monthly focus

surgical intervention video

Faisabilité d'une colectomie laparoscopique pour cancer colique T4b

Objectives: 

Authors present a laparoscopic sigmoidectomy with partial cystectomy of a sigmoid neoplasm with bladder invasion. 



Materials and methods:

A 54-year-old male patient, chronically medicated for arterial hypertension, diabetes, and dyslipidemia, was referred for a general surgery consultation with complaints of fecaluria and pneumaturia. Due to a suspicion of colovesical fistula, a renovesical ultrasound, a pelvic CT, and a colonoscopy were performed, which confirmed the presence of a colovesical fistula associated with an extensive sigmoid neoplasm, histologically confirmed. After completion of staging (cT4bN0M0), a laparoscopic sigmoidectomy with partial cystectomy was proposed to the patient. 

Results: 

In the perioperative period, the urology team performed a cystoscopy with bilateral placement of double-J catheter, identifying the invasion of the bladder dome by the neoplasm. The laparoscopic surgical procedure, with ‘en bloc’ resection and primary intracorporeal anastomosis, and the postoperative period were uneventful, with discharge on postoperative day 4. 

After the histological report, the neoplasm was classified as a colon adenocarcinoma moderately differentiated with regional lymph node metastases and serosal perforation with involvement of the bladder wall and negative surgical margins (pT4bG2N1a(1/27)M0R0) - stage IIIC, and the patient was offered adjuvant chemotherapy. At 2 months of follow-up, the patient is tolerating chemotherapy treatment without complications or any urinary disfunction. 

Conclusion: 

Up to 15% of patients with colon cancer will have tumors adherent to adjacent organs. The most frequently involved organs are small bowel (29%) and bladder (24%). While minimally invasive surgery for non-locally advanced colon cancer is performed worldwide, this approach for T4 tumors, which requires technically demanding surgical skills, is still not widely accepted, due to the historically high postoperative morbidity and high risk of microscopically positive surgical margins. The clinical case presented confirms what has been evidenced in the recent literature, namely that laparoscopic ‘en bloc’ resection of multiple organs combined with colon cancer is a safe and feasible option in selected patients and in the hands of skilled surgeons. 

Laparoscopic T4b colon cancer resection: is it feasible?

Résection segmentaire laparoscopique du rectosigmoïde avec prélèvement par orifice naturel (NOSE) pour endométriose intestinale

In this educational video, authors demonstrate laparoscopic segmental rectosigmoid resection due to deep intestinal endometriosis, with natural orifice specimen extraction (NOSE). The authors perform this approach using 4 trocars, one 11mm, one 12mm, and two 5mm trocars. The surgery was initiated by the gynecology team with excision of deep endometriotic lesions and total hysterectomy, leaving only the lesion in the rectum, and authors proceeded to segmental resection with NOSE extraction through the vagina. 

Laparoscopic segmental rectosigmoid resection with natural orifice specimen extraction (NOSE) for bowel endometriosis

Hémicolectomie droite laparoscopique à trois trocarts chez un patient obèse

The authors demonstrate a laparoscopic right hemicolectomy performed using a three-trocar technique in a patient with a BMI >40. 

Three-trocar laparoscopic right hemicolectomy in an obese patient

The authors present the case of a laparoscopic Hartmann procedure in fecal peritonitis due to iatrogenic perforation after endoscopic polypectomy.

Laparoscopic Hartmann procedure in fecal peritonitis

Procédure laparoscopique de Hartmann dans la péritonite fécale

Préservation des organes avec préservation complète des veines et des artères (CoVAP) dans le cancer colique gauche

Anastomotic leakage still represents a complication of colorectal surgery that can seriously compromise the postoperative course. The preservation of central vascularization should play a protective role for anastomotic perfusion. Additionally, it should reduce the risk of edema. The aim of this technique is to reduce anastomotic leakage in laparoscopic left hemicolectomy for oncological patients with complete vascular preservation of the inferior mesenteric vein and artery. 

The authors present the case of a 59-year-old man with cancer of the descending colon that was planned for 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. The LCA was divided between clips with preservation of the IMA, of the splenic flexure, and of the inferior mesenteric vein (IMV). The colon was divided between mechanical staplers and a side-to-side isoperistaltic anastomosis was performed. The postoperative course was characterized by a Clavien-Dindo I complication. The patient was discharged on postoperative day 5. The preservation of the inferior mesenteric artery vein could reduce the risk of anastomotic leakage and improve oncological outcomes. 

Organ-sparing with complete vein and artery preservation (CoVAP) in left colon cancer

Lacération iatrogène de la veine cave lors d'une dissection ganglionnaire laparoscopique guidée par vert d'indocyanine dans le cadre d'une résection rectale antérieure basse : prise en charge laparoscopique 

Fluorescence-guided surgery provides the surgeon with an increased visualization of anatomical structures, and particularly so in oncologic surgery, it considerably increases the surgeon’s therapeutic possibilities. The visualization advantage often translates into a greater number of harvested lymph nodes, ensuring oncological radicality: in an augmented reality context, it is often difficult not to exaggerate with dissection. In this video, the authors present the case of a laparoscopic low anterior resection (LAR) with ICG-guided lymph node dissection for adenocarcinoma with total mesorectal excision (TME) dissection. Intraoperatively, during AMI lymph node dissection, the authors caused a vascular laceration of the inferior vena cava with a sudden massive hemoperitoneum that was repaired with a laparoscopic lateral suture. 

This video is of high educational value since it shows the possibility to laparoscopically manage a vascular iatrogenic damage that caused an acute massive hemoperitoneum. 



Iatrogenic vena cava laceration during laparoscopic ICG-guided lymph node dissection in low anterior rectal resection (LAR): a laparoscopic repair (or despair?)

video lecture

In this key lecture, Dr. Gyu-Seog Choi, MD, PhD outlines the standardized robotic lateral pelvic lymph node dissection (LPND) based on anatomy.

Standardized robotic lateral pelvic lymph node dissection (LPND) - based on anatomy

Curage robotisé standard des ganglions lymphatiques pelviens latéraux basé sur l'anatomie

In this key lecture, Dr. Dean Koh, MBBS, FRCS, FRCSEd, FAMS focuses on the specific complications of robotic surgery.

Laparoscopic and robot-assisted colorectal surgery