Laparoscopic left hemicolectomy of descending colon carcinoma with superior rectal artery （SRA）preservation and natural orifice specimen extraction （NOSE）:a standard operation procedure----with a video

doi:10.21203/rs.3.rs-1843451/v1

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Laparoscopic left hemicolectomy of descending colon carcinoma with superior rectal artery （SRA）preservation and natural orifice specimen extraction （NOSE）:a standard operation procedure----with a video

https://doi.org/10.21203/rs.3.rs-1843451/v1

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Background: Laparoscopic-assisted radical resection of colorectal cancer and Natural orifice specimen extraction surgery（NOSES）are widely used around the world. However, due to the low incidence of descending colon cancer, there are still some problems in the application of laparoscopic and NOSES techniques in left hemicolectomy, such as surgical route, blood vessel preservation, dissociation of splenic flexure, specimen pulling out, and intracorporeal anastomosis. Herein, we introduce the technical procedure of laparoscopic left hemicolectomy with Superior rectal artery （SRA）preservation and NOSE.

Methods: A retrospective analysis was performed on 39 patients who underwent laparoscopic left hemicolectomy with SRA preservation and NOSE in the Gastrointestinal Surgery Center of Sichuan Cancer Hospital from November 2017 to May 2021. General information about the patients, preoperative data and short-term postoperative results were analyzed.

Results: All operations were completed smoothly, with an average operation duration of 227.17 ± 65.51 min , intraoperative bleeding of 91.05 ± 66.71 ml, first time off bed of 11.97±2.15 h, first time to anus exhaust of 20.20 ± 10.08 h, first time to liquid diet of 2.48±0.72 days,and average postoperative stay of 7.66 ± 1.89 days. Two patients developed temporary intestinal obstruction, and one patient developed pulmonary infection. One patient developed chyle fistulay.One patient developed intestinal infection. All of them recovered well after active supportive treatment, and were discharged successfully.

Conclusion:Laparoscopic left hemicolectomy with SRA preservation and NOSE is safe and feasible, with satisfactory short-term results, and is worthy of further clinical investigation.

Laparoscopic left hemicolectomy

Descending colon

Natural orifice specimen extraction (NOSE)

Superior rectal artery

Globally, colorectal cancer is the third most common malignancy and the second most common malignancy cause of death. According to the GLOBOCAN project of the WHO Cancer Research Center, the number of new cases of colorectal cancer worldwide in 2020 will be approximately 1.93 million, and the number of deaths will be approximately 940,000[1].Colorectal cancer is closely related to the level of socioeconomic development. The prevalence of Western lifestyles, changes in dietary patterns and reduction in physical activity have led to its continuous rise in the world[2].The main treatment for colorectal cancer is still surgery-based comprehensive treatment. Since the 1990s, with the standardized application of total mesocolic excision (TME), complete mesocolic excision (CME) and D3 lymph node dissection, the survival rate of colorectal cancer has increased significantly[3]. Since the 21st century, laparoscopic technology has gradually developed. In the past 30 years, with the rapid development of laparoscopic technology and instruments, based on the principles of the CME,TME principles and D3 radical tumor resection, laparoscopic-assisted radical resection of colorectal cancer is characterized by its minimal trauma, It has the advantages of light pain and fast recovery, and is widely used around the world based on high-level clinical evidence[4–6].

Traditional minimally invasive surgery assisted by laparoscopy requires a abdominal-assisted small incision to remove specimens, which increases the incidence of incision infection, incisional hernia, and postoperative pain [7–10]. However, NOSES has obvious advantages in postoperative pain control, bowel function recovery, postoperative hospital stay, incision complications and cosmetic results because it does not require additional abdominal incisions[11–12].

Currently, it has been well used in laparoscopic radical resection of rectal cancer, and achieved good results. However, due to the low incidence of descending colon cancer, there are still some problems in the application of laparoscopic and NOSES techniques in left hemicolectomy, such as the surgical route, blood vessel preservation, dissociation of the splenic flexure, how to remove the specimen, and intraluminal anastomosis. Therefore, we shared this standard surgical procedure with you based on our single-center experience.

1 General materials

The clinical data of patients who underwent laparoscopic left hemicolectomy of descending colon cancer NOSES with SRA preserved in the gastrointestinal surgery of Sichuan Cancer Hospital from November 2017 to May 2021 were collected retrospectively. There were 39 patients in this group, including 20 males and 19 females; The average age was 59.97 ± 12.79 years, the average body mass index(BMI) was 22.59 ± 2.64 kg / m2, the average preoperative CEA level was 2.73 ± 1.83 ng / ml, the diameter of the tumor was 3.52 ± 1.02 cm; There were 14 patients of AJCC stage I,20 patients of AJCC stage II and 5 patients of AJCC stage III. All patients were confirmed to have adenocarcinoma by pathological biopsy before the operation.

2 Surgical technique

The laparoscopic left hemicolectomy with the SRA preservation and NOSE Follows the principles of D3 dissection, CME.The pulling out method of surgical specimens is to select transanal specimen extraction(TASE) for descending colon cancer. The intracorporeal end-to-end anastomosis was completed with a circular stapler.

2.1 Body position and trocar position

The patient took the lithotomy position with left side elevated slightly to facilitate the free operation of the root of the inferior mesenteric artery (IMA). The pneumoperitoneum and operation channel were established by the five-hole method that has been shown in Fig 1.

2.2 Operation of IMA root( D3 lymph nodes dissection）

The mesosigmoid was elevated in order to expose the Toldt's space.The mesentery was opened at the root of the sigmoid colon through an intermediate approach, and the left Toldt's space was entered. The approach to the IMA root is performed not too close to the root but from the head side of the IMA root to the bare area of the nerve in front of the abdominal aorta to better protect the superior hypogastric plexus (SHP) and more completely clean the lymph nodes of the blood vessel root.

2.3 Superior rectal artery preservation

The key to the anatomical dissociation of the left colonic artery (LCA),sigmoid artery(SA) and SRA was to open the vascular sheath at the root of the IMA, sharply separate along the vascular sheath to the caudal side, and expose the LCA, SA and SRA. At the same time, the fat and lymphoid tissue around the artery were cleaned. Then we could clearly see the branches of the IMA.The LCA and SA was ligated at the root of each branch with the SRA preservation(Fig. 2）.

2.4 Dissection of mesorectum ( CME procedure)

According to the principle of CME, sharp dissection was performed to dissociate the descending colon.we dissociated the descending mesocolon along the medial side of the inferior mesenteric vein(IMV),and continuously to the lateral side until we saw the Monk’s line. The IMV was ligated at the inferior pancreatic edge, and dissection of the fascia was performed along this edge to the splenic flexure.Then we changed the position to head high and feet low,and began to dissociate the splenic flexure.The first step was to open the gastrocolic ligament along the gastroepiploic vessels, dissection was extended to the splenic flexure,and then disconnected the splenocolic ligament.The second step was to disconnect the root of the left transverse mesocolon along the lower edge of the pancreas, dissection was extended to diaphragmatic colonic ligament,and then the splenic flexure wsa fully mobilized. After dissection of the lateral fascia of the descending colon,Completed dissociation of left hemicolon. (Fig. 3）

2.5 Specimen extraction(NOSE)

TASE for descending cancer, the following steps were performed: (1)the mesocolon was dissected towards approximately 10 cm proximal and distal to the tumor, and dissected the the proximal and distal colon with endoscopic liner staplers.(2)under the protection the broken end of sigmoid colon with Iodophor gauze, the sigmoid colon was opened. Then a plastic bag was placed in the intestinal tube to avoid tumor implantation and intracorporeal contamination with bacteria.(3) a gastric tube was inserted from the anus,and the specimen was sutured on the gastric tube and removed transanal.(4)after the plastic bag was removed, the anvil head was put into the abdominal cavity,then the sigmoid colon was closed with a linear stapler.(Fig. 4）

2.6 Digestive tract reconstruction

When the proximal of colon was closed, the manually purse string suture was processed.Then the closed end was removed , the intestinal cavity was opened, and the anvil head was placed. Under the direct observation, the end-to-end anastomosis was completed with a circular stapler.We did reinforced suture with absorbable strings, and the retroperitoneum was closed (Fig. 5)

The average operation time was 227.17 ± 65.51 min, and the intraoperative bleeding was 91.05 ± 66.71 ml. The average time to dissect the IMA and preserve the SRA was14.58 ± 2.29min.The average time to release the splenic flexure was 21.87 ± 3.20min .Intracorporeal anastomosis time was 10.84 ± 3.20min. Dissected lymph nodes were 16.41 ± 5.57.The first time of getting out of bed was after 12.42 ± 3.56h, anal exhaust was after 20.20 ± 10.08 h, and the time of fluid inflow was after 2.86 ± 1.12 d.The average postoperative discharge time was 7.66 ± 1.89 d. One patient developed pulmonary infection after the operation. The patient was complicated with COPD before the operation and improved after anti-infection treatment. A patient developed chyle fistula after the operation, which was cured after conservative treatment such as fasting. One patient developed intestinal infection, which was cured after anti-infection treatment. Two patients had transient intestinal obstruction, which were relieved after 3–5 days of conservative treatment. No anastomotic leakage or pelvic abscess occurred in this group.

Laparoscopic technology has been widely used in colorectal surgery, but there are still some difficulties in laparoscopic left hemicolectomy, lack of standard surgical procedures, and it is even more difficult to add NOSES technology to laparoscopic technology, such as the dissection of root blood vessels, the preservation of SRA, how to more easily dissociate the colon and splenic flexure, how to remove the specimen, and intracorporeal anastomosis.

The preservation of SRA is a bit like the dissociation of the Henle's Gastrocolic Trunk in the right hemicolectomy. We often do not do ligation at the root, which will bring more trouble to us. Why? If the root is ligated, you need to dissociate each branch again, because the superior rectal artery is not the scope of the lymph nodes to be cleaned and needs to be preserved, and the SA and LCA need to be cleaned and severed. Therefore, the IMA is not severed, which can maintain the vascular tension, make it easier to perform vascular dissection, and make the operation simpler. Another study has shown that preserving the SRA can ensure better blood supply to the anastomotic stoma, thereby reducing the occurrence of postoperative anastomotic leakage[13]. Of course, this is controversial. However, our clinical experience suggests that the preservation of the main blood vessels, for the second operation of recurrent colorectal cancer, the blood supply of the bowel is a good guarantee, avoiding excessive and large-area resection of the bowel. Of course, from a technical point of view, this method is also very easy to operate and master.In this group of patients,the average time to dissect the IMA and preserve the SRA was14.58 ± 2.29min.

For the dissociation of the splenic flexure, such as the lateral approach, the medial approach, and the cephalic omental sac approach,we were often confused. The dissociation process of the the splenic flexure needs to be re-understood first. The anatomy of the splenic flexure of the colon clearly recognizes two anatomical structures: the splenocolic ligament and the phrenocolic ligament[14]. The phrenocolic ligament is actually the continuation of the left greater omentum to the spleen and the splenic flexure, and forms the greater omentum bridge between the colon and the spleen, which is the first layer covering the splenic flexure. The second layer is the continuation of the retroperitoneum from the diaphragm to the splenic flexure and covers the transverse colon and splenic flexure, and it also covers the retroperitoneal organs such as the pancreas. Based on this anatomical feature, we used the intermediate approach combined with the omental sac approach to dissociate the splenic flexure of colon. First, the intermediate approach was used to dissociate cephalad to the lower edge of the pancreas, and then dissociate laterally until the projection of the spleen could be seen. Then, open the gastrocolic ligament and enter the omental sac. The first step is to cut off the splenocolic ligament to expose the phrenocolic ligament and the root of the transverse mesocolon. In this way, the splenic flexure of colon was easily dissociated. In this group of patients, no spleen injury occurred and the the dissociation of the splenic flexure not exceeded 20 min.

At present, NOSES surgery has become a better choice for laparoscopic colorectal surgery because it does not require additional abdominal incisions, and brings less postoperative pain, faster postoperative recovery and aesthetic effects to patients[15]. The application of rectal cancer is widely performed, the low rectal specimen can be everted, and the high rectal specimen and sigmoid colon can be excised and pulled out. At present, the surgical method has been widely accepted by doctors, but in the left colon, due to its longer specimen and more mesangium, it was often difficult to pull out the specimen through the anus.Some surgeons choose transvaginal specimen extraction, but it will also cause additional vaginal damage, and this method is limited to female patients [16]. For this reason, we introduce a simple method for left-colon specimen extraction, of course, we will also choose the patient's BMI and the diameter of the tumor.

When we removed the specimen of the left colon, there were problems such as more mesentery and longer bowel, it was hard to pull out. The method that we solved the problem was to use a gastric tube as traction, we putted the gastric tube into the abdominal cavity transrectum, and then the gastric tube and the specimen were sutured, the specimen was pulled out of the body transrectum. The whole process followed the principle of aseptic and tumor-free. None of the patients we reported happened abdominal and pelvic infection. Based on some special tumor-free procedures under NOSES, Karagul reported no tumor recurrence at the extraction site in 21.1 months[17], our technique had been described in detail and demonstrated in the surgery video.

Intracorporeal anastomosis is necessary for NOSE surgery. Compared with traditional extracorporeal anastomosis, intracorporeal anastomosis has the advantages of less trauma and faster recovery. There were many descriptions of the intracorporea anastomosis methods, such as triangular anastomosis, delta anastomosis, and reverse puncture anastomosis[18,19]. To date, there was no standard method for intracorporeal anastomosis. However, in these anastomotic methods,such as triangular anastomosis, delta anastomosis, more staples were required, and there was a dangerous triangle (postoperative anastomotic bleeding, anastomotic leakage), and the operation procedure was complicated. And longer intestinal segments were required. The author performed end-to-end transverse colon-sigmoid colon (rectal) anastomosis, which was more in line with the structural characteristics of the patient in anatomy and physiology, and the risk of anastomotic leakage and anastomotic bleeding after surgery was rare. Planellas’ research showed that end-to-end anastomosis has lower complications and better recovery of bowel function[20]. In this group of patients, no one had anastomotic leakage, anastomotic bleeding and anastomotic stenosis. Compared with delta anastomosis by Zhou and reverse puncture anastomosis by Xu,our end-to-end anastomosis did not significantly prolong the operation time.

Another serious complication after laparoscopic left hemicolectomy is that patients will have transient or intestinal obstruction requiring reoperation. Studies have shown that in laparoscopic colorectal surgery, the proportion of postoperative small intestinal hernia was 0.65%, but most cases were in the left colon surgery, accounting for 64.3%[21]. Because the small bowel mesenteric root is in the retroperitoneum ,it is distributed from upper left to lower right, so the internal hernia is especially prone to occur in the left colon once the retroperitoneum was unclosed. Therefore closing the peritoneum was the last important step in our operation. In our consecutive patients, no internal hernia occurred.

Patient’s safety and benefit are the driving force behind our continued development in colorectal surgery. Laparoscopic left hemicolectomy (NOSES) with preservation of the SRA is very safe and effective,and the standard procedure is worth promoting. Of course, its long-term effect needs further observation.

Acknowledgements

The publication of this article was funded by the Health Department of Sichuan Province.

Funding

The processing fees for publication of this article were funded by the Health Department of Sichuan Province (Award Number: 19PJ145). The funding body does not played any roles in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript, and there is no conflict of interest.

Authors’ contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis, surgery were performed by Zhang Ke. Data analysis, video editing and critical revision of manuscript were performed by Deng Zijian, Rui Yuanyi,andYibo.The surgery and critical revision of the manuscript were performed by Hu Hai and Yan Jin.Study concept and design, data analysis, and writing and revision of the manuscript were performed by Zheng Yangchun . All authors read and approved the final manuscript.

Data availability Data is available on request from the corresponding author.

Ethics approval This study was approved by the Ethics Committee of Sichuan Cancer Hospital (approval number:SCCHEC-03-2018-008)). An informed consent form was obtained from all patients.

Consent to participate Informed consent was obtained from all participants included in the study.

Consent for publication Patients signed informed consent regarding publishing their data. All authors have provided consent for the article to be published in Langenbeck’s Archives of Surgery.

Conflict of interest The authors declare no competing interests.

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No competing interests reported.

LaparoscopiclefthemicolectomyofdescendingcoloncarcinomawithsuperiorrectalarterySRApreservationandnaturalorificespecimenextractionNOSE.mp4

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Laparoscopic left hemicolectomy of descending colon carcinoma with superior rectal artery （SRA）preservation and natural orifice specimen extraction （NOSE）:a standard operation procedure----with a video

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