腹腔镜下乙状结肠癌（图文演示）

10. Division/sigmoid

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Once it is freed, the sigmoid colon is divided, at least 5 cm below the tumor and 10 cm above the tumor. This rule is applicable for long, supple sigmoid colons. Otherwise, complete sigmoidectomy must be performed down to the colorectal junction, or even down to the upper portion of the rectum for lesions of the distal portion of the sigmoid colon.

• Distal division

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Division of the rectum or the colorectal junction is performed at least 5 cm below the tumor, removing all of the surrounding fat. Exclusion of the colon below the tumor, just above the staple line, is advised. Lavage of the rectal stump can then be performed before dividing it with the stapler.

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The freed distal portion of the sigmoid colon is excluded with either ligature, a clamp or a row of staples. The rectum is then washed with a saline solution or a solution with polyvinylpyrolidone iodine by introducing a cannula via the anal canal.

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Division is performed using a sharp suturing device to divide and staple without opening the digestive tract. The stapler is introduced through trocar C into the right iliac fossa. We prefer using staplers for thick tissues (green cartridges), which are applied perpendicular to the digestive tract. Staplers with adjustable angles can be useful.

• Proximal division

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Proximal division should be performed at least 10 cm above the tumor. It includes division of the mesocolon, followed by division of the colon. It is not necessary to exclude the colon, which will be subsequently divided.

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Division is performed with a high frequency hemostasis device, ultrasonic dissectors or linear staplers, removing the totality of the sigmoid mesocolon along with lymph nodes.

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A sharp suturing device is used to perform a clean division and stapling without opening the digestive tract.
The stapler (blue cartridges) is introduced through trocar C into the right iliac fossa.

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The sigmoid colon is isolated in a plastic airtight extraction bag introduced through trocar C. This permits continuation of the procedure without manipulating the tumor in the abdominal cavity. If the sigmoid colon is too bulky, extraction can be done immediately, before completing mobilization of the left colon.

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Preservation of the left colic artery:
Division of the IMA distal to the origin of the LCA preserves the vascular supply of the descending colon better and does not prevent it from being lowered. We use it more and more frequently, along with a lymphadenectomy to the origin of the IMA.
The IMV is divided distal to the pancreas, or even lower, resecting the surrounding tissues to remove the lymph nodes. The left colic veins are often divided to facilitate the descent of the left colon.

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In the event that a long segment of sigmoid colon is resected, mobilization of the left colon is necessary to allow for a tension-free colorectal anastomosis.
The left colon is freed by division of its posterior and lateral attachments. Occasionally, division of the left colic vessels is required for full mobilization of the left colon.
The vascular supply of the mobilized left colon should be preserved. This is often difficult to assess in laparoscopic surgery.
Mobilization of the splenic flexure is frequently required. This can be achieved in a number of different ways. It is important for the surgeon to be familiar with all these approaches in order to select the approach most suitable for each case.

12. Lateral mobilization

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1. Attachments of omentum to colon
2. Phrenicocolic ligament
3. Toldt’s line
4. Toldt’s fascia
This approach is conventional in open surgery. It is used in simple cases with an easily mobilized splenic flexure. It includes freeing of the lateral and posterior attachments.

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An ascending incision is made along the white line of Toldt using scissors introduced via trocar D.

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The phrenicocolic ligament is then divided using scissors introduced through trocar D. Retracting the colon and the splenic flexure toward the right iliac fossa using graspers introduced through trocars C and E helps in this exposure.

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Attachments are incised close to the colon until the omental bursa (lesser sac) is opened. Division of these attachments is pursued as needed toward the right, to facilitate lowering of the left transverse colon.

13. Medial mobilization

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Medial mobilization is perfectly suited to the laparoscopic approach as the surgeon, situated to the patient’s right, has an excellent view of the anterior surface of the pancreas and the base of the left transverse mesocolon.
It follows the medial posterior freeing of the sigmoid mesocolon, which then continues upward, anterior to Toldt’s fascia.

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The splenic flexure is freed on its posterior surface while remaining close to the left mesocolon. This avoids the risk of a dissection posterior to the pancreas with an attendant injury of the splenic vein. Division of the IMV just below the inferior border of the pancreas facilitates this operative step.

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On the anterior inferior border of the pancreas, the base of the transverse mesocolon is identified. This is divided caudad to cephalad and from right to left, opening the omental bursa (lesser sac). Anterior to the pancreatic tail, care must be taken not to injure the pancreas and small mesocolic vessels, which course through the left transverse mesocolon.

14. Extraction/sigmoid

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Extraction is performed through a mini-incision while protecting the abdominal wall. In cancer, the specimen is isolated and placed in an airtight plastic bag before extracting it.

• Incision

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The size of the incision, its location, and the extraction technique take into account the volume of the specimen, the patient’s body habitus, and cosmetic concerns.

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The incision should be adapted to the size of tissues to be extracted. Care must be taken not to crush the specimen during extraction.

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The incision is generally performed in the suprapubic region (1), more rarely in the right iliac fossa (2), but never in the left iliac fossa (3). The lowering of the colon in (1) or (2) allows evaluation of the possibilities of mobilization of the colon in the pelvis. If the mobilized colon reaches the extraction area in a tension-free manner, it may be safely assumed the anastomosis will be tension free as well.

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The wall should be protected to avoid bacterial and cellular contamination (risk of cancer cells). This protection is made up of a waterproof plastic-coated drape with a ring (7 or 11 mm in diameter).
The same plastic-coated protection is also used during intracorporeal anastomosis to ensure the airtightness of the abdominal cavity before its final closure.

• Extraction

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The extraction of the specimen is performed using an airtight plastic bag. In current practice, protection of the incision by a plastic-coated drape with a ring is added, to ensure that the abdominal cavity is airtight during the intracorporeal colorectal anastomosis, which follows the extraction.

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After introduction of the waterproof plastic-coated drape in the abdominal incision, the bag containing the resected sigmoid colon is withdrawn from the abdomen. The bag is then opened to extract the colon avoiding abdominal contamination.

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After placing the sigmoid colon in an airtight waterproof plastic-coated bag, the extraction is done directly through the abdominal opening.

15. Preparation/anastomosis

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The colorectal anastomosis is a delicate step. We always use a mechanical circular stapling device to transfix the rectal stump.
Performing the anastomosis includes an extra-abdominal preparatory step and an intra-abdominal step performed laparoscopically
The extra-abdominal step takes place after exteriorization of the left colon through the incision protected by the plastic-coated drape.

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If necessary, the colon is cut again in a healthy, supple and well-vascularized zone. The anvil (at least 28 mm in diameter) is then introduced into the colonic lumen and closed with a purse string. The left colon with the anvil is then reintroduced into the abdominal cavity.

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The closure ensures the airtightness of the abdominal cavity required to perform the anastomosis under laparoscopic guidance. The closure is achieved either by primary closure of the abdominal wall or by introducing a plastic-coated drape with an airtight ring. The second option is more attractive because it leaves the surgeon the possibility of exteriorizing the colon if necessary.

16. Anastomosis

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The intra-abdominal step is performed entirely under laparoscopic guidance after reinflation of the abdominal cavity. It includes transfixing the rectal stump and performing the colorectal anastomosis with a circular mechanical stapler.

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After ensuring that the abdominal cavity is airtight, the pneumoperitoneum is reestablished. The circular stapler is introduced into the rectum through the atraumatically dilated anus. The rectal stump is then transfixed with the tip of the head of the circular stapler.
To avoid ischemic risks, the stapler can be introduced in the middle or at one of the ends of the rectal stump staple line while avoiding leaving lateral ear-shaped flaps.
In women, the posterior vaginal wall should be retracted anteriorly.

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Once the anvil has been clicked onto the proximal part of the circular stapler, it is mandatory to ensure that the proximal part of the colon is not twisted. The stapler is then closed; the surgeon should check that no neighboring organs are incarcerated before stapling in accordance with the manufacturer’s recommendations.
The stapler is then loosened and withdrawn through the anus.

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Verification of the anastomosis is mandatory. This includes checking for the circular aspect of the amputated rectal and colon rings, optional air test and for some authors, endoscopic transanal evaluation of the anastomosis.

17. Conclusions
Laparoscopic sigmoid colon resection for cancer has been described in a standardized manner. It enables the surgeon to perform a reproducible oncological procedure (Köckerling et al., 1998). Its morbidity, the risk of recurrence on the trocar sites and risks of local recurrence do not seem higher than the results of conventional surgery (Franklin et al., 1996; Leung et al., 1996; Milsom et al., 1998).
Although no studies have demonstrated the usefulness of the guidelines which have often been quoted as references by some authors (Balli et al., 2000), and even though other authors (Wexner and Cohen, 1995) recommend using the safety guidelines of Scientific Societies which are not obtainable in an official form, it is wise to comply with certain rules and to agree to participate in controlled studies to perform this surgical technique.

The smooth performance of laparoscopic sigmoidectomy for early stage cancer depends on:
- the quality of the equipment;
- perfect knowledge of surgical anatomy;
- respecting the operative strategy (medial approach);
- the experience of the surgical team.
Surgeons learning the technique must do so with a skilled, experienced team. The ideal learning strategy is to start by reproducing the various steps of the procedure with an open approach but under the same conditions as those in laparoscopic surgery.

18. Reference
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