Totally double laparoscopic colon resection with intracorporeal anastomosis and transvaginal specimens extraction

Abstract

Dear Editor: Laparoscopic colorectal resection is equivalent to open resection in terms of oncologic outcomes, with superior perioperative results. Usually, an abdominal incision is required for anastomosis and specimen extraction. Recently, natural orifice specimen extraction (NOSE) and intracorporeal anastomosis have been proposed to improve the quality of laparoscopic colon resections. Transvaginal and transanal specimen extraction have been reported in association with right and left colic intracorporeal anastomosis and these two technical innovations may maximize the advantages of laparoscopic surgery. We present a case of double colon resection with intracorporeal anastomosis and transvaginal specimens extraction. A 73-year-old female obese patient was admitted for rectal bleeding and hypochromic microcytic anemia. Past medical history was significant for hypertension, COPD, myocardial infarction, treated with double stenting 4 years before, and sigmoid diverticular disease with several episodes of diverticulitis in the last 6 years. Her BMI was 36 kg/m. She denied any change in bowel habits, neither constipation nor diarrhea. She underwent colonoscopy revealing a gradually narrowing stenosis of the sigmoid with intact mucosa. Multiple biopsies were negative for cancer and confirmed the inflammatory disease. Due to the stenosing lesion, the procedure was incomplete and a virtual colonoscopy was performed. A right-colon mass, highly suspected for cancer but apparently not involving the lymph nodes, was found. Metastatic disease was excluded with contrast-enhanced total body CT scan. Preoperative carcinoembryonic antigen (CEA) level was normal (<5 ng/ml). Because of the patient’s general conditions and to reduce the risks related to anesthesia, we decided to treat both lesions at the same surgical time. In the aim to minimize complications and according to the patient willingness, we choose a minimally invasive approach with totally laparoscopic right colectomy and sigmoidectomy. Her low-dose aspirin therapy was stopped 7 days before surgery and therapeutic-dose of lowmolecular-weight heparin was administered. Mechanical bowel preparation was avoided, a single enema was given the night before. Broad-spectrum intravenous antibiotics were administered 30 min before the skin incision and postoperatively for 24 h. The patient underwent general endotracheal anesthesia and was positioned in the lithotomic position; nasogastric tube and urinary catheter were placed. The surgeon stood at the left side of the patient for the right colectomy and on the right for the sigmoidectomy. A medial to lateral right colectomy followed by a side to side ileocolic anastomosis with linear stapler was first performed. Subsequently, a sigmoidectomy with inferior mesenteric artery preservation and side to end colorectal anastomosis, using a circular stapler, was carried out. A colotomy was made just proximal to the transection site. The anvil was introduced inside the abdomen through one of the trocar incisions, and inserted in the proximal colon through the colotomy. The proximal colon was closed with a linear stapler, and an end to side anastomosis was established using a transrectal circular stapler. A 12-mm trocar was inserted through the posterior fornix under laparoscopic vision. The culdotomy F. Stipa :V. Giaccaglia : E. Santini : L. Tammaro Department of Surgery, San Giovanni Hospital, Rome, Italy