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Laparoscopic left colectomy for cancer: transmesenteric passage of the transverse colon

Authors

Abstract

The aim of this video is to show a tip involving the transmesenteric route of the transverse colon to perform a tension-free colorectal anastomosis following an extensive excision of the left colon.

Classification

tips and tricks

Keywords

Laparoscopic left colectomy, cancer, transmesenteric passage, transverse colon

Media type

Duration

05'36''

Publication

2009-09

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E-publication

WeBSurg.com, Sept 2009;9(09).
URL: http://www.websurg.com/doi-vd01en2724_2.htm

Laparoscopic left colectomy for cancer: transmesenteric passage of the transverse colon

1. Introduction 00'17''

The aim of this video is to show a tip involving the transmesenteric route of the transverse colon to perform a tension-free colorectal anastomosis following an extensive excision of the left colon. Indeed, following an extensive mobilization, colonic lowering posterior to the mesentery is rarely possible. Lowering anterior to the mesentery can lead to a mesenteric nip and cause an internal hernia that will be difficult to close. We therefore decide to retract the mesentery and the small bowel to the left part of the abdomen until the last bowel loop can be visualized and exposed. We can see the latter here, with the ileocaecum and the appendix. The appendix will be removed at the end of the procedure. We aim at performing a passage from the left colon through the mesentery of the last small bowel loop. This will allow to diminish the distance between the hepatic flexure of the colon and the rectal stump.

2. Creation of the mesenteric window 01'38''

First, we open the mesentery in order to create a window while preserving the ileocaecum’s vascular supply. This window should be large enough to allow the passage of the transverse colon that is only vascularized by the superior mesenteric vessels. These predominantly vascularize the right colon and the marginal arteries. The window is created while preserving the ileocaecum’s vascular supply. To facilitate the passage, this opening should be wide enough.

3. Freeing the transverse colon 03'45''

It is also necessary to free the transverse colon of its attachments, particularly of its omental attachments and folds that would impede the passage through the mesentery. Here can see the evaluation of the distance that needs to be covered, and we notice that there are problems moving everything above the mesentery. To ease the passage, we place a landmark on the shaft of the anvil that was introduced through the transverse colon. The left colon is freed of a few omental adhesions before passing the guide wire that will allow to bring the anvil through the mesentery atraumatically. Here we see its passage, performed without any trauma to the mesentery. With the left colon being perfectly prepared, we can bring the left transverse colon through the mesenteric defect. We then transfix the rectal stump and we connect the anvil using a grasper while checking that there are no twists: this allows to lower the colon.

4. Anastomosis 04'55''

Once these two elements have been connected, we perform the anastomosis and check it to make sure that there is no tension. We finally fix the colon on the border of the mesenteric passage and close the posterior mesenteric window (or gap) to avoid internal hernias.

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