Resection of the colon

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.

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.

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 radical hysterectomy with aortoileac and pelvic lymphadenectomy (operation according to Wertheim) with the resection of rectum

Laparoscopic radical hysterectomy with aortoileac and pelvic lymphadenectomy (operation according to Wertheim) with the resection of rectum.
Professor Puchkov K.V. is performing an operation (2017).

The patient was 48 years old, had retrocervical infiltrating endometriosis, invading to the uterine cervix, sacroiliac ligament on the left side, vaginal wall and rectum, with the development of moderately differentiated adenocarcinoma of an endometrioid type with the focus of planocellular metaplasia of fornix of vagina, invading to the cervix and vaginal wall (in rectum the tumor had not been found out). In this video the technique of radical hysterectomy with aortoileac and pelvic lymphadenectomy with transsection of sacrouterine and cardinal ligaments near the pelvic wall and removal of the upper one-third of vagina is demonstrated. Hysterectomy was performed with the help of a 5 mm LigaSure («MEDTRONIC-COVIDIEN») instrument. When performing aortoileac and pelvic lymphadenectomy, the technique of removing of nodes simultaneously by a 5 mm ultrasonic dissector, called Harmonic Scalpel, produced by Ethicon Company, was demonstrated. The use of ultrasound gives a possibility “to weld” thin lymphatic ducts, it is a kind of prophylaxis to prevent development of lymphatic cysts. This technique of operation gives a possibility not to use the drainage system. Lymphatic nodes were placed in separate plastic bags and were removed from the abdominal cavity alongside with the uterus. The author had shown a safe technique of exposure of tumorous infiltrate and exposure of ureter until the area where it confluences into the urinary bladder by means of a 5 mm thin hook. The zone of rectum exposure was 2/3 of its circumference, then the edge resection of colon was performed with using of a 45 mm EndoGIA («MEDTRONIC COVIDIEN») intestinal reloads, leaving the affected area in the tumorous infiltrate. Vagina was exposed as low as possible in the caudal direction and was transected at the distance of 4 cm from the cervix within the limits of healthy tissues (1/3 of it was removed). In this video a special attention is paid to the restorative stage-stitching of vagina, that was done by the interrupted suture, using “Monocril” thread. The operation time was 2 hours 50 minutes.

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

Laparoscopic appendectomy in case of endometriosis of the vermiform appendix.

Laparoscopic appendectomy in case of endometriosis of the vermiform appendix..
The operation is performed by Professor Puchkov K.V. (2017).

The patient is operated on for endometriosis of appendix. Resection of rectum is performed for retrocervical endometriosis. In this video the technique of dissection of mesentery of vermiform appendix by means of a 5 mm Liga Sure MEDTRONIC COVIDIEN instrument and by instruments, produced by Karl Storz Company, is presented. Then suturing of its base is done, and it is stitched by a linear stitching MEDTRONIC COVIDIEN apparatus. The apparatus is removed from the abdominal cavity, using a 12 mm troacar. The duration of this stage of appendectomy is 6 minutes.

Laparoscopic disc-shaped resection of rectum with using of a linear stitching device

Laparoscopic disc-shaped resection of rectum with using of a linear stitching device
Professor Puchkov K/V. is performing an operation (2017).

A patient haв infiltrative endometriosis, invading to the anterior wall of rectum without deformation of lumen. In this situation “shaving “ was not efficient. In this film the technique of exposure of endometriosis infiltrate out of surrounding tissues by a 5 mm LigaSure instrument («MEDTRONIC COVIDIEN») was demonstrated. Endometriosis infiltrate was stitched by thread that was used as a “holder”. An affected part of colon was resected by a linear endoscopic stitching device («MEDTRONIC COVIDIEN») in the transverse direction. Duration of this stage was 16 minutes.

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

Laparoscopic disc-shaped resection of the rectal wall by means of the circular stitching apparatus

Laparoscopic disc-shaped resection of the rectal wall by means of the circular stitching apparatus.
Professor Puchkov K.V. is performing an operation (2017).

The patient had infiltrating endometriosis, invading to the anterior wall of the rectum without deformation of the lumen. In this situation “shaving” is not efficient. In this video the technique of exposure of endometriosis infiltrate from the surrounding tissue is presented, using a 5 mm monopolar electrode and LigaSure («MEDTRONIC COVIDIEN») instrument. At the first stage the endometriosis infiltrate was dissected as much as possible up to the submucous layer (in order to decrease the volume of the affected tissue), and the affected area is immersed with the help of the thread between the edges of a 31 mm circular stitching («MEDTRONIC COVIDIEN») device, that was inserted in the lumen of rectum. The affected area of rectum was resected with a stitching device in the transverse direction – it is one/third of its circumference. The duration of this stage aws 36 minutes.

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