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Laparoscopic low anterior resection of rectum (partial TME-total mesorectal excision) with the use of a monopolar “hook” electrode

Laparoscopic low anterior resection of rectum (partial TME-total mesorectal excision) with the use of a monopolar “hook” electrode.
D-r Jim Khan is performing an operation (Great Britain, Portsmouth) (2018).

In this film the technique of performing low anterior resection of rectum (partial TME - total mesorectal excision) with the use of a monopolar “hook” electrode is presented. A 44 year-old male patient was treated, having the diagnosis: Cancer of middle third part of rectum fT2N0M0, G2. During the preoperation investigation of organs of abdominal cavity and small pelvis, using MRT and RCT, no data about pathologic lymphatic nodes in the abdominal cavity, small pelvis and mesorectum had been obtained. The “classical” scheme of positioning of trocars was used: on the right in the iliac area, to the right and to the left-in the mesogastric area. Operation started with the incision of peritoneum to the right of rectum, identification of interfascial layer without vessels with the help of a monopolar instrument “hook” (“Karl Storz”). Transection of the inferior mesenteric artery took place near the origin with Harmonic (“Ethicon”) device after preliminary clipping of it by titanic clips. Then exposure of rectum along its posterior wall took place with identification of the left ureter. The next stage was exposure of the inferior mesenteric vein, identification of embryological layer of the large colon, its exposure in the medialateral direction towards the splenic flexure. For safe mobilization of the splenic flexure of the colic colon inframesocolic access was used. Preliminary dissection of pancreas was done, opening of omentum sac, after that peritoneum of the left lateral canal was dissected, mobilization of the descending part of the colic colon and the splenic flexure of the colic colon was done. Exposure of rectum was done in 5 cm lower than lower border of tumour along the posterior wall, then-along the right and left semicircumference, and only at the end-along the anterior wall. Transection of the colon in its distal part was done EchelonFlex-60 instrument (a blue reload) (“Ethicon”). Then midline minilaparotomy (approx.5 cm) was performed, the latex ring “Dextrus” was placed in the wound for restriction the tissue of the anterior abdominal wall from the colon with tumour. The colon was exteriorized, resection of specimen was done, CDH-29 (”Ethicon”) device head was inserted into the proximal part, it was fixed by purse-string suture, using “Vicryl” 2-0 thread, and immersed into the abdominal cavity. CDH-29 device was inserted transanally, stitching was done, then CDH-29 was removed. The next stage loop ileostoma was created in the right iliac area. The operation was finished by placing drainage transabdominally via trocar wound in the left mesogastric area. Operation duration was 240 minutes.

Laparoscopic abdominal perineal resection (APR) of rectum, using a monopolar hook

Laparoscopic abdominal perineal resection (APR) of rectum, using a monopolar hook
Professor Puchkov K.V. is performing an operation (2018).

In this film the technique of performing of abdominal perineal resection (APR) of rectum with the expanded lymphadenectomy, using a monopolar “hook” electrode is presented. A 59 year-old female patient was treated with the diagnosis: Low rectal cancer fT3N1M0, G1. She had a course of neoadjuvant chemotherapy (CLT) with preoperative radiotherapy.
Exposure of rectum had done within the injuring of mesorectal fascia, with preserving the structures of upper and lower hypogastral plexus (sympatic and parasympatic nerves) laparoscopically. The “classical” positioning of trocars had been used: in the right and left iliac area, and in the mesogastric area to the left. The operation was started with dissection of pelvic in the right side of rectum, then exposure of rectum along the posterior wall with identification of the left ureter. Lymphodissection was performed in the area of origin of the inferior mesenteric artery, transection of superior rectal artery (with preserving of the left colic artery) was done with a 5 mm “LigaSure” («MEDTRONIC COVIDIEN») instrument. The next stage was dissection of the left lateral canal and mobilization of the descending part of the colic colon. Exposure of rectum up to pelvic floor along the posterior semicircumference took place within the injuring of the mesorectal fascia, then along the right and left semicircumference, and only at the end-along the anterior wall. Transection of the large colon in its proximal part had performed with EndoGIA-60 (a blue reload) device («MEDTRONIC COVIDIEN»).
The perineal stage had done in a classical approach. Stoma was created in the left iliac area. The drainage was placed via perineal wound. Operation duration was about 150 minutes.

You can read about this technique in detail on the personal cite of Professor Puchkov Konstantin Viktorovich. To go to the link.

Anterior resection of rectum with the expanded D4 lymphadenectomy

Anterior resection of rectum with the expanded D4 lymphadenectomy
D-r Puchkov D.K. (CMS) is performing an operation (2017).

In this film the technique of performing the anterior resection of rectum with the expanded D4 lymphadenectomy is demonstrated. A 51 year-old female patient was treated, having the diagnosis: Cancer of upper third of rectum f T3N2M0, G2. During preoperation investigation of abdominal cavity organs by RCT multiple increased (up to 1.5-2 cm) lymphatic nodes along the inferior mesenteric artery, aorta, in the area of aorta bifurcation have been found out-mass of lymphatic nodes with the diameter up to 4 cm. The “classical” scheme of positioning of trocars had been used: to the right of the iliac area, and in the mesogastric area –to the left and right. The operation was started with aortocaval lymphadenectomy by a 5 mm Harmonic Scalpel instrument (“Ethicon”). Transection of the inferior mesenteric artery took place at the origin with LigaSure device («Medtronic Covidien»). Then dissection of peritoneum took place to the right of rectum, exposure of rectum along the posterior wall with the identification of the left ureter. The next stage was exposure of the inferior mesenteric vein, identification of embryologic layer of the large colon, its exposure in medialateral direction towards the splenic flexure. Then peritoneum of the left lateral canal was dissected, and mobilization of descending part of the colic colon took places. Exposure of rectum was done in 5 cm lower than the distal border of tumour along the posterior wall and then along the right and left semicircumference and only at the end-along the anterior wall. Transection of the large colon in its distal part was done with the EchelonFlex-60 (a blue reload) device (“Ethicon”). Then midline minilaparotomy was performed (approx. 5 cm), the latex ring “Dextrus” was placed into the wound to restrict tissues of the anterior abdominal wall from the colon with tumour. Colon was exteriorized, resection of specimen was done, CDH-29 device head (“Ethicon”) was inserted into the proximal end, it was fixed by purse-string suture, using ‘Vicryl” 2-0 thread and immersed into the abdominal cavity. CDH-29 device was inserted transanally, stitching was done. The operation was finished by placing drainage transabdominally via trocar wound in the right iliac area. Operation time was 140 minutes.

Laparoscopic obstructive anterior resection of rectum with the formation of temporary terminal sigmostoma with the further reconstructive-restorative operation with formation of colorectal anastomosis

Laparoscopic obstructive anterior resection of rectum with the formation of temporary terminal sigmostoma with the further reconstructive-restorative operation with formation of colorectal anastomosis
Professor Puchkov K.V. is performing an operation (2016).

A 65 year-old female patient was treated, having the diagnosis: Cancer of the upper third of rectum fT4N0M0. She was admitted to hospital with subcompensated tumourous stenosis of the large colon, microcytic hypochromic anemia (Hb-79g/L), tumourous intoxication, cachexia. During preoperation investigation of abdominal cavity organs due to RCT the single increased up to 1.0 cm lymphatic node along the superior rectal artery has been found out. The “classical” scheme of positioning of trocars was used: in the right and left iliac area, and to the left in the mesogastric area. The operation was started with dissection of peritoneum to the right of rectum, exposure of rectum along the posterior wall with the identification of the left ureter. Transection of the inferior mesenteric artery was done near the origin with applying two titanic clips. The next stage was dissection of peritoneum of the left lateral canal and mobilization of the descending part of the colon. Exposure of rectum was done in 5 cm lower than distal border of tumour along the posterior wall, then along the right and left semicircumference, and only then-along the anterior wall. Transection of the large colon in its distal part was done with EndoGIA-45 (green and blue reload) device («MEDTRONIC COVIDIEN»). Removal of specimen was done by performing a minilaparotomy. In the left mesogastric area sigmostoma was created. The operation was finished by placing drainage transabdominally via a trocar wound in the right iliac area. Operation time was 115 minutes. After a radical operation, a specimen was sent for histological investigation. Histological conclusion was: highly and moderately differentiated adenocarcinoma of rectum with invasion to the muscle layer of the large colon (without invading to the serous membrane), with invasion to the muscle layer of the loop of the sigmoid colon (without invading to the mucous membrane). In lymphatic nodes, there were no symptoms of tumour growth. Molecular-genetic investigations (NRAS, BRAF, KRAS): the symptoms of mutations had not been found out. A chemotherapeutic specialist had consulted her and recommended to have adjuvant polychemotherapy according to XELOX scheme (oxalaplatin+xelode). The patient had 8 courses of chemotherapy.
In 10 months after resection of the primary tumour reconstructive-restorative operation was performed for restoration of intestinal continuity with the formation of colorectal anastomosis, creation of temporary ileostoma. The “classical” scheme of positioning of trocars was used: in the right and left iliac area, and to the left of mesogastric area. The operation was started with stitching stoma on the anterior abdominal wall, exposure out of tissues of the anterior abdominal wall. CEEA-29 («Medtronic-Covidien») device head was inserted into the proximal part and fixed by purse-string suture, using “Vicryl” 2-0 thread, was immersed into the abdominal cavity. Then adhesyolisis was performed; exposure of descending colon along the left lateral canal with 5 mm LigaSure («Medtronic-Covidien») device took place. The mandatory condition of successful performing an operation by laparoscopic approach is separation of all possible adhesions between colon and surrounding tissues, dissection of abdomen along the posterior
semicircumference with the identification of the left ureter. After handling of the proximal part of the colon the stump of rectum was exposed with a monopolar “hook” electrode. CEEA-29 device was introduced transanally, adjustment of the head and apparatus was done, then stitching and removal of the device. At the end of operation single interrupted suture was placed between the proximal and distal parts of anastomosis. Operation was finished by placing drainage transabdominally through a trocar wound in the right iliac area, creation a temporary loop ileostoma in the right iliac area. Operation time was 120 minutes. In 3 months a new operation was performed for intraabdominal closure of ileostoma.

You can read about this technique in detail on the personal cite of Professor Puchkov Konstantin Viktorovich. To go to the link.

Laparoscopic anterior resection of rectum with aortocaval lymphadenectomy

Laparoscopic anterior resection of rectum with aortocaval lymphadenectomy
Professor Puchkov K.V. is performing an operation (2015).

A 59 year-old female patient was treated, having the diagnosis: Cancer of the upper third part of rectum fT3N1M0, G2. During preoperation investigation of abdominal cavity due to RCT, multiple increased up to 1.5-2 cm lymphatic nodes along the inferior mesenteric artery, aorta until the area of aorta bifurcation have been found out. The “classical” scheme of positioning of trocars was used: in the right and left iliac area and to the left of mesogastric area. The operation was started with performing an aortocaval lymphadenectomy with a 5 mm Harmonic Scalpel instrument (“Ethicon”). Transection of the inferior mesenteric artery was at the origin with applying two titanic clips. Then dissection of peritoneum to the right of rectum was done, exposure of rectum along the posterior wall with the identification of the left ureter. The next stage was dissection of peritoneum of the left lateral canal and mobilization of the descending part of the colic colon. Exposure of rectum was done in 5 cm lower from the distal border of the tumour along the posterior wall and then along the right and left semicircumference, and only at the end-along the anterior wall. Transection of the large colon in its distal part was done with Endo GIA-45 (a violet reload) device («MEDTRONIC COVIDIEN»). Extraction of specimen was done via minilaparotomy. At the end of operation, continuous suture was placed between peritoneum and the proximal part of rectum, higher then anastomosis level. Operation time was 120 minutes.

You can read about this technique in detail on the personal cite of Professor Puchkov Konstantin Viktorovich. To go to the link.

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