Laparoscopic Right Colectomy

Laparoscopic Right Colectomy Shawnee Mission Medical Center February 22, 2011 Hi, and welcome to the program. My name is Dr. Sanjay Thekkeurumbil, and I m a colorectal surgeon at Shawnee Mission Medical Center; and I m your host for today s program. Hello, I m Dr. Bruce Graham. I m a colon rectal surgeon. This woman has a large villous adenoma, which is a benign, premalignant tumor of the ascending colon. Most of the time we can remove these through a colonoscopy; however, this was so large it could not be removed through the scope; so she was a surgical candidate. What we do is we inject the area with tattoo Indie ink and this is the area right there. You can see the bluish discoloration where we injected the ink. This lets us know where the tumor is. Since these tumors are premalignant, there is a slight chance that this could be a malignant cancer in the polyp specimen at some place, so this is treated as if it were a cancer. Now, my assistant next to me is Ty Taylor. Sue Marty is our nurse assistant. Lori Patterson is our nurse anesthetist. And Cherie is our circulator. Right now, we re mobilizing the right colon. That s the first thing you do is mobilization of the large intestine. The cecum is the area where it is the first part of the large intestine of the colon. This is the cecum here. The appendix is attached to it. This is the appendix right there at the end portion of the cecum. The small intestine is right here, and it comes into the large intestine where that begins the cecum. And then it goes into the ascending colon, where our polyp is. So the first thing we do is mobilize the right colon from its attachments to the right side of the abdominal wall. And that s what we ve done so far we have mobilized fairly decently. Now we re going to have to mobilize it a little bit more. And we ve divided the ileocolic ligament, which is pretty much divided by now; but we ve still got a little ways to go. We re going to divide a little bit more here. Dr. Graham is performing this procedure through a lateral to medial technique. With any laparoscopic procedure, the abdomen is insufflated with carbon dioxide; and the way this is done just above the umbilicus, a small incision is made and we access the peritoneal cavity and place a specialized port through which we can insufflate the abdomen with carbon dioxide. Dr. Graham has chosen to place two ports -- they re 12.0mm ports in the left upper portion of the patient s abdomen and also another one on the left side just left of the midline on the lower abdomen. Using these ports, you can see the extensions of his hands with the grasper and a device called the ENSEAL which allows him to cut and seal blood vessels at the same time. Right now Dr. Graham is continuing the process of separating the colon and its mesentery which contains the lymph nodes and the blood supply to the colon from the retroperitoneum. During the procedure, we often irrigate to keep our field clear and give us good visualization of the anatomic structures. Dr. Graham, what do you think are some of the key technical aspects in this part of the procedure that you think we should look out for? Well, there s two main things you want to look out for well, actually three. Number one, the duodenum is very close, which is the first portion of the small intestine. The second is the ureter, which is the little tube going from the kidney to the bladder; and that s deep; and the retroperitoneal structure is below

here. We ll probably go looking for that later on. And the third thing is the larger iliac vessels that are in this neighborhood as well. But we re well away from all those structures right now. We re still mobilizing. This lady had a previous hysterectomy and previous open cholecystectomy gall bladder removed and that created a lot of adhesions and scar tissue. And those scar tissues have a little bit more vascularity or blood vessels within them. So when you take the scar tissue down, it bleeds a little bit more; and we re just taking care of that. It s not a major issue at all, but it just gives us a little bit more to do. This is the small intestine here. For the most part, most patients are ineligible for this type of operation. And when we compare laparoscopic surgery to open surgery, there are several advantages. One, there is a cosmetic advantage of a smaller incision; but more importantly, with laparoscopic surgery we have a much smaller incision than we ll see at the end of the case for the same operation. And that s the key thing -- the same operation has to be performed, whether it s open or laparoscopy, for the maximum benefit of achieving the goal of the operation. Most patients are placed on a clear liquid diet the first day. On the second day, we usually give a button that gives pain medicine. Usually after the first 24 to 48 hours, the pain control is much improved. And as your bowel function returns -- which is another advantage of laparoscopic surgery, is faster return of bowel function -- we re able to advance diet. And usually we expect patients to be discharged home by postoperative day three. Right now Dr. Graham is continuing to take down some of the attachments of the colon at the area called the hepatic flexure. There is some loose areolar tissue here that hugs this part of the colon against the liver, which you can see him take down. Dr. Graham, can you give us some information about what is the difference between open and laparoscopic surgery in terms of benign and malignant lesions of the colon? Well, the data has now shown conclusively that, if done by an experienced laparoscopic surgeon for cancer, the outcome regarding cure of the cancer is the same as if it were done open but with the benefits of less hospitalization, less pain, less scarring but again, equal outcome. So if you can do it laparoscopically, it s well worth doing. Now, sometimes you cannot do it laparoscopically say if the tumor is so large it s growing into other structures or if there s obstruction or a perforation. In those situations, laparoscopic surgery would not be indicated. Right now we see a little bit more than usual adhesions or scarring in this area, as this patient has had a cholecystectomy in the past and with any type of abdomen surgery, there is some kind of reactive process that happens where the tissues tend to become more stuck down and sometimes obliterates the normal planes. However, Dr. Graham has been able to identify these planes well and is slowly teasing his way through complete mobilization of the colon. Right now Dr. Graham has mobilized most of the colon and is finishing up taking down the hepatic flexure. He s actually rotating the mobilized colon from the patient s right side towards the midline; and what you re viewing is the bulge over there is the right kidney under that layer of fat. Right now Dr. Graham is just irrigating the field to improve his visualization of some of the critical anatomic structures within the peritoneal cavity. Right now he s pointing at a structure which is the right ureter. Again, everything we do is placed through these little trocars, about 5.0mm in size, that goes in and this probe can not only irrigate but perform suction of any fluid within the peritoneal cavity. On Dr. Graham s left hand, he s using a grasper, called a Babcock Grasper, to retract the colon. This is an atraumatic device that prevents puncture of the intestine while grasping it. Outside of that, there is only one more port --as I mentioned in the beginning -- by the umbilicus, where the laparoscope, or the camera, is introduced to give us this wonderful picture. 2

At this side, we can see Dr. Graham is completing the mobilization of the hepatic flexure; and that pinkish structure in the middle of the screen is the duodenum. And this was one of those critical landmarks that Dr. Graham had mentioned earlier which you would want to identify so that you ensure that this structure is left untouched. And usually with this gentle traction and teasing like you see Dr. Graham is doing, the colon and its mesentery easily separates off the structure. And this is now the final last remnants of what s holding the hepatic flexure, or the post segment of the colon by the liver, in its normal anatomic position. And adequate mobilization of the colon is key to doing this procedure laparoscopically to void a healthy, well-vascularized tissue for the anastomosis later. While Dr. Graham is completing the mobilization, we could look at where he has placed the ports on the abdominal cavity. In the center of the screen you see the umbilicus; and just above it, he has a 12.0mm port that was initially used to access the peritoneal cavity and establish pneumoperitoneum for the procedure. And through that port, you see a silver structure; that is the camera, also known as the laparoscope. And there is some suture there that holds the port in place. On the patient s left side, there are two working ports through which Dr. Graham is performing the operation. The one on the lower abdomen is his left hand, which he uses to retract the colon and give it the exposure for the dissection, which is predominantly done with his right hand using the ENSEAL device, which not only divides tissue but also coagulates at the same time, providing hemostasis. At a later point we ll see, once the colon is fully mobilized, where Dr. Graham chooses to make his incision in order to remove the colon. Dr. Graham, how are you feeling? Oh, doing great. Things are going very nicely. Looks nice. What have you got there? We re going to identify the blood vessels going to the large intestine the cecum. And the way you do that, you tent the bowel up; and you can see the blood vessels going here were clearly obvious going to the cecum area. So the next step would be to divide these blood vessels, and this will complete the mobilization of the large intestine so we can remove it through the skin wound. I m just making a small incision over the thin lining over the blood vessels. We ll skeletonize the vessel so we can it adequately; then we ll divide it. And this instrument the ENSEAL is really a remarkable instrument. It s really helped us quite a bit. It cauterizes, coagulates, and then divides the bowel in one step. And it s been very useful. This is the ileocolic vessel. And I m getting on both sides of this. This is a critical step also for a patient who would have a malignancy of the tumor, as the distribution of lymph nodes follows this vessel. And it s critical to get a fairly high ligation of this vessel in order to harvest all the lymph nodes when we talk about colon cancer in this part of the colon. Dr. Graham right now has a good grasp over the ileocolic vessel, and you can see the device making its way through it and coagulating it at the same time. At this point, the ileocolic vessels have been divided. And this is a really critical step in a laparoscopic colectomy, as it allows the mobilized colon to be fully redundant, and it gives us the ability to bring it up to the wound for resection of the segment of colon and anastomosis in an extracorporeal fashion. Dr. Graham is right now dividing the remaining mesentery to the colon to complete this part of the procedure. On the lower aspect of the screen, you can see the ileocolic vessels, which has been well ligated, and you see a pulsatile structure; and Dr. Graham is completing final irrigation of this area prior to proceeding with the last part of this operation. 3

Dr. Graham is retracting the mobilized colon and assessing for optimal site for making an incision on the abdominal cavity to eviscerate the mobilized colon and then proceed with the removal of this section of the bowel and performing an extracorporeal anastomosis. What do you think? Looks pretty good -- Dr. Graham? Yeah, I think so. I think we re well mobilized. Actually a lot more adhesions than many times we see, but that s okay; we deal with that. Okay, now I need a measuring device. Yeah, lights are on. Now, I put about a four and a half or four-centimeter incision and that s less than two inches to get this segment of bowel out. And I do it just lateral to the rectus musculature. Right now Dr. Graham has made an incision just to the right of the right rectus abdominis muscle. Using some retractors and cautery, he s dissecting through the abdominal wall. You see the fat layer of the abdominal wall just under the skin. And after that, we go layer by layer. Next we ll find the fascia, which is the strength layer of the abdominal wall. And once we divide the fascia and peritoneal lining, we have access into the peritoneal cavity to remove the colon. We will have a specialized retractor a wound retractor plate, to keep this opening (inaudible) in order to eviscerate the bowel contents. Looks like Dr. Graham is placing some sutures through this opening in order to help keep the wound open and allow placement of the retractor. These are temporary sutures that will be removed at the end of the procedure. It s just for exposure at this moment. Right now Dr. Graham is placing the wound retractor after the stay sutures were introduced. And this two-ring system will keep the wound spread open nicely without the use of anyone s assistance for the bowel to be eviscerated from the abdominal cavity. And here we see -- using a grasper -- we see the colon and small intestine coming out. This part of the operation would be impossible without full mobilization of the colon as you saw laparoscopically. Now Dr. Graham is performing what s known as a side-to-side functional end-to-end anastomosis, and this is done by removing first the mobilized colon by dividing the terminal ilium by using a device that fires a row of staples to seal the bowel and also cut the bowel at the same time. This was fired against the terminal ilium just now to divide it. And in a similar fashion, the colon distal to the lesion will also be divided with a similar stapling device. Here we see completion of dividing the remaining blood vessels or mesentery, which is the envelope of adipose tissue through which the blood supply travels through on the proximal aspect of the bowel in other words, by the terminal ilium. And here we see similarly dividing the colon distal to the polyp, using this device that runs the row of staples and cuts the tissue at the same time. Once this is fired, the colon will be free from the patient s body; and we re set up to perform the anastomosis, which is putting the two ends of the intestines back together and restore GI tract continuity. Right now you can see the two ends of the bowel the terminal ilium and the colon lined up against each other. And Dr. Graham is placing some sutures to line them up for the stapling device that performs the side-to-side anastomosis. This is the specimen the part of the colon that was removed. And this is the terminal ilium as it goes into the colon; and this is where it was divided with the staple line that seals the bowel. Over here we see the appendix, which is at the tip of the cecum, which is the first part of the colon. And then over here is this bluish discoloration, which is the tattoo injection site that was done during colonoscopy to mark the area of the polyp. And over here is the line of transection of the colon. And this is its normal position in the body as the small intestine goes into the colon, and then the colon proceeds up this way. 4

Now, we ve done the anastomosis here; and we re just looking for any bleeding. But everything looks fine. I m putting a stitch right at the apex, or the top part of the anastomosis, to avoid tension or pulling on that area where we spliced the two ends of the bowel together. Now, this is the small intestine here; and this is the large intestine. We ve done a side-to-side staple the anastomosis. I think there s some advantages to a side-to-side. Side-to-sides are larger in diameter than an end-to-end. That s the reason why I like it a lot. And everything looks really good. Both ends of the bowel are very viable and pink. Looks good for blood supply, no tension and those are the things you need for a good healing of an anastomosis. We re going to retain the pneumoperitoneum, and then we re going to take another look around, and then we ll start to close. And this is our anastomosis of the bowel; and that s where we spliced the two ends of the bowel back together, right along here. Again, looks good. Right now we re basically making sure that there s good hemostasis or make sure that there s nothing actively bleeding or any abnormality, but everything looks pretty good. We re going to wash things out a bit now. The irrigation will remove any old debris and any pre-tissue that is around any bacteria that s running around. Everything looks pretty good. And the scar tissue had adhesed to the bowel this is part of the abdominal wall that the scar tissue adhesed the intestine to the bowel wall from the previous hysterectomy. It s not uncommon. Anytime any surgery is done, there s always adhesions or scar tissue that forms sometimes more than others. Everything looks really pretty good. Of course, this is the liver. This fat layer here is the omentum that lays over the transverse colon. This looks real good. Just for review -- the technical aspects of the procedure: establishment of pneumoperitoneum, division of the ileocolic ligament, mobilization of the colon, dividing the ileocolic vessels to complete the mobilization, and exteriorization of the bowel through an incision of the abdominal wall, followed by resection of the colon and performing a side-to-side anastomosis. We then place the bowel that is put back together back into the peritoneal cavity with a final survey. And now we proceed to close the wound. All right, I think we re out of time right now. And I d like to thank you for joining us here at Shawnee Mission Medical Center. This was a presentation of a laparoscopic right hemi colectomy by Dr. Bruce Graham. This procedure is available for review again at any time on the hospital website. From Shawnee Mission Medical Center at Merriam, Kansas, I m Dr. Thekk. And from Dr. Graham and all of us here, thank you very much and have a nice day. 5