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Laparoscopic colonic resection for splenic flexure cancer: our experience.

Pisani Ceretti A, Maroni N, Sacchi M, Bona S, Angiolini MR, Bianchi P, Opocher E, Montorsi M - BMC Gastroenterol (2015)

Bottom Line: The mean number of harvested lymph nodes was 20.8.Mean operative time was 190 min and mean estimated blood loss was equal to 55 ml.As regard major postoperative complications, one case of postoperative acute pancreatitis and one case of postoperative bleeding from the anastomotic suture line were reported.

View Article: PubMed Central - PubMed

Affiliation: Department of General Surgery II, Ospedale San Paolo, University of Milan, Milan, Italy. andreapisaniceretti@yahoo.it.

ABSTRACT

Background: The treatment of colon cancer located in splenic flexure is not standardized. Laparoscopic approach is still considered a challenging procedure. This study reviews two Institutions experience in laparoscopic treatment of left colonic flexure cancer. Intraoperative, pathologic and postoperative data from patients undergoing laparoscopic splenic flexure resection were analyzed to assess oncological safety as well as early and medium-term outcomes.

Methods: From October 2005 to May 2014 laparoscopic splenic flexure resection was performed in 23 patients.

Results: Conversion rate was nihil. In 7 cases the anastomosis was performed intracorporeally. Specimen mean length was 21.2 cm, while the distance of distal and proximal resection margin from tumor site was 6.5 and 11.5 respectively. The mean number of harvested lymph nodes was 20.8. Mean operative time was 190 min and mean estimated blood loss was equal to 55 ml. As regard major postoperative complications, one case of postoperative acute pancreatitis and one case of postoperative bleeding from the anastomotic suture line were reported.

Conclusions: Although our experience is limited and appropriate indications must be set by future randomized studies, we believe that laparoscopic resection with intracorporeal anastomosis appears feasible and safe for patients affected by splenic flexure cancer.

No MeSH data available.


Related in: MedlinePlus

Division of left colic artery at his origin from inferior mesenteric artery
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Fig2: Division of left colic artery at his origin from inferior mesenteric artery

Mentions: Informed consent was obtained from all patients. No patient received mechanical oral bowel preparation. All patients received perioperative antimicrobial (Cefuroxime and Metronidazolo) and antithrombotic prophylaxis. An urinary catheter was placed at the beginning of each procedure. All procedures were performed by three surgeons with proven experience in laparoscopic colorectal surgery. We adopted classical Lloyd-Davis position with both patient arms along the body. The operator and the first assistant were placed on the patient right side, with the second assistant between patient’s legs. The laparoscopic tower was on the left of the patient. The patient was kept in anti-Trendelenberg position and tilted 20 degrees rightward during the whole procedure in order to keep the operative field clean from small bowel loops. Four to five trocars were placed. The open technique was used to insert a 10–12 mm trocar on the umbilicus right side to introduce a 30 degrees scope. After pneumoperitoneum induction insufflation was maintained at 12 mm Hg. A 12 mm trocar was placed in the right lower quadrant for the operator right hand. A 5 mm trocar was inserted in the right hypocondrium for the operator left hand. A second 5 mm trocar was placed on the left side. A third 5 mm trocar could be added if necessary in the subxiphoid region. Trocars position is illustrated in Fig. 1. The primitive root of left mesocolon was incised from bottom to top, starting at the promontory and arriving at the duodenojejunal juncture. After inferior mesenteric artery identification, left colic artery was isolated and tied up at its origin (Fig. 2). The left Toldt fascia was dissected free from the prerenal fascia, from medial to lateral. Inferior mesenteric vein was identified close to the inferior pancreatic edge and closed off between clips. Transverse mesocolon was divided right to left along the inferior pancreatic edge, lowering the splenic flexure of the colon. The left paracolic gutter was incised bottom to top, joining the previous dissection of the left Toldt fascia. Division of splenocolic and gastrocolic ligaments from left to right completed splenic flexure mobilization releasing the distal third of transverse colon. The great omentum was divided using Harmonic scalpel and its left part was removed en bloc with the splenic flexure. The left branch of middle colic artery was ligated and divided as well as the ascending branch of the first sigmoid artery. Finally, descending colon was transected by linear stapler. Through a trasverse mini-laparotomy in left hypocondrium the colon was extracted and an extracorporeal double layer manual colo-colic anastomosis was performed. In the last two years, once we improved our laparoscopic technical skills and taking advantage of the experience we gained from right hemicolectomy, we began to performe intracorporeal anastomosis. In the latter case, the transverse colon was transected by linear stapler and an isoperistaltic side-to-side completely intracorporeal stapled anastomosis was maked (Fig. 3). The remaining enterotomies were closed in a double layer continue intracorporeal suture (Fig. 4). The specimen was routinely extracted through a suprapubic mini-laparotomy. In all cases we extracted the specimen using an abdominal wall protection device.Fig. 1


Laparoscopic colonic resection for splenic flexure cancer: our experience.

Pisani Ceretti A, Maroni N, Sacchi M, Bona S, Angiolini MR, Bianchi P, Opocher E, Montorsi M - BMC Gastroenterol (2015)

Division of left colic artery at his origin from inferior mesenteric artery
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4494171&req=5

Fig2: Division of left colic artery at his origin from inferior mesenteric artery
Mentions: Informed consent was obtained from all patients. No patient received mechanical oral bowel preparation. All patients received perioperative antimicrobial (Cefuroxime and Metronidazolo) and antithrombotic prophylaxis. An urinary catheter was placed at the beginning of each procedure. All procedures were performed by three surgeons with proven experience in laparoscopic colorectal surgery. We adopted classical Lloyd-Davis position with both patient arms along the body. The operator and the first assistant were placed on the patient right side, with the second assistant between patient’s legs. The laparoscopic tower was on the left of the patient. The patient was kept in anti-Trendelenberg position and tilted 20 degrees rightward during the whole procedure in order to keep the operative field clean from small bowel loops. Four to five trocars were placed. The open technique was used to insert a 10–12 mm trocar on the umbilicus right side to introduce a 30 degrees scope. After pneumoperitoneum induction insufflation was maintained at 12 mm Hg. A 12 mm trocar was placed in the right lower quadrant for the operator right hand. A 5 mm trocar was inserted in the right hypocondrium for the operator left hand. A second 5 mm trocar was placed on the left side. A third 5 mm trocar could be added if necessary in the subxiphoid region. Trocars position is illustrated in Fig. 1. The primitive root of left mesocolon was incised from bottom to top, starting at the promontory and arriving at the duodenojejunal juncture. After inferior mesenteric artery identification, left colic artery was isolated and tied up at its origin (Fig. 2). The left Toldt fascia was dissected free from the prerenal fascia, from medial to lateral. Inferior mesenteric vein was identified close to the inferior pancreatic edge and closed off between clips. Transverse mesocolon was divided right to left along the inferior pancreatic edge, lowering the splenic flexure of the colon. The left paracolic gutter was incised bottom to top, joining the previous dissection of the left Toldt fascia. Division of splenocolic and gastrocolic ligaments from left to right completed splenic flexure mobilization releasing the distal third of transverse colon. The great omentum was divided using Harmonic scalpel and its left part was removed en bloc with the splenic flexure. The left branch of middle colic artery was ligated and divided as well as the ascending branch of the first sigmoid artery. Finally, descending colon was transected by linear stapler. Through a trasverse mini-laparotomy in left hypocondrium the colon was extracted and an extracorporeal double layer manual colo-colic anastomosis was performed. In the last two years, once we improved our laparoscopic technical skills and taking advantage of the experience we gained from right hemicolectomy, we began to performe intracorporeal anastomosis. In the latter case, the transverse colon was transected by linear stapler and an isoperistaltic side-to-side completely intracorporeal stapled anastomosis was maked (Fig. 3). The remaining enterotomies were closed in a double layer continue intracorporeal suture (Fig. 4). The specimen was routinely extracted through a suprapubic mini-laparotomy. In all cases we extracted the specimen using an abdominal wall protection device.Fig. 1

Bottom Line: The mean number of harvested lymph nodes was 20.8.Mean operative time was 190 min and mean estimated blood loss was equal to 55 ml.As regard major postoperative complications, one case of postoperative acute pancreatitis and one case of postoperative bleeding from the anastomotic suture line were reported.

View Article: PubMed Central - PubMed

Affiliation: Department of General Surgery II, Ospedale San Paolo, University of Milan, Milan, Italy. andreapisaniceretti@yahoo.it.

ABSTRACT

Background: The treatment of colon cancer located in splenic flexure is not standardized. Laparoscopic approach is still considered a challenging procedure. This study reviews two Institutions experience in laparoscopic treatment of left colonic flexure cancer. Intraoperative, pathologic and postoperative data from patients undergoing laparoscopic splenic flexure resection were analyzed to assess oncological safety as well as early and medium-term outcomes.

Methods: From October 2005 to May 2014 laparoscopic splenic flexure resection was performed in 23 patients.

Results: Conversion rate was nihil. In 7 cases the anastomosis was performed intracorporeally. Specimen mean length was 21.2 cm, while the distance of distal and proximal resection margin from tumor site was 6.5 and 11.5 respectively. The mean number of harvested lymph nodes was 20.8. Mean operative time was 190 min and mean estimated blood loss was equal to 55 ml. As regard major postoperative complications, one case of postoperative acute pancreatitis and one case of postoperative bleeding from the anastomotic suture line were reported.

Conclusions: Although our experience is limited and appropriate indications must be set by future randomized studies, we believe that laparoscopic resection with intracorporeal anastomosis appears feasible and safe for patients affected by splenic flexure cancer.

No MeSH data available.


Related in: MedlinePlus