Three-Port Laparoscopic Splenic Flexure Colectomy for Descending Colon Cancer with Intracorporeal Colocolic Anastomosis and Transvaginal Natural Orifice Specimen Extraction

Abstract

Introduction: Transanal and transvaginal natural orifice specimen extraction (NOSE) are viable alternatives to transabdominal specimen retrieval after laparoscopic colorectal surgery in selected patients without increasing morbidity or compromising oncologic outcomes.1 Conventional laparoscopic colorectal surgery is performed using one camera port, two operator ports, and one or two assistant ports. Three-port surgery is feasible2 and complementary to NOSE for laparoscopic colorectal cancer surgery to reduce surgical trauma to the abdominal wall.3 Transanal NOSE avoids an additional vaginal incision, however, the transvaginal route is preferable for larger tumors because of the elasticity of the vagina.3 Although dyspareunia and rectovaginal fistulae are theoretical concerns following transvaginal NOSE, these fears are thus far unfounded.1,3 Placement of a transvaginal wound protector protects against the risk of tumor seeding. Transvaginal NOSE following three-port laparoscopic D3 right hemicolectomy4 and three-port laparoscopic anterior resection5 have been previously demonstrated. Compared with other locations within the large bowel, cancers of the splenic flexure are relatively uncommon.6 Splenic flexure colectomy preserves bowel and is safe and oncologically comparable with a subtotal colectomy or formal left hemicolectomy.7,8 However, segmental resection and anastomosis for tumors in this area can be technically challenging. Methods: A 69-year-old patient with a descending colon cancer and body mass index of 29.2 kg/m2 presented for resection. Preoperative bowel preparation with 2 L polyethylene glycol was administered. A 12-mm transumbilical camera port was used, with a 12- and 5-mm right iliac fossa and right flank working ports, respectively. The splenic flexure was mobilized from medial to lateral. The inferior mesenteric artery was identified, and the left colic artery was ligated at its origin, with adequate distal mesenteric division to ensure satisfactory lymph node harvest. Proximal and distal bowel transection were performed intracorporeally with a linear stapler. An isoperistaltic side-to-side colocolic anastomosis was fashioned, with a two-layer closure of the colonic defect. The uterus was hitched to the anterior abdominal wall with a transabdominal suture. The vagina was cleansed before a posterior vaginotomy was created with the help of a transvaginal sizer. A double ring wound protector was inserted transvaginally with one ring completely within the abdominal cavity and the other ring opened against the perineum to shorten the channel for specimen delivery. The wound protector was removed and the vaginotomy was closed using a barbed suture. Results: Operative time was 3 hours 15 minutes, with 20 mL intraoperative blood loss. There was minimal postoperative pain with return of gastrointestinal function on the first postoperative day. The patient was discharged uneventfully on postoperative day 2. Histology was pT4N1 and 27 lymph nodes were harvested. Adjuvant chemotherapy was administered, with no evidence of disease recurrence at 6 months follow-up. Conclusion: The reduced port technique is feasible and synergistic with NOSE for splenic flexure colectomy in selected patients, augmenting the minimally invasive nature of laparoscopy. No competing financial interests exist. Runtime of video: 5 mins 49 secs Patient Consent: The authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.