Antonio LACY emicolectomia dx VL

Thank you very much Professor Fabrizio for inviting me again to your extraordinary

congress and I think it's important because you choose, for me, the ideal technique is the right

colectomy by laparoscopy because at the moment when you go around the world and you can see

different hospitals, different operating theatres, you can find the rectal resection is performing

very well with excellent results. However, in colon surgery, they're not performing probably

the ideal technique. And that's in this case, we have a demonstration how we can use a laparoscopy

to do a D3 in right colectomies. Probably indication of D3, probably you can discuss

us about that, but in a young patient, so in an advanced team, etc., I think you should

to use the D3 technique. D3 technique is probably, you know, in operative time is 30, 45 minutes

more than a normal right colectomy. However, better results in terms of oncological point

of view. And at the same time, the only problem is if you can make an injury, important

an injury into the mesenteric vessels. That's correct. However, in our experience with more

than 100 cases operated, we never have an injury into the mesenteric vessels.

And I think it's time to start with the video. The video is described by one of my colleagues,

sarah nogueira and i think will be good if you need to have you know i propose to you to make

a chat you know if you have some questions etc thank you very much indeed again hi i'm sarah

nogueira i'm here in the or11 in hospital clinic the video is online thank you thank you where we

have dr lacey performing a right colectomy laparoscopic right colectomy with a detriling

for the anectomy. This is a 73 year old patient with an adenocarcinoma of the ascending colon

with no distal disease and we decided to perform this laparoscopic right colectomy because it's the

well the standard surgery oncologic resection of this of the tumor with the with the main

lymphatic drainage. We see here I was trying to to show you because we we already started

the surgery and Dr. Lacey usually starts the pneumoperitoneum with a varus needle, usually

in the umbilical region, sometimes in the left hypochondrium, but in the surgery we

start in the umbilical region.

And the first trocar he puts in is the optical trocar, which is a 12mm trocar, usually a

little bit left to the umbilical region where you can see it here in the video.

And since we are using air seal, we always use air seal for the surgery.

The second trocar, which is the trocar he puts in the subcyphoidal region, usually we use the trocar for the air seal.

As you can see here, this is a patient that doesn't have any previous surgeries.

And he has a BMI of 26 and we are trying to find the tumor.

we can see that dark spot that we used to mark the tumor that is in the colonoscopy.

So for the surgery to be performed we usually put three other trochars, working trochars,

two for the assistant surgeon and another one for the main surgeon for Dr. Lacey in this case.

So one that we are putting right now is the trochar in the right hypochondrium or

or right upper quadrant, that is going to help in the exposure of the surgical field.

And we put another one in the right lower quadrant, that is this one we are putting

right now, usually two 5mm trochars.

And the last one, which is another trochar for the surgeon, we usually put it in the

suprapubic region usually a little bit to the left and we use a 12 millimeter

trocar inspecting the abdomen again but usually put it the 12 millimeter trocar

that we use to cut the the bowel and for the intracorporeal anastomosis that we

usually perform an intracorporeal anastomosis that's the trocar we are

putting right now as you may as you may see so regarding past medical history this patient

doesn't have anything too important we it has a hypertension and nothing more no diabetes no

cardiac and we're trying to watch here the tumor yes no not pulmonary or cardiac disease and now

the first step is to we already have identified the tumor with the stain and now the first step

is to get the best exposure possible that's why the the trochers in the the right weather and

of the the patient are very important because they help us get the exposure

needed to look for the superior mesenteric artery and vein which are

for the exposure with the clinch that is in the the upper right quadrant in the

the transverse colon, and the second one, which is in the lower right quadrant, usually

showing us, we can see here, because this patient is not, doesn't have many fat tissue,

and this lower clinch we usually have in the iliocolic vessels.

And now, Dr. Lacey is trying to find the superior mesenteric artery and vein, because to perform

a detrilephodonectomy, well, that's the ideal medial limit of the dissection.

So we usually start with the peritoneum, opening the peritoneum slowly with the hook, electrocautery

both directions, cranial and caudal direction, and as the peritoneum is open

well we start deepening the dissection to get to the the plane where we have

the plane. Well, as I told you in the beginning, this is a tumor of the ascending colon, so

following the principles of the correct detrilling for the anectomy and complete

metacolic excision, the idea or the plan that we have, of course, that we try to achieve is to

ligate the vessels, the ileocolic vessels in the origin, the right branch of the medium colic

artery and no more we don't need to go to the right epiplytic artery because

this is the tumor of the ascending colon so the lymphatic drainage will only be

at the level of these vessels the hook is one of the probably one of the best

instruments to dissection because you can do it really carefully you can see

here we start to see something in the back that looks like an artery and now we at once is going

to follow the same plane to see if we are indeed at the level of the superior mesenteric artery

performing dissection because too much bleeding will compromise the surgical field and it's

difficult to see the structures when we have too much bleeding and there's something else we can

achieve with the hook. As you see many times Dr. Lacey just tries to see if the ileocolic vessels

that we have in the in the clinch in the lower right quadrant if they are in the

same direction because it is really really important to understand where is

the origin of the vessels and to ligate them in the origin which was we seem to

energy devices because there's no need to use clips or anything of sort when

they are very small and using the hook may lead to bleeding so using

the vessels the best way possible we try to to see them at the origin to make

sure we are at the origin and to dissect and to to achieve it to allow us to see

the artery and the vein separated isolated one from another once again we

small vessels that you think they may cause bleeding, it's best to use an energy device.

So here we are now trying to find the origin of the ileocolic vessels.

Now we follow, because now that we have the superior mesenteric vein, we try to follow

the direction of the ileocolic vessels to get to the origin.

The dissection needs to be very careful, because we don't want to injure these vessels.

It's important to do the traction with the hook to avoid doing so.

Now we can finally see the iliocollic vessels, the artery on our right and the vein on our left.

trying to go to the other side with the hook. We have a little bit of

hemorrhage here. Once again with the hook we try to control it and here we have it.

the iliocolic artery dissected isolated and I believe we're ready to start the

ligation no we're going to better the dissection with the dissector and now

it's perfect so every surgeon has its preferences

regarding the ligation of the important vessels of a surgery some prefer clips

and prefers suture, Dr. Lacey prefers to use the hemlock clips that you see here.

You have to have hemlock clip that goes into a 5 millimeter trocar in this case

because he uses the trocar in the subsyphoid region. And to complete the

ligation use an energy device. So now that we have the artery it's time to

move to the iliacolic vein that we can see here something is showing behind the duodenum.

We have to be very careful when we do this step. Once again confirming that we have the right

vessels and opening the peritoneum in the direction that we want to dissect and to finish

vein which is the medial limits of our dissection. We can see the iliocolic

in the retromasocholic plane so the dissection needs to be in the correct

plane to allow that all the structure to retroperitoneal structure stay in this

in the in its place and the mesocolon is removed with this serosa intact

that when we when we separated the vessels from the duodenum there's a bit

of a spot here that looks like a terminal injury or a terminal injury in

injury development so Dr. Lacey decided to make a stitch here which is a great way

to avoid problems in the future so if you when you're performing a surgery

when you're dissecting this plane something happens and you feel like you

may have injured the serosa the best thing to do is to correct it with a stitch as you see here

this is a silk suture but you can use whatever suture it's better for you and you're used to

you can all sleep a little bit more and with not so much worries today that's it just a simple

to avoid trouble so we continue the dissection and we are in the distal part of the of our specimen

right because we have the ileocolic vessels ligated and now we are dissecting the posterior

plane and also as we have seen it just before we are opening or dissecting the mesenteric plane of

the terminal ileum there's going to be part of our specimen. Dissection can be

achieved with the electrocautery hook and with energy devices. To help

with the with the posterior plane you may use a gauze like we are using right

now. It has two main purposes helping with the dissection of course and if you

have any bleeding well you have a gauze in the field and you can use it to stop

it to contain it whatever you feel it's needed you can see here dissection of

the posterior plane when we go in the right plane well we avoid that bleeding

which is one of the main complications and as you see as you can see here if

use the gauze it helps with the traction and helps with the traction without

same traction counter traction trying to stop any inadvertent bleeding that may

very careful when dissecting this plane because as you may know in about 15% of

people we also have a right colic artery and it can be found here so we do it very carefully

make sure we don't have any vessel and of course the best way of knowing it before the surgery is

to to do a reconstruction of the vascularity of the of the bowel in a CT scan careful dissection

and vein already ligated and it's time for us to go find the right branches of the medium

colic artery and vein.

an artery well it seems like we have found our middle colic artery with her

Again, the amyloid clip, as I have told you, is Dr. Lacey's favorite, as you can see, and

the energy device to complete the vision of the vessel.

It is important to avoid injury to the left branch so that he can have the best vascularization

possible in our anastomosis.

anything like this happened we just have to be quick, avoid that we have any

excess bleeding in the field and trying to control the bleeding like we just did

which is the dissection and vascular ligation. So now it's time to complete the dissection of the

the transverse colon and the plane of the dissection of the mesocolon that

we're going to follow. You see that this is a patient with a great omentum with a

lot of tissue that we were also will have to well to get like we're doing

dissection of the great omentum at the level where we decided that we're going to cut the transverse

colon as we can see here. These vessels of the omentum can be tricky so using an energy device

dissection from medial to lateral and after dissection is complete we start

the descent of the hepatic flexor of the colon. The best way to do it so is to

to start in the attachments of the colon to the liver and the stomach of course

omentum has some strong attachments to the gallbladder. We don't have any history

with the RA disease but the attachments are strong as we can see here. Some

Some traction, counter traction, careful dissection, and slowly we are liberating the gallbladder

and entering in our space, in our plane.

The scissors is also a good option as we can see here.

This very strong attachments that seem to have an avascular plane.

important to make sure that all the colon has the staplers. A little bit of

bleeding which is normal when you pass the stapler and you have still the parts

of mesocolon that are not dissected. See once again we have the left branch of

the medium colic artery just going to the left side doing a curve to the left

side which is usually what you see in the books that you're dead is that here

anastomosis, our transverse colon. I'm going to clean it a little bit more

since we're going to perform a linear anastomosis, mechanical linear anastomosis,

it's better to have the bowel cleaned and avoid fat tissue in the middle of

the vascularity. So we clean only the superficial tissue that comes from the

attachments we haven't dissected the terminal ilium nor we had transected it

and we still have these attachments to the wall that we saw just in the

beginning of the surgery so still there's a lot of work to do to have our

specimen completely liberated and free these are attachments of the great

momentum to the wall as i've told you in the beginning the patient has no previous surgeries

some inflammatory cause asymptomatic or clinical clinically silent because as you may see here

it looks that they're just attachments of the great omentum. So here we have the

hepatic flexor, the attachments of the hepatic flexor of the colon that we need

to take down. You can use the electrocautery hook, energy device,

almost all dissection from medial to lateral, through the posterior

plane, well we can see here that now that we have almost completed the descent of

the colon, the takedown of the hepatic flexor, the posterior plane is

completely dissected and freed. So now the terminal ileum, we usually take with

the specimen about 8-10 cm of terminal ileum and we follow the plane of the ileocolic vessels

trying to leave the highest amount of terminal ileum possible that won't be compromised by

the vascular dissection of course because this is going to be our anastomosis.

linear stapler in the terminal ilium. There we go. Some surgeons prefer to place the 12 millimeter

trocar in the subshifoidal region because it might be easier to transect the bowel either

the colon or the ileum but as you are going to see in a few minutes the fact

is is that for the to perform the linear stapler anastomosis between

between the terminal ileum and the transverse colon entering the stapler

from below it's better it's it okay it's it's a little bit easier we believe

Dr. Lacey believes and here in our in our in our hospital we have surgeons that

use the 12 millimeter trocar above some below and but in this case and Dr. Lacey

likes it better below and for the anastomosis it's more ergonomic probably

now we are going to dissect the mesentery of the terminal ilium it looks

here first year resident's favorite organ in the abdomen the appendix we all have been first year

residents we all know how much we enjoyed to perform appendectomies and now the final attachment

have our specimen, transverse colon, descending colon and terminal ilium and

appendix unblock. To perform the anastomosis we usually try to put the

specimen just above the liver so it doesn't go in the way and since we had a

gauze well we try to put them together so they are removed together at the end

of the surgery. Well in this view we can see that we don't have any important

and bleeding and now it's time to make sure that the terminal ileum can be mobilized for

the anastomosis sometimes they have attachments in the wall maybe this is the case i see here some

camera is that you can get into those places that are not so easy to reach

ilium and bring it closer to the transverse colon and we can see here the medial limit

of our dissection supremus enteric vein so we usually perform side-to-side linear staple

doesn't move well usually Dr. Lacey uses this stitch which is only to to get the

two sides together and aligned before the stapler is is used for the

talk too much because I'm not sure yes because he usually doesn't just make the

knot just passes the stitch from the transverse colon to the terminal ilium and the assistant

camera was dirty but as i was i was going to tell you usually use the electrocotomy hook

to perform the enterotomies and if it is needed well the dissector to to make

reach the other side of the ball and of course well try to avoid contamination

of the peritoneal cavity with intestinal content but the clot as you

see like we were talking like I was saying better kiss and the linear staple

coming from below it's probably the best when we talk about side to side

anastomosis because you easily follow the direction of the bowel once again

our transverse colon going to clean it a little bit more since we're going to

perform a linear anastomosis mechanical linear anastomosis it's better to have

be careful with the mesocolon because of the vascularity so we clean only the superficial

with some attachments we haven't dissected the terminal ilium nor we had

transected it and we still have these attachments to the wall that we saw just

in the beginning of the surgery so still there's a lot of work to do to have our

okay norm known episodes uh interdominal disease and possibilities attachments are just from some

inflammatory cause asymptomatic or clinical clinically silent because as you may see here

it looks that they're just attachments of the the greater momentum so here we

have the hepatic flexor the attachments of the hepatic flexor of the colon that

we need to take down you can use the electrocautery hook energy device

almost all dissection, from medial to lateral, through the posterior plane we can see here

that now that we have almost completed the descent of the colon, the takedown of the

hepatic flexure, the posterior plane is completely dissected and freed.

So now the terminal ileum, we usually take with the specimen about 8-10 cm of terminal

ilium and we follow the plane of the ileocolic vessels trying to leave

the highest amount of terminal ilium possible that would be not that we

won't be compromised by the vascular dissection of course because this is

the other side, so we are able to pass a linear stapler in the terminal ilium. There we go.

Some surgeons prefer to place the 12 mm trocar in the subshifoidal region because it might

might be easier to transect the bowel, either the colon or the ileum, but as you are going

to see in a few minutes, the fact is that to perform the linear stapler anastomosis

between the terminal ileum and the transverse colon, entering the stapler from below, it's

better it's okay it's it's a little bit easier we believe dr. Lacey believes and

here in our in our in our hospital we have surgeons that use the the 12

millimeter trocar above some below and but in this case and dr. Lacey likes it

better below and for the anastomosis it's more ergonomic probably now we are

going to dissect the mesentery of the terminal ilium. It looks like we have

structure here, first-year resident's favorite organ in the abdomen, the

appendix. We all have been first-year residents, we all know how much we

have our specimen transverse colon descending colon and terminal ilium and appendix unblock.

To perform the anastomosis we usually try to to put the specimen just above the lever

so it doesn't go in the way and since we had a gauze well we try to put them together so they

are removed together at the end of the surgery well in this view we can see that we don't have

any important bleeding and now it's time to make sure that the terminal ileum can be mobilized

for the anastomosis sometimes they have attachments in the wall maybe this is the case

i see here some some struggle i believe right yes so when we're going to take down these additions

of our dissection supremus enteric vein so we usually perform side to side linear staple

anastomosis peristaltic side to side and to make sure that the bowels is in place and we

to talk too much because I'm not sure yes because he usually doesn't just make

the knot just passes the stitch from the transverse colon to the terminal ilium

and the assistant surgeon is going to to hold it to hold it hold it together for

going to tell you usually use the electrocotomy hook to perform the

enterotomies and if it is needed well the dissector to to make sure that we

other side of the bowel and of course well try to avoid contamination of the

peritoneal cavity with intestinal content the colon has deflated with with

the colotomy as you see like we were talking like i was saying better kiss um the linear staple

coming from below it's probably the best when we talk about um side to side anastomosis because you

of your assistant surgeon well you can follow the direction of the bowel

sure we don't have any bleeding and we do not contaminate the peritoneal cavity

able to see there's no bleeding which is good. Well Dr. Lacey usually performs a continuous

suture with, in this case, we have a bargrill suture and it usually uses two

stitches. One larger one that is this one and a shorter one that he puts in on the

assistant surgeon is the one that is going to be holding the suture to make

to close the knot. Well this means we are getting closer to the end of the surgery because now that

Dr. Lalisa performs this stitch with the idea of reducing the pressure in the closure, a

sort of amentoplasty to protect the staple line.

performs a knot with the intent of reducing the pressure in the anastomosis.

of the surgery.

Now we have to make sure that we don't have any bleeding, everything looks well and we

try always to move the great omentum to the surgical field.

We see here the 12 mm trocar and we are going to try to amplify it a little bit to introduce

an endo bag to remove the specimen.

You can see through the outside camera how Dr. Lacy tries to enlarge the incision of

the draw car, just enough to introduce an endo bag and remove the specimen. This has to be a

quick maneuver to avoid that the pneumobrytonium, the air, comes outside. We have to be very careful

with all these maneuvers. Of course this patient is COVID negative because we test our patients

before surgery but we always try to do things the most carefully possible.

specimen because we have all the great omentum, the colectomy specimen and the

we have it. Not going to be easy to remove it. So now through the same

now because we need to check to see if the trocars are okay if we don't have

any bleeding we usually put the 12 trocar 12 millimeter trocar in place

again using a gauze as you can see yes as you can see here to avoid that the

the air just escapes to the room, to the OR room. No bleeding, everything in place.

going to remove the trochars, remove the neoperitoneum first, then remove the trochars,

the anastomosis, we can see here the supremacenteric vein, ligation of the ileocolic

artery and vein, the left branch of the medium colic and the ligation of the right branch,

and now with the bipolar which is another tool that Dr. Lacey uses a lot to try to coagulate

this. It's important to be to be careful and watch everything. So now here we have the specimen.

specimen, we can measure the length of the mesocolon to see the distance between the

medial limit of our dissection and the tumour, which must be over 10 cm, at least 10 cm.

Thank you very much, I hope you enjoyed the surgery.