Retroileal anastomosis in hand-assisted laparoscopic left colectomy: experience at a single institution

Gaining Mesenteric Length following Colorectal Resection: Essential Maneuvers to Avoid Anastomotic Tension

A surgeon must possess the knowledge and technical skill to obtain length following a left-sided colorectal resection to perform a tension free anastomosis. The distal target organ - either rectum or anus - is fixed in location, and therefore requires surgeons to acquire mastery of proximal mobilization of the colonic conduit. Generally, splenic flexure mobilization (SFM) provides adequate length. Surgeons benefit from clearer understanding of the multiple steps involved in SFM as a result of improved visualization and demonstration of the relevant anatomy - adjacent organs and the attachments, embryologic planes, and mesenteric structures. Much may be attributed to laparoscopic and robotic platforms which provided improved exposure and as a result, development or refinement of novel approaches for SFM with potential advantages. Complete mobilization draws upon the sum or combination of the varied approaches to accomplish the goal. However, in the situation where extended resection is necessary or in the case of re-operative surgery sacrificing either more proximal or distal large intestine often occurs, the transverse colon or even the ascending colon represents the proximal conduit for anastomosis. This challenging situation requires familiarity with special maneuvers to achieve colorectal or coloanal anastomosis using these more proximal conduits. In such instances, operative techniques such as either ileal mesenteric window with retroileal anastomosis or de-rotation of the right colon (Deloyer's procedure) enable the intestinal surgeon to construct such anastomoses and thereby avoid stoma creation or loss of additional large intestine.

Central vascular ligation and mesentery based abdominal surgery

In the nineteenth century the idea of a correct surgical approach in oncologic surgery moved towards a good lymphadenectomy. In colon cancer the segment is removed with adjacent mesentery, in gastric cancer or pancreatic cancer a good oncologic resection is obtained with adequate lymphadenectomy. Many guidelines propose a minimal lymph node count that the surgeon must obtain. Therefore, it is essential to understand the adequate extent of lymphadenectomy to be performed in cancer surgery. In this review of the current literature, the focus is on "central vascular ligation", understood as radical lymphadenectomy in upper and lower gastrointestinal cancer, the evolution of this approach during the years and the improvement of laparoscopic techniques. For what concerns laparoscopic surgery, the main goal is to minimize post-operative trauma introducing the "less is more" concept whilst preserving attention for oncological outcomes. This review will demonstrate the importance of a scientifically based standardization of oncologic gastrointestinal surgery, especially in relation to the expansion of minimally invasive surgery and underlines the importance to further investigate through new randomized trials the role of extended lymphadenectomy in the new era of a multimodal approach, and most importantly, an era where minimally invasive techniques and the idea of "less is more" are becoming the standard thought for the surgical approach.

Retroileal colorectal anastomosis after left-sided or transverse colectomy for advanced serous carcinoma of the ovary or uterus

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In advanced or recurrent ovarian and uterine cancer, the ability to achieve optimal cytoreduction is a prognostic factor.

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Colonic resections are commonly required to achieve minimal or no residual disease.

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The retroileal technique can be used to achieve complete gross resection in cytoreductive surgery for gynecologic malignancy.

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Lack of postoperative complications and acceptable time interval to return of bowel function suggest this technique is safe.

The ability to achieve complete or optimal cytoreduction in advanced or recurrent ovarian and uterine cancer is a well-established prognostic factor. Colonic resections are commonly required to achieve minimal or no residual disease. When multiple colonic resections are required there is a corresponding difficulty in obtaining sufficient colonic mobility to create tension-free anastomoses for restoration of gastrointestinal continuity; specifically, when a left hemicolectomy or a transverse colectomy is required in addition to a rectosigmoid resection, it may be difficult to achieve a tension-free colorectal anastomosis. We describe the use of retroileal routing of the colon to address this scenario in the context of gynecologic cancer debulking surgery. We report four cases in which the surgeon encountered limited colonic mobility after performing either a left hemicolectomy or a transverse colonic resection in addition to a rectosigmoid resection. In using a retroileal path to perform the colorectal anastomosis, we were able to achieve well-perfused and tension-free anastomoses. Complete gross resection was achieved in all four cases, with acceptable rates of perioperative complications.

Novel technical modifications of hand-assisted laparoscopic dissection of a large obturator mass: A case report and literature review

Laparoscopic lateral pelvic tumor dissection (LLPTD) for transobturator tumors may be technically challenging due to the requirement for sufficient operative space. The present study discusses a technique modification with combination of the laparoscopic approach and hand-assisted (HA) open surgery for patients with large obturator masses. LLPTD was performed using the combined approach, defined as HA-LLPTD, with one case treated. According to this technique, a combined working space is constructed based on the outreached laparoscopic space and open extraperitoneal approach, followed by HA-LLPTD. Finally, a literature review was performed to retrospectively evaluate 17 cases of obturator tumors, in terms of tumor type and operative approach. The tumor in the present case was successfully and completely resected, without any obvious intra- and post-operative complications. Based on the literature review, the majority of the cases were benign (~75%) and originated from neurological tissue (~50%). The selection of the operative approach was either open or minimally invasive (50% each). HA-LLPTD allows experienced urological laparoscopic surgeons to safely and completely perform obturator surgery without obstruction of the obturator foramen or formation of intraperitoneal adhesions and associated complications. Therefore, HA-LLPTD may be more useful for transobturator tumor resection compared with the conventional intraperitoneal approach.

Colorectal anastomosis after laparoscopic extended left colectomy: techniques and outcome

AIM

After extended left colectomy, traditional colorectal anastomosis is often not feasible because of insufficient length of the remaining colon to perform a tension-free anastomosis. Total colectomy with ileorectal anastomosis could be an alternative but this can lead to unsatisfactory quality of life. Trans-mesenteric colorectal anastomosis or inverted right colonic transposition (the so-called Deloyers procedure) are two possible solutions for creating a tension-free colorectal anastomosis after extended left colectomy. Few studies have reported their results of these two techniques and mostly via laparotomy. The aim of this study was to describe the trans-mesenteric colorectal anastomosis and the inverted right colonic transposition procedure via a laparoscopic approach and report the outcome in a series of 13 consecutive patients.

METHOD

This was retrospective chart review of laparoscopic colorectal surgery with trans-mesenteric colorectal anastomosis or the inverted right colonic transposition procedure from January 2015 up to 2019. An accompanying video demonstrates these two techniques.

RESULTS

Thirteen consecutive patients underwent either a laparoscopic trans-mesenteric colorectal anastomosis (n = 9) or an inverted right colonic transposition procedure (n = 4). One patient had intra-operative presacral bleeding that was stopped successfully without conversion. Two patients had a postoperative intra-abdominal abscess, but no anastomotic complications were recorded. The median number of bowel movements per day after 6 months was 2 (range 2-5).

CONCLUSIONS

Trans-mesenteric colorectal anastomosis or the inverted right colonic transposition procedure is feasible laparoscopically. The now well-established classical advantages of the laparoscopic approach are associated with good functional outcome after these procedures.

The retro-ileal pull-through technique for colorectal and coloanal anastomosis

BACKGROUND

Performing a tension-free anastomosis following extensive left-sided colorectal resection can be challenging due to limited length. The retro-ileal pull-through approach, where the colon is carefully delivered to the pelvis through a mesenteric window made under the ileocolic vessels, is a technique to perform such an anastomosis.

METHODS

This series is a retrospective review of patients who underwent a colorectal or coloanal anastomosis using the retro-ileal pull-through approach. Patient demographics, operative reports, and short-term outcomes were reviewed.

RESULTS

Seven patients had a retro-ileal pull-through technique with colorectal or coloanal anastomosis. The cohort included 3 patients who had a Hartman's reversal, 3 who had a redo colorectal anastomosis and one in whom this technique was used in an acute setting for sigmoid colectomy for acute perforated diverticulitis with primary anastomosis. Successful implementation of the technique was achieved in all patients with good short-term outcomes.

CONCLUSIONS

In our cohort of patients, a retro-ileal pull-through technique was shown to be a successful approach to achieve a tension-free colorectal or coloanal anastomosis in various scenarios. This technique may prevent performing an ileorectal anastomosis or a permanent colostomy. We believe that this approach should be popularized among colorectal surgeons dealing with complicated colorectal operations.