03/09/2018

Prof. Lirici - Laparoscopy in the treatment of locally advanced gastrointestinal diseases

The role that laparoscopic surgery may play in the treatment of locally advanced gastroenteric diseases, which require en-bloc resection of two or more organs, is still controversial. Factors that make laparoscopic surgery challenging, and possibly contra-indicated, include: size of the organs, and then of the surgical specimen, to be removed, unclear anatomy, massive adhesions and, above all, the impossibility to accomplish a radical procedure, and carry on surgery, without injuring tissues during dissection, thus easing cancer seeding in case of malignancy. Nonetheless, in the last decade, more and more Authors reported multiorgan laparoscopic resections, mostly as single cases, or small series of patients, with synchronous diseases. An effective surgical technique, especially mandatory in case of locally advanced diseases, derives from a good knowledge of anatomy. Only the profound knowledge of surgical anatomy, gives surgeons the instruments to accomplish safe, embryologically based, and oncologically correct dissections, minimizing tissue trauma and bleeding. Laparoscopic surgery, that lacks direct tactile feel, requires an even higher grade of anatomical knowledge, to drive instruments along the correct planes, and trace structures. This is especially seen in those cases, where a locally advanced disease, makes difficult to dissect critical structures, without compromising tissues around them. Advanced colorectal diseases may infiltrate adjacent pelvic organs. In those cases, radical surgery entails the en-bloc removal of the sigmoid colon and rectum, with the compromised organs. This video is the first of two, showing the feasibility of laparoscopic surgery, in the treatment of locally advanced colorectal diseases: a recto-sigmoid resection was carried out, en-bloc with hemi-cystectomy, for a stenosing lesion of the recto-sigmoid junction, infiltrating the bladder wall. Surgery was accomplished with radical intent, for the high suspicion of a locally advanced malignant lesion. _____________________________________________________________________________ VIDEO 58 years old man with 1-year lasting symptoms of severe pain and stipsis and a rectosigmoid stenosis at 15 cm from the anal verge not passable by the colonoscope. CT scan showed a 10 cm stenosing mass in continuity with the sigmoid colon and rectum, infiltrating the bladder wall, and diverticular disease of the remaining sigmoid colon. CT scan shows the encasement of the left ureter. Endoscopic biopsies of the upper rectum at the level of the stenosis showed a moderate dysplasia. The patient, hospitalized on emergency for symptoms worsening and bowel obstruction, underwent surgery on the next day with high suspicion of a locally advanced malignant lesion. Adhesions between greater omentum and the sigmoid mass and the bladder are partially divided and the peritoneum overlying the bladder incised, accessing the Retzius space. The removal of the mass with adjacent organs is unlikely achievable without circumventing it. Thereafter, the sigmoid colon proximal to the mass is dissected on its lateral and medial aspect. The mesentery is easily scored along its medial aspect and the sigmoid mesentery is retracted away from the retroperitoneum. An infra-mesocolic window is created with such maneuvers, and the dissection is furthered posteriorly and downward reaching the avascular holy plane, thus completing the dissection of the posterior upper rectum and the mid rectum caudal to the mass. At this point the inferior mesenteric artery is dissected free through a sub-adventitial route and divided between clip. The descending mesocolon is opened at the level of descending colon transection and the bowel divided by endostapler. The division of the colonic mesentery is furthered cephalad from the point of colon transection reaching the inferior mesenteric vein which is dissected free and then divided between clips. At this point, the mass is freed from its attachment to the descending colon and the mesentery upstream of it. The left ureter is searched for and followed downward till the mass. Sharp dissection is carried on carefully and frozen section taken from tissue suspected for tumor infiltration. The ureter is encircled by tape and dissected free till the merging into the trigonus. The mid rectum downstream from the mass is now dissected free and stapled, thus freeing the mass and the sigmoid colon from the attachments to the lower rectum, but still fixed to the bladder. The bladder wall is incised all around the area of suspected ab-extrinsic infiltration. The appearance of the mucosa excludes a full-thickness bladder infiltration. The last attachments with the left ureter are then divided and a last frozen section taken excluding cancer infiltration. The specimen is withdrawn through a mini-laparotomy with abdominal wall protection. Double layer bladder closure is accomplished by deeper interrupted sutures and a running suture to close the overlying peritoneum. A double stapled colorectal anastomosis is carried out and a drain left on the pelvic cavity. Histology showed no malignancy but a fistulized sigmoid diverticulitis with two tracts to the rectum and the bladder and an intramural bladder chronic abscess. _____________________________________________________________________________ As we have seen, a correct technique, with dissection along the anatomical planes, allows surrounding the lesion, with a no-touch approach, accomplishing a safe and radical surgery, even through laparoscopy, with same results of open surgery, and improved postoperative quality of life.