DE MANZINI EMICOLECTOMIA destra LAPAROSCOPICA4

So this is the last patient of our day. It's a woman of 66 years old, who's history is remarkable for a previous non-Hodgkin lymphoma, radiochemotherapy treated.

Essentially she came to our attention because of altered bowel movements, so she performed a pancolonoscopy that showed an adenocarcinoma just close to the ileocecal valve.

She performed a CT scan and the images are arriving that confirm the thickening of the right colon with some lymph nodes. We already started the operation laparoscopically so the patient is in a supine position, legs up on allen stirrups.

we have a super umbilical in the camera and then we use a trocar of 12

millimeters in left hypochondrium another trocar of 12 millimeters in the

left iliac fossa and one more trocar in hypogastrium

We first made a mapping of the lymph node system by injecting endocyanine green serously.

There is a little bit of ICG, as you can see, on the wall, but most of it, you know, it's

on the wall.

It's on the bow.

Now the aim is to demonstrate how we can achieve lymph node mapping, and now you are seeing

quite this.

this, and moreover here, and now we can try to move to the ascending colon, and perhaps

we can be able to see if we find, not this one, but cephalad staining, a blue staining

on the root of the right middle colic artery.

Cancer is near in front of the ileocecal valve,

so that probably this will be unuseful.

Further studies are necessary,

and we are trying to understand

if a correct mapping could be useful in determining the choice of the correct lymphadenectomy in these cases,

or if the mapping can allow us to verify where is the first responsible lymph node in order to apply,

for instance, sent in a lymph node protocol to the first one.

Why? Because we have found that at five years follow-up,

that T3 versus T2 cancer, five years overall survival,

was not so strongly different.

And we ask the question if a certain number of second stage colon cancer was understaged with a normal staining and a normal lymph node appreciation.

So that one way could be to appreciate the sentinel lymph node in order to improve the pathological staging.

Of course, the other idea of the mapping is to understand and to decide the extent of

the lymphadenectomy in another route.

Here it is quite evident that we have to choose just the ileocecal pedicle you are seeing.

Being that here we have already started the operation, but in some other cases or in re-operations

as we have previously demonstrated, it could be interesting to understand if there is a

secondary pathway for the lymph node invasion by the cancer cells.

Okay, now you see we have opened this first window between the pedicle and the duodenum

you are seeing here just above, and I'm trying to open a sort of window, you have seen here

it, here, and now following this first preparation we are going low just at the level of the

the origin of the right, the ileocolic vessel, sorry.

Marina?

More about the fact that you not

form a complete mesorectal excision.

Yeah, there is a wide debate about the advantage

of an extended lymphadenectomy in right colon cancer.

Literature is, in my mind, a little bit controversial

controversial because for some authors have very good results and that means that you

should do it for obtaining the best oncological results for patients.

On the other side, there are some functional drawbacks because the dissection

Just to clean the optics, right?

Because the functional results after an extended lymphadenectomy at that level can lead to

diarrhea, to very bad functional results, and in most of patients, you do not achieve

a better oncological result.

In effect, in a recent colorectal meeting a couple of months ago, we have seen, we have

listened that most Anglo-Saxon authors do not use at all this kind of lymphadenectomy.

And the common opinion is also that if there is a positive note at that level, the illness is a quite generalized one.

So that the technical trick is not, the technical advancement is not perhaps supported by survival.

survival. So we prefer to stay at that level and to use an extended dissection just if we think

that there is a special lymphatic drainage or in case of reoperation for a secondary ileocolic

resection or whatever else, but not as a routine. It's not so easy now to isolate the artery from

from the vein. I could, if necessary, fire a vascular staple line, but if I am able to

prepare the artery separately from the vein, it should be better. I try to achieve the

origin of the vessel. Of course, the danger is the superior arteric vein. It could be

be very hard to restore in case of a damage.

Probably I will stop here.

Just trying to separate the artery from the vein.

Normally the artery is in the first gland.

The field is very thin.

OK, see, if the dissection is not achievable in an easy way,

I can also clip it entirely with one shot, but if possible, I prefer to avoid it.

There is no real cause for this, but just another collapse here.

I think I have the artery on my grasper and the vein under the energy device.

eyes okay clip i will stop here uh just uh

just i try to have a look with the okay

it is too early probably

to see a passage no mapping is not so efficient now instead of the original

So, very honestly, the lymph node mapping has to be standardized much better because

spillage is a confounding element.

really the lymph node mapping techniques.

In the past, we did it with patent blue and direct vision, honestly, just to obtain an over-staging of second-stage cancer patients without being able to continue this experience.

So that now we have achieved the vascular phase of the operation.

Okay, the advantage, okay, so you see the advantage of such clips,

non-metallic one you can cut with an energy device very close.

Now the second step is to follow the external part of the duodenal curve

in order to start with the medial to lateral dissection of the right mesocolon.

So you see I follow the duodenum by moving it as smoothly as I can.

It is suspected that the extensive mobilization of the duodenum

could lead to an impairment of the postoperative bowel movements.

of course it is not clearly demonstrated

ok stop

now

we try to open

you see a little window opened

separating the mesocolon here and the mesentery here

the common right iliac artery

just inside the window

and my direction towards the towards the last the last part of the small bowl okay so I can

proceed this direction but that Molla I think one gross appraisal okay perfect lift it very well

Okay, now it is easy to continue.

You see the ureter, and so you see that I should not follow this plan, but this one.

Okay, you see very clearly the right ureter.

It is possible that that succeeds, but normally you should be able to avoid opening the gelatofascia, disturbing too much the duodenum.

But following the external curve of the duodenum, with this grasper, with this one, you will be able to arrive under the hepatic flexure of the colon and probably to be able to see the liver through the peritoneum, through the transverse mesocolon, if it is at least a little bit thin.

Anyway, as we did in the left colon, we can do the same thing with the right one, trying

to stay completely bloodless, and we try to go as far as possible.

possible. Okay, we move to the mesentery for a moment. Now with this kind of traction,

we are sure that the iliac trunk is free, the ureter is free, so we can easily cut the

the rest of the part of the mesentery and to reach the preferred point for the small

bowel transection.

This is a good example of how such devices are strong.

If someone remembers the old time for the open right colectomy, this part was achieved

by section with ligature of every vessel.

and now you can quite imagine that there are no more vessels okay before leaving this part I just

check if the small bowel is free from any adhesion to the pelvic wall that's the case today otherwise if you

do not check it you can have a final difficulty in performing the anastomosis okay now let's go

go to see the distal point of section.

So pulling up the transverse mesocolon,

we can finally separate the vertical part of the duodenum

up to the superior angle, superior knee of the duodenum,

and trying to see the lever through this medial to lateral way.

Very often at the end of this part you can cut this part and this part and this part,

but finally you have to put one instrument in this position

and to see from another point of view the achievement of the preparation of

the splenic flexure. I mean that you can put this instrument here, you can release

the colon, you can move and you can see where you are. Where is the liver? Far.

far, because hopefully today the hepatic flexure is really low and easy to find.

But even in case of very high flexure, this medial to lateral approach allows you to obtain

a clear, a very clear achievement of freeing this flexure.

okay and now you have the choice to achieve this the opening of the told

fascia from up to bottom or from bottom to up as you want as the single anatomy

of the the specific anatomy of every patient does it more easier to do from

from cephalad to caudad, or vice versa.

Eh, sì, però adesso proviamo la 45 grip.

Vediamo.

Solo un attimo.

You see that all is free.

Now we have just to...

Mola pure, Pio.

Just to choose where to cut the colon.

So a good idea is that...

Prendi qua, per piacere.

Al posto mio, sull'Atenia, qua.

Very well, sull'Atenia.

Yes.

No?

The assistant, with his left hand, can be a little bit in difficulty.

I change my hand also.

I use the device with the left hand.

For this case, I do not need any further cephalic extension of my dissection.

Because due to the position of the cancer, due to the absence of dye passage in the axis

of the of the right colic artery I can do it okay here I have probably the marginal arcade

attention to the other to the duodenum I have to prepare it a little bit better okay here okay

I probably opened the artery of the vascular arcade normally it is very easy to achieve the

the hemostasis just that way. I just want to reverse the fat tissue a little bit, okay,

that way in order to have a completely clear operating field. If I can use, if I cannot

use a clip, I use an advanced bipolar and I cut in between or even I leave that the

the cutting is achieved by the bipolar coagulation.

Have to approach the bowel.

a momentum from the colon but as we are doing the section here probably it is enough or or we can

refine this section after having sectioned the bowel okay

Okay, we are quite ready.

We can, just for demonstration, show you the ICG coloration of right colon.

Possiamo andare?

So the intended point of section is this one.

You see it very well.

Si?

Okay.

Okay, don't worry about the blue in the abdominal wall,

but just have a look here,

and you see immediately how the vascularization is very good here.

And let's move to the small bowel, okay, here,

just against the iliac artery.

Okay, really no problem, eh?

But it is just for the fun, just for demonstration.

Now let's go to expose the point of section, I feel a little bit tired so I use a powered

This is a small bowel, but you won't loose this one, because this way you will prepare this and then a v-curl and two v-locks, and maybe even a second v-curl.

Now, we go to put the future specimen...

The correct position should be this one.

Now we put a first stitch and you will see the homemade trick to

simplify a little bit the correct positioning of the anastomosis. I take

the colon, pass a stitch, I take the bowel and I pass the stitch.

Now wait, I'll do a half-knot and then push it towards the wall.

Back, back, back.

There's a knot here.

There is a small knot here.

Scrub nerves will be punished.

Sorry, but I have the...

It is a little bit short for...

Okay.

Okay.

Gently touch the knot.

Stop.

stop no unfortunately i have a knot inside the morning

and the two sides of the of the stitch are not equal sorry for that

yeah okay now if i succeed because the stitch is a little bit short now

Now I will try to do another thing easier, okay, temporarily I fix the anastomosis, the

two parts of the bowel to be anastomosed on the abdominal wall.

Sorry, because I have the, the thread in front of the needle is too short, but I hope to

succeed in doing that. Okay, and the second stitch, this is only temporary, but it allows

to have a steady anastomotic line. That means that you, yeah, yeah, okay. That means that

that you have a free instrument to help the final part of the anastomosis, Agu fuori.

Okay, un'altra pinza.

Now we are slightly going to the end of the operation.

We have to see how to put the bowel.

This is the proximal part.

This is the distal one.

one, so the anastomotic line should be this one. Before doing it, before doing it I close

the breech so that now we prepare it and it is very useful to have a hand free here, I

I close the bridge, I close the mesenteric bridge before doing the anastomosis.

It is easier and it is a supplementary way to be sure, to be sure that there is no torsion

in the anastomosis.

You remember perhaps that the main twist of the anastomosis benedicta are described in

an extracorporeal anastomosis instead of the intracorporeal one, but nevertheless we prefer

to be very cautious in doing that because there are some mistakes that are very peculiar

peculiar to laparoscopy, and if it succeed that you have one of them, the question that

but bad passage the first of course I have to to peek into the mesocolon and

not in the not in the duodenum of course perhaps this passage will be better it

will be better and this one too finally the risk of internal hernia is not so

well described but it arrives anyway

In my opinion, the main part, the most important part of this closure is this one, is the more

posterior one, being very hard that an internal hernia develops close to the viscera.

and so that I think that it should be the final point of the closure not so

difficult the only important thing is to bake to begin very close to the

diodenum okay ultra now we are ready for anastomosis talking about anastomosis

you prefer intercorporeal or extracorporeal anastomosis I have very

good question we started at the beginning of our experience with a wide number of extra

extracorporeal anastomosis ultra moving then with intracorporeal one

it is surprising in literature and in our experience as well that

that right colectomy is not an operation without leakage.

And the leakage rate was quite similar

in open laparoscopic intra and extracorporeal.

Of course, a critical point in intracorporeal

is the closure of the bridge.

And it appears very strange

danger, quite unethical, to have a major difficulty, I mean major is perhaps too big an adjective,

but an important risk of leakage due to the closure of a bridge. Some Anglo-Saxon colleagues

colleagues prefer to avoid such a stupid risk and to perform every time an extracorporeal

one.

Okay.

Suturatrice.

Suturatrice.

We have had a reduced but not zero number of leakage.

Now, hopefully, changing some details in closure of the breach, as in literature, we can avoid

that.

But it has been a major concern, and to understand that such a concern is unacceptable for this

part of the operation.

It is unacceptable that a right colectomy could have a specific complication named anastomotic leakage.

So if it was true, it has been better to use an extracorporeal anastomosis.

this now with a double layer check and with some details in such a closure we can achieve a good

result and so we continue this way of course without pull pushing too much the indication

If there is a particular patient, an IBD, or other particular situation, we use selectively the extracorporeal.

One trick is to put the two breeches very close to each other at the moment of positioning of the stapler

in order to reduce the length of the bridge and to achieve an easier and quicker closure.

Now I go to check the absence of hemorrhage inside.

You see that seems good.

There is no stool spillage.

We do not use any mechanical bowel preparation, just a diet without fibers one week before.

And now the main final step is the closure of the breech here.

Here you see a point that is not, I'm not very happy, there is a little bit of fatty

I will remove this part, it is not a good thing to leave it, okay, now my personal trick

is to start the closure in the very posterior part of the anastomotic line, so I do not

start closing the breach I start putting a stitch over the final part of the

mechanical stapling I try to show you how that way prepare very carefully my

the stitch the need turning on the needle holder okay you see okay this

first stitch is a on the posterior aspect of the of the anastomosis the mechanical part okay i

prepare and you will see how it will change the exposure of the suture or the future suture line

if i succeed inserting my needle okay no 3d is better for that okay no you should hold your

breath when you pass this first stitch okay now let's go to see how it works now if i pull this

first stitch the posterior part becomes anterior or quite anterior and they can

contain the closure of the posterior part of the anastro the stapled line

Can we clean the camera?

And now I can pull.

I try to pull.

OK.

And now all my posterior plan became an anterior one.

Sorry.

OK.

So that now, only with this point,

I start in reality to close the bridge.

But I have two previous passages allowing just to present

the anastomotic line of the bridge more easily.

Just only that.

So two tricks to fix temporarily the anastomotic plan

to the abdominal wall and second to start very posteriorly the anastomosis and of course to

assess the proper tension to the thread paying attention that this kind of barbed wire is very

fragile it is rigid and it doesn't support a strong holding by a needle holder or by a

grasper to angulated and now it becomes easier and easier okay just pay attention to be regularly

Now, as I started with two extra breech stitches, I will finish with two extra breech stitches.

This one and the final one.

Okay. Ultra.

Let's pull a little more.

More lapio.

Okay.

We can retrieve the needle.

Hold it.

We can retrieve...

Let's see if we can put the clip inside.

We can retrieve the temporary fixation, we can check the anastomosis, this bridge is

completely not influent, no bleeding, and now we have just to retrieve the specimen.

We just open a little bit around the hypogastric trocker.

Okay, we just try to show you.

Why did you remove the trocker?

The trocker? Why did you remove it?

Did I remove it? Give me the mandarin.

You should never remove it.

Ok, we'll put it back in.

Farabef? Resolved.

We use the path of the...

The electric bisturi doesn't work.

We use the path of this trocker to widen the opening of the hypogastric trocker.

okay perhaps now it's okay we will try to show you the external part but I don't know if the

technician is in the in the theater now okay media socket on it pronto here we go yeah the

retrieve it, ok.

Now the operation is over, the operation is over, we do not put any drainage because we

We do not have any spillage.

Thank you to all people.

The specimen is here.

Cancer is here.

You can see it.

very good Marina and you see that the lymphadenectomy is all this one normally

in our experience we have around 35 lymph nodes for every right

colectomy piece thank you to all people we can close the we can close the

contact with Rome. Thank you again

to Giorgio Palazzini

and thank you to all my team

that you are perhaps seeing

now. Goodbye from Trieste.

Possiamo mettere il paziente a piatto

e chiudere.