Vol. 10 NO.7 Jul, 2010  

Dr. Parveen Bhatia, MS FRCS (Eng) FICS FIAGES FMAS FIMSA, Chairman

Dr. Sudhir Kalhan, MS, Vice Chairman

Dr. Mukund Khetan, MS, Consultant

Dr. Suviraj John, MRCS MS DNB FNB, Consultant

Institute of Minimal Access, Metabolic and Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi.

Introduction

Colorectal cancer is one of the most common cancers in both female and male persons in the industrialized nations of Asia, Europe, America, and Australia1. Cancer of the colon is a highly treatable and often curable disease when localized to the bowel. Surgery is the primary form of treatment and results in cure in approximately 50% - 70% of patients. Numerous phase III multi center trials testify to the oncological completeness of laparoscopic oncological resections for colo-rectal cancer2-4. In the past, many pioneers had moved to introduce safe and ergonomic versions of laparoscopic colectomy5-9. Techniques are now well described and standardised. Prime among these is the ‘medial to lateral – standardised’ approach described by Senagore et al9 for laparoscopic right colectomy for colon cancer. A notable ergonomic modification of the above has been described by Palanivelu et al10 and is described below. We present the case of a fifty year old lady who presented with anaemia who on comprehensive investigation was found to have an ascending colon ulcero-proliferative growth which was reported as a moderately differentiated adenocarcinoma on histopathology. Contrast - enhanced computerised tomography of the abdomen revealed a T3N2Mx annular lesion involving the ascending colon. After pre-operative evaluation, preparation and optimisation she was taken up for a laparoscopic assisted right colectomy.

Operative Technique

The patient was placed in the supine position (position varied according to the operative stage), induced, catheterized (urinary) and carboperitoneum created. The initial camera port (also doubles up as the right hand working port) is placed at the umbilicus (10mm). Secondary ports inserted are suprapubic (camera / working port, 10mm), right iliac (left hand working port, 5mm) and epigastric (left para-median siting; retracting and right hand working port, 5mm).

Ventral caecal retraction displays the retrocolic plane which is opened up beginning from distal end of the terminal ileal mesentery and retro-caecal plane and opening up the white line of Toldt and retrocolic plane, by ultrasonic shears.

The retrocolic plane is dissected and opened up to the anterior aspect of the 2nd part of the duodenum and the head of the pancreas.

The Gerota’s fascia falls posteriorly. This raises the lateral fascial sheath (lateral peritoneal colonic reflection) and the medial lympho-vascular pedicle (ileo-colic and right colic vascular sheaths), both of which are left intact. The vascular roots are skeletonised individually before transection and the lympho-adipose tissue here is swept towards the resected specimen.

Mobilisation of the gastro-colic (head-end up position) and hepato-colic ligaments are transected with ultrasonic shears beyond the proposed point of transection of the transverse colon.

Care was taken to protect the duodenum during this step. Transection of the right branch of the middle colic was performed. Extension of the umbilical port incision (7 cms) and exteriorisation of the specimen through the mini-laparotomy, protected by an indigenous endo-channel (plastic bag covering the wound edges) to protect the wound from tumour seeding. Extra-corporeal bowel resection and anastomosis (stapled) was performed. The anastomosis was interiorised, closure of main wound performed, check laparoscopy undertaken, drain tube placed and port sites were closed. Standard disposable/ reusable ports and laparoscopic instruments (graspers, scissors, and monopolar electrocautery) were used. For dissection/ transection and haemostasis we utilised the Harmonic Ace.

In the immediate post-operative period, the patient was placed on a naso-gastric tube and removed within 36 hours (this is optional). The patient was given a liquid diet after 36 hours which was advanced subsequently. The patient was ambulated on the first post-operative day and urinary catheter removed. The patient was given intravenous Diclofenac thrice daily for the first two days and required no supplemental analgesia. The patient was planned for early discharge.

Discussion

It is high time that we adopt the laparoscopic management of colo-rectal malignancy on a mainstream basis11. Operative innovation, standardization and improved equipment are big steps in the right direction. With advancing learning-curves12 reaching quality-curve levels, it should not be difficult for surgeons with large laparoscopic experience to attempt this technique and compare this experience with traditional approaches.

REFERENCES

1. Schwenk W et al. Systematic Reviews/ Meta-Analysis: Short term benefits for laparoscopic colorectal resection: Cochrane Database of Systematic Reviews 2005, Issue 2.

2. Nelson H et al. 5 – Year Outcomes of the Clinical Outcomes of Surgical Therapy Study Group (COST Trial): A Comparison of Laparoscopically Assisted and Open Colectomy for Colon Cancer: Annual meeting of the American Surgical Association 2007.

3. Guillou PJ et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet. 2005 May 14-20; 365(9472):1718-26.

4. The Colon cancer Laparoscopic or Open Resection Study Group (COLOR Trial): Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial; Lancet Oncol 2005; 6: 477–84.

5. Young-Fadok TM, Nelson H. Laparoscopic right colectomy: five-step procedure. Dis Colon Rectum 2000; 43:267–271; discussion 271–273.

6. Darzi A, Hill ADK, Henrey MM, et al. Laparoscopic assisted surgery of the colon. Operative technique. Endosc Surg 1993; 1:13–15.

7. Fujita J, Uyama I, Sugioka A, et al. Laparoscopic right hemicolectomy with radical lymph node dissection using the no-touch isolation technique for advanced colon cancer. Surg Today 2001; 31:93–96.

8. Allam M, Piskun G, Kothuru R, Fogler R. A three trocar midline approach to laparoscopic-assisted colectomy. J Laparoendoscopic Adv Surg Tech 1998; 8:151–155.

9. Senagore AJ, Delaney CP, Brady KM, Fazio VW. Standardized Approach to Laparoscopic Right Colectomy: Outcomes in 70 Consecutive Cases. J Am Coll Surg 2004; 199:675–679.

10. Palanivelu C, John SJ, Parathasarathi R. Initial Retrocolic Endoscopic Tunnel Approach: IRETA. - for Laparoscopic Right Colectomy in malignant disease: 13 Year Experience; Presented at ELSA 2006 as an Oral Presentation (Endoscopic and Laparoscopic Surgeons of Asia Congress at Seoul, South Korea, October 18th to 21st 2006).

11. K.M. Mohandas. Laparoscopy-assisted resection of colon and rectal cancer: Good evidence has arrived. Natl Med J Ind 2005; 18:144-145.

12. P.A. Paraskeva, O. Aziz, A. Darzi. Laparoscopic surgery for colon cancer. Surg Clin N Am 85 (2005) 49–60.