphincter preservation, and it allows the surgeon to start the most difficult part of the operation first.

In conclusion, taTME is a convergence of the evolution of rectal cancer management and minimally invasive surgery, and therefore it will be the path to the future of rectal cancer surgery.

TaTME: the future

Excision totale du mésorectum par voie d'abord transanale : le futur

In this key lecture, Dr. Masaaki Ito provides an excellent and clear stepwise approach to perform a taTME procedure. The procedure is divided into the 9 following steps, which are shown schematically as well as in real-life surgery videos: (1) marking and placing a purse-string suture, (2) opening the rectal wall, (3) posterior I, (4) anterior, (5) posterior II, and (6) lateral dissection

(7) neurovascular bundle dissection, (8) rendezvous procedure, and (9) creation of anastomosis. 

This lecture shows all essential steps of a taTME procedure including tips and tricks, and how to avoid pitfalls.



Step-by-step procedures of TaTME according to pelvic surgical anatomies for low rectal cancer

Excision totale du mésorectum par voie d'abord transanale : procédure étape par étape selon les anatomies chirurgicales pelviennes pour cancers du bas rectum

In this key lecture, Dr. Antonello Forgione presents a clear and precise description of the most important anatomical points as well as the surgical technique for complete mesocolic excision (CME) during a right laparoscopic colectomy, in cases of cancer.

As described in the video, four ports are used, all located on the left flank. A caudocranial dissection of the mesocolon is performed along the superior mesenteric vein to the inferior margin of the pancreas, exposing, ligating and dividing the ileocolic, right and middle colic vessels in their origins. The gastrocolic trunk is completely dissected and the upper right colic vein is cut and divided. The transverse colon and the terminal ileum are divided, the colon is mobilized, and the ileo-transverse intracorporeal stapled anastomosis is fashioned.

Laparoscopic CME is feasible and very useful. However, it is necessary to have an extensive knowledge of the vascular anatomy of the right colon, as well as an experience in advanced laparoscopic techniques to obtain the expected outcomes.

Finally, Dr. Forgione provides recommendations to perform the surgery in obese patients.

A standardized approach for complete mesocolic excision (CME) for right colon cancer

Excision mésocolique complète : approche standardisée pour cancer du côlon droit

The vascular anatomy of the colon has some anatomical variations [1]. In this video, starting from the normal surgical anatomy of the colon, authors show many vascular anomalies of surgical interest, which should be known in order to avoid intraoperative complications. In the right colon, the ileocolic artery and the middle colic artery are constantly present in all patients as they arise from the superior mesenteric vessels [2]. Right colic vessels are present only in 80% of cases. The position of ileocolic vessels related to the superior mesenteric vein (SMV) is a key landmark. In this video, starting from the normal surgical anatomy of the right colon, authors show variant ileocolic vessels position defined type A pattern, with ileocolic artery (ICA) which lies in the anterior position in respect to the ileocolic vein (ICV). Authors also show an anomalous origin of the ileocolic vessels, which are more upper in respect to their standard position. Commonly, the ileocolic artery (ICA) lies posterior to the SMV (83%, type B). However, the ICA sometimes lies anteriorly to the SMV (17%, type A) [1]. The vascular system of the left colon has fewer variations in terms of position and origin, contrarily to the right colon. The most frequent variations of the inferior mesenteric artery (IMA) supply involve the division of the sigmoid arteries, as classified by Latarjet in two different types, depending on the anatomical relationship between the left colic and sigmoid arteries [3]. However, in this video authors show a rare case of IMA arising from the superior mesenteric artery [4]. 

References: 

1. Milsom JW, Böhm B, Nakajima K. Laparoscopic Colorectal Surgery 2006, Springer. 

2. Wu C, Ye K, Wu Y, Chen Q, Xu J, Lin J, Kang W. Variations in right colic vascular anatomy observed during laparoscopic right colectomy. World J Surg Oncol 2019;17:16. 

3. Patroni A, Bonnet S, Bourillon C, Bruzzi M, Zinzindohoue F, Chevallier JM, Douard R, Berger A. Technical difficulties of left colic artery preservation during left colectomy for colon cancer. Surg Radiol Anat 2016;38:477-84. 

4. Yoo SJ, Ku MJ, Cho SS, Yoon SP. A case of the inferior mesenteric artery arising from the superior mesenteric artery in a Korean woman. J Korean Med Sci 2011;26:1382-5. 

The authors of the video do not have any conflicts of interest or financial ties to disclose.

Vascular anatomy of left and right colon: standard vs. variations

Anatomie vasculaire du côlon gauche et droit : standard vs. variations

Sigmoïdectomie laparoscopique pour cancer : une procédure éducative en direct

In this live educational video, Prof. Corcione, MD demonstrates an excellent stepwise laparoscopic sigmoid resection for an endoscopically unresectable sigmoid polyp with a histologically proven T1 adenocarcinoma in a 66-year-old female patient. In this procedure, a splenic flexure and left colon mobilization are performed via a medial-to-lateral approach. After transection of the specimen and removal trough a mini Pfannenstiel’s incision, a circular stapled transanal anastomosis is made. 

Prof. Corcione, MD and his co-authors do not have any conflicts of interest or financial ties to disclose in this video.

Focus on Laparoscopic and transanal colorectal surgery