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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.

Laparoscopic anterior resection of rectum

Laparoscopic anterior resection of rectum
D-r Puchkov D.K. (CMS) is performing an operation (2018).

In this video the technique of performing the anterior rectal resection for chronic diverticular disease of the sigmoid colon is presented. A 58 year-old female patient was treated, having the diagnosis: Diverticular disease of the sigmoid colon, relapsing diverticular without complications. Within the last 5 months a patient thrice was hospitalized for acute complications of diverticular disease. During preoperation investigation according to fibrocolonoscopy, had found multiple diverticula with the symptoms of inflammation in the sigmoid colon, and in rectum on the border of middle ampullar and upper ampullar parts and proximally thickening and rigidity of rectal wall had been found out. RCT of abdominal cavity had shown multiple diverticula in the sigmoid colon, some indirect symptoms of presence of “chronic” abscess in Douglas cul-de-sac.
“Classical” scheme of positioning of troacars had been used: in the right iliac area, the right and left mesogastric area. The operation was started from rectum, identification of interfascial layer with help of Harmonic scalpel (”Ethicon”) device. In case, if it is not possible clearly visualize the layer between Toldt’s fascia and fascia Gerotae distally to the inferior mesenteric artery, the layer could be visualized under the inferior mesenteric vein. Transection of the inferior mesenteric artery was done near at the origin with LigaSure instrument (“Medtronic”). The next stage was exposure of the inferior mesenteric vein, identification of embryologic layer of the large colon, we use from media-to-lateral direction towards splenic flexure. For safe mobilization of the splenic flexure of the colon was dissected in inframesocolic way. Preliminarily dissection of pancreas should be done, then opening of omentum sac, after that the abdomen of the left lateral canal was incised, then mobilization of the descending part of colon and of splenic flexure of the colon took place. Then exposure of rectum along the posterior wall with the identification of the left ureter took place. Exposure of rectum is up to the infiltrate level along the posterior wall, then – along the right and left half - curcumference, and only after at the end-along the anterior wall. Transection of the large colon in the distal part was done with EcheloFlex-60 (a blue cassette) device (“Ethicon”). Then minilaparotomy was performed (about 5 cm), a latex ring “Dextrus” was placed in the wound to restrict tissues of the anterior abdominal wall from the colon. The colon was exteriorized, resection of specimen was done, the head of CDH-29 device (“Ethicon”) was inserted into the proximal end, it was fixed by purse-string suture, “Vicryl” 2-0 thread was used, then, it was immersed into the abdominal cavity. CDH-29 device was introduced transanally, created an anastomosis. Operation was finished by draining the small pelvis. The duration of operation was 130 minutes.

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.

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