Oncology

Laparoscopic anterior resection with D3 - lymphadenectomy, preserving of the left colic artery, transvaginal specimen extraction (N.O.S.E.S. technique)

Laparoscopic anterior resection with D3 - lymphadenectomy, preserving of the left colic artery, transvaginal specimen extraction (N.O.S.E.S. technique)
Surgeon D.K. Puchkov (2020y.)

This film shows the technique of performing laparoscopic anterior resection with D3 - lymphadenectomy, preserving of the left colic artery, transvaginal specimen extraction (N.O.S.E.S. technique).

Patient B., 49 years old, was treated with the diagnosis: Cancer of the upper third part of the rectum fT2N2M0, G2. During the preoperative examination, according to MRI of the small pelvis in the rectum about 11 cm from the anal verge was found a formation 2 cm in diameter. According to CT-scans along the upper rectal artery, in the area of the origin of the inferior mesenteric artery were found a few enlarged lymph nodes.

A 10 mm trocar, endoscope were introduce above the umbilicum. In the right and left mesogastrium region 5 mm trocars were introduced; in the right iliac region a 10 mm trocar was introduced. Firstly, the patient was transferred to the Trendelenburg position. The tumor was not visually defined; intraoperative colonoscopy was performed to determine the border of the resection.

The parietal peritoneum was dissected along the IMA, medial-to-lateral mobilization was performed, the left ureter was visualized, then the IMA was mobilized, the superior rectal artery and the first sigmoid artery were selectively crossed with the 5mm LigaSure device. The left part of the colon was mobilised using a Harmonic scalpel (Ethicon).

The mobilisation of the rectum to the level of resection within the mesorectal fascia was performed.

A colpotomy was performed, a plastic sleeve was inserted into the abdominal cavity to prevent tumor contamination of the vagina. The colon was removed, the proximal resection border was visualised (the demarcation line), the specimen was cut off extracorporeally. The head of the CDH-29 device was inserted into the proximal part of the colon and fixed with a purse string suture (thread “Vicryl 2.0”), immersed in the abdominal cavity. The colpotomy opening was intracorporeally sutured. Leak control - no air intake.

The CDH-29 device was transanally introduced. The head was adapted with the device; the device was removed. The trocar wounds were sutured and the skin was trimmed with OmniStrip stripes. Operation time 145 minutes.

This film shows the technique of dissecting of the left parts of the colon, modified combined approach for splenic flexure mobilization for cancer of the descending colon.

This film shows the technique of dissecting of the left parts of the colon, modified combined approach for splenic flexure mobilization for cancer of the descending colon.
Surgeon D.K. Puchkov (2019y).

This film shows the technique of dissecting of the left parts of the colon, modified combined approach for splenic flexure mobilization for cancer of the descending colon.

Patient M., 62 years old, was treated with a diagnosis of cancer of the descending colon fT3N0M0, G2. During the preoperative examination, RCT of abdominal organs in the descending colon was found a volumetric formation ~ 4 cm in diameter, no enlarged lymph nodes in the abdominal cavity were detected.

A 10 mm trocar, camera were introduced in the umbilical area. In the mesogastrium, in the right and left iliac regions three 5 mm trocars were introduced. The tumor was located in the proximal third of the descending colon, mobile, dense, the serous layer was not involved.

The parietal peritoneum was dissected along the IMA, the IMA was mobilized at the origin of its bifurcation. IMA branches were skeletonized, the left colon artery was selectively cut with a 5mm Ligasure device, and then the IMV was transsected. The left parts of the colon were mobilized with the Harmonic device in medial-to-lateral (inframesocolic) approach in the interfascial layer with visualization of the pancreatic tail.

An entrance to the omental bursa was made through the mesentery of the transverse colon, the mesentery was separated from the pancreas to the splenic flexure. The peritoneum was dissected along the left lateral canal to the splenic flexure.

Dissection of the gastro-colon ligament was performed, the splenic flexure of the colon was mobilized. The operation stage time was 65 minutes.

Laparoscopic organ preserving resection of two pheochromocytes from a single left adrenal gland

Laparoscopic organ preserving resection of two pheochromocytes from a single left adrenal gland.

Professor Puchkov K.V. is performing an operation (2019).

Patient 24 years old, in the single left adrenal gland were found two tumors about 2 cm each in diameter, they located in the medial pedicle and in the body of the organ. At the age of 20, he was examined about hypertensive crises. In 2015, bilateral adrenal lesions were diagnosed: on the right a tumor - up to 5 cm, on the left side - 2 lesions: 1 and 1.5 cm. Right-sided adrenalectomy was performed, the histological conclusion was: malignant pheochromocytoma. The patient refused bilateral adrenalectomy. In the future, according to CT data, the growth of lesions of the left adrenal gland is noted. In the analyzes: daily urine metanephrins: maximum metanephrine 8.897 mg/day, normetanephrine 319.3 mg/day. In the preoperative period, he received «Cardura». A laparoscopic organ-sparing surgery was performed - removal of two formations with full preservation of the adrenal tissue. Access to the adrenal gland was done by mobilising the splenic angle of the colon and dissecting the tissue between the Tolds fascia and Herota fascia. The intersection of the vascular structures and adrenal tissue is performed by alternating ligation systems — 5 mm Thunderbeat Olympus instrument and 5 mm LigaSure MEDTRONIC COVIDIEN instrument. The operation is carried out quickly and bloodless. The tumor is cut off from the body of the adrenal gland and placed in a plastic container in which was removed from the abdominal cavity. For the hemostasis «Tachocombe» was used at the sites of tumor removal. The operation time was 40 minutes. Histology - pheochromocytoma of solid-alveolar structure with polymorphoncellular composition.

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

Laparoscopic resection of the kidney with ZERO ischemia

Laparoscopic resection of the kidney with ZERO ischemia
Professor Puchkov K.V. is performing an operation (2019).

Laparoscopic resection of the kidney with ZERO ischemia

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

Laparoscopic ischemic resection of the left kidney

Laparoscopic ischemic resection of the left kidney
Professor Puchkov K.V. is performing an operation (2019).

The film shows the technique of left-sided laparoscopic resection of the kidney in a malignant tumor (4 cm) located in the lower pole. Mobilization of the kidney and dissection of the renal artery and vein is performed using 5 mm instruments using the Thunderbeat (Olympus) and LigaSure system (MEDTRONIC COVIDIEN). A De Bekey vascular clamp (AESCULAP) is temporarily superimposed on the renal artery. Kidney resection is performed with a 5 mm Thunderbeat (Olympus) instrument within healthy tissue. Hemostasis in the area of the bed is carried out by the bipolar instrument of the Karl Storz Company. For the purpose of additional hemostasis, the wound is covered with a hemostatic plate Tachocomb (Austria). Next, the clamp is removed from the renal artery and blood flow is restored in the kidney. The time of thermal ischemia is 24 minutes. The tumor is immersed in a special plastic container MEDTRONIC COVIDIEN, which is removed through umbilical access. Operation time 1 hour 5 minutes.

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

Laparoscopic right-sided enucleation of adrenal tumor for pheochromocytoma

Laparoscopic right-sided enucleation of adrenal tumor for pheochromocytoma.

Professor Puchkov K.V. is performing an operation (2018).

Patient 53 years old was admitted to the hospital, it was found a 3 cm tumor of the right adrenal gland, located in the medial pedicle. The patient noted a history of hypertensive crises. A laparoscopic organ-sparing surgery was performed - right-sided enucleation of the tumor. Access to the adrenal gland was done by dissecting the tissue between the Tolds fascia and Herota fascia. The intersection of the vascular structures and adrenal tissue was performed by alternating the ligation systems — 5 mm Thunderbeat Olympus instrument and 5 mm LigaSure MEDTRONIC COVIDIEN instrument. The tumor was cut off from the body of the adrenal gland and placed in a plastic container in which was removed from the abdominal cavity. The operation time was 30 minutes.
The operation was carried out quickly and bloodless. Additional hemostasis was carried out by the PerClot system (Italy). At the end of the film, the removed specimen is shown - adrenal pheochromocytoma (3 cm).
Histology - adrenal pheochromocytoma.

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

Laparoscopic right hemicolectomy

Laparoscopic right hemicolectomy.
D-r Puchkov D.K. (CMS) is performing an operation (2018).

• In this video the technique of laparoscopic right hemicolectomy is presented. A 53 year-old female patient was operated with diagnosis: Cancer of the hepatic flexure of the colon fT3N0M0, G2. During preoperation investigation of the abdominal cavity according to RCT, was found extensive formation about 5.5 cm in diameter and multiple increased lymphatic nodes along the artery ileocolica, without symptoms of their metastatic lesion. The first stage of operation: a 10 mm troacar was placed above the umbilicus, 10 mm optic was introduced. Then a 5 mm troacar was introduced in epigastrium along the midline of abdomen under the guidance of optic, 5 mm troacars were introduced into the right and left iliac areas. During revision of the abdominal cavity where was not found any sings of metastases in liver. The tumour was found in the cecum, movable, firm, does not involve the serous layer. Increased lymphatic nodes of the first priority were visualized. Intraoperatively surgeons decided to perform a right hemicolectomy with the high ligating of artery and vein ileocolica. Artery and vein were visualized, skeletonized, transected near the area of its origin with 5 mm LigaSure (“Medtronic Covidien”) device. The right part of the large colon was mobilized from “downwards-to- upwards” within the boundaries of Toldt’s fascia with Harmonic (“Ethicon”) scalpel, the descending part of duodenum was visualized, the head of pancreas, infrapyloric lymphatic nodes are intact. The abdomen of the right lateral canal was transected, resection of gastrocolic ligament up to the level of middle one-third of the transverse colon was done. Mesentery of the colic colon was mobilized up to the level of middle one-third of the transverse colic colon. Mesentery of the iliac colon was transected at the distance of 15 cm proximally to Bauhin’s (ileocecal) valve. Middle minilaparotomy was performed. Latex ring “Dextrus” was placed into the wound to restrict tissues of the anterior abdominal wall from the colon with tumour, the colon is exteriorized into the wound, resection of the right parts of the colon and iliac colon was done. Bistapler ileotransversoanastomosis “side –by-side” was performed. Edges of anastomosis were additionally stitched by “Vicryl” 3-0 thread. The abdominal cavity was drained via troacar incision in the right iliac area. Minilaparotomic and troacar wounds were stitched layer by layer. Aceptic bandage was applied. Operation duration is 80 minutes.