Laparoscopic Left Hemicolectomy Research Articles

Unveiling the hidden: identification and management of overlooked blood vessels in laparoscopic left hemicolectomy for splenic flexure cancer

BackgroundDuring laparoscopic left hemicolectomy procedures, a previously overlooked consistently thick blood vessel within the gastrocolic ligament near the splenic hilum may contribute to post-operative bleeding complications. The purpose of this study was to investigate the identification and management of the previously overlooked blood vessel.MethodsThis is a retrospective descriptive study of patients undergoing laparoscopic left colectomy for splenic fexure cancer conducted at a national gastrointestinal surgery centre in China. Consecutive patients with splenic fexure cancer who underwent laparoscopic left colectomy using our“five-step process”(n = 34) between January 2021 and July 2023 were included.ResultsThe vessels can be effectively exposed using the aforementioned “five-step process.” It was observed that the overlooked vessels consistently present in all patients were identified as the omental branch of the left gastroepiploic artery and vein.ConclusionWe have identified the origin of previously overlooked blood vessels and recommended a safe method for their management. This may offer advantages to colorectal surgeons performing laparoscopic left colectomy for splenic flexure cancer

Evaluation of early outcome of laparoscopic versus open left hemicolectomy in patients with left colon cancer

Background Colorectal cancer is a prominent global health concern, and while laparoscopic surgeries offer minimally invasive benefits, there is a noted underrepresentation of left-sided colon cancer in current research. This study seeks to bridge the gap by assessing the safety and efficacy of laparoscopic (LC) versus open left hemicolectomy (OC) in patients with left-side colon cancer. Patients and methods This prospective, nonrandomized study was conducted from May 2020 to May 2022 at Menoufia University Hospital and Damanhur Medical National Institute, enrolling 40 patients diagnosed with left-sided colonic carcinoma. Participants were divided into two groups: 20 underwent LC, and 20 had OC. The primary outcomes were operative time, blood loss, and incision length, with several secondary outcomes like analgesic needs and postoperative hospital stay. Results Both groups showed no significant differences in age, BMI, and other demographic characteristics. However, intraoperatively, the OC group completed procedures significantly faster than the LC group, with average times of 2.58 h compared with 4.48 h (P<0.001). Postoperatively, the LC group showed faster recovery, taking 2.35 days (P=0.019) to resume a liquid diet compared with 4.45 days for the OC group and 2.35 days (P<0.001) to pass the first flatus versus 3.45 days in the OC group. The LC group also had a shorter hospital stay, averaging 4.1 days compared with the OC’s 8.75 days (P<0.001), and harvested a higher number of lymph nodes (13 vs. 11.85, P<0.001). Conclusion The findings of this study demonstrate that LC and OC were comparable as regards intraoperative and postoperative complications. On the other hand, LC was considered a good and effective method for resection of left colonic carcinoma as it has many benefits, such as early recovery and short hospital stay.

Testicular metastasis 9 years after resection of primary descending colon cancer with simultaneous pulmonary metastasis: a case report

BackgroundMetastatic testicular cancer is rare. In particular, primary colorectal cancer rarely metastasizes to the testes. This study reports a case of testicular metastasis recurrence 9 years after the resection of a primary colorectal cancer and a simultaneous metastatic lung tumour.Case presentationA 69-year-old man underwent a laparoscopic left hemicolectomy for descending colon cancer. Preoperative computed tomography revealed a solitary left lung mass. Postoperative chemotherapy reduced the size of the lung mass, and 6 months after the primary resection, the patient underwent a left upper segmentectomy. Based on the pathological examination, he was diagnosed with pulmonary metastasis from colorectal cancer. After four courses of adjuvant chemotherapy, the patient was recurrence-free. However, 9 years and 6 months after the primary resection, he complained of discomfort in his left testicle. Physical examination revealed a left testicular mass. Since a malignancy was not excluded via imaging, left testicular resection was performed to confirm the diagnosis. The pathological diagnosis was testicular metastasis from colorectal cancer. The patient was followed up without medication, and remained healthy, without recurrence, 11 months postoperatively.ConclusionsIt is important to follow up with testicular metastasis in mind, although it is rare.

Laparoscopic left hemicolectomy with extracorporeal anastomosis surgical technique: how I do it

Laparoscopic left hemicolectomy with extracorporeal anastomosis surgical technique: how I do it

A Case of an Aggressive Triple Negative Metastatic Metaplastic Breast Cancer

Introduction: We present a case of a 69 years old Bulgarian patient with a Triple Negative (TN) MBC. One year after the Breast-Conserving Surgery (BCS), adjuvant chemo- and radiotherapy she was diagnosed with metastases in the sigmoid colon, mesosigmoid, loco-regional lymph nodes and in the brain. Case report: The patient was initially diagnosed with locally advanced TNBC of the left breast in March 2021. She had undergone 6 courses of neoadjuvant chemotherapy and BCS with axillary lymph node dissection on 15.07.2021. The patient had received 4 courses of CarboTAx and whole breast radiation therapy postoperatively until December 2021. Eight months after that she was diagnosed with large bowel lesion in the sigmoid and a second small one in the mesosigmoid on the follow up PET/CT. She was admitted and had undergone laparoscopic left hemicolectomy. Due to signs of central system disorder (headache, impaired vision and vertigo) she was sent to additional examination with MRI (17.10.2022). Several heterogenous formations were found in the supratentorial space. Discussion: TNBC presents an aggressive subgroup, associated with worse prognosis and in about 30-40% of the cases early metastases and recurrence are observed. MBCs have poor response rates to cytotoxic chemotherapy compared to other types of BC. Conclusion: The presented case is here to show the unpredictable biological behaviour of this pathology regardless of the adequate treatment plan and careful follow up and to remind the physicians to be permanently aware of the numerous manifestations of the disease.

A novel U-tied end-to-end anastomosis in total laparoscopic left hemicolectomy for colorectal cancer-a video vignette.

A novel U-tied end-to-end anastomosis in total laparoscopic left hemicolectomy for colorectal cancer-a video vignette.

558 BIVENTRICULAR PERIOPERATIVE TAKOTSUBO CARDIOMIOPATHY

Abstract Introduction Perioperative Takotsubo cardiomyopathy (pTC) represents a rare and still not well characterized disease. Biventricular involvement is an uncommon manifestation of TC and is associated with a more severe clinical presentation. Case report A 72-year-old male, hospitalized for a laparoscopic left hemicolectomy, was transferred to ICU after having developed severe bradycardia, treated with Adrenalin, and cardiogenic shock during induction of general anesthesia. EKG showed complete atrio-ventricular block, so a temporary PMK was placed. Troponin was raised. Echocardiogram showed severe biventricular disfunction (LVEF 25%, TAPSE 12 mm) with akinesia of medio-apical segments, suggesting a biventricular pTC. Also, there was a reduction of 3D LV longitudinal strain (- 5,8%), particularly of the medio-apical portion, and RV free wall longitudinal strain (- 11%). Coronary angiography resulted negative. Patient's hemodynamic was supported with Noradrenalin and a cycle of Levosimendan, allowing to reach stability. Further echocardiogram showed improvement of biventricular function and longitudinal strain values. Due to the persistency of atrio-ventricular block, a definitive PMK was placed. Patient was discharged after therapy optimization. Discussion pTC is a little-known disease, as incidence and etiology are not well definite. Literature suggests a relation between pTC and physical or emotional stress due to surgery to promote an increase of catecholamine release. Other potential factors may be inadequate depth of anesthesia or tracheal manipulation during intubation and catecholaminergic drugs administration. On the other hand, the use of anesthetic volatile agents seems to have a cardioprotective effect. PTC is more common during general anesthesia and when occurs intraoperatively has a worse clinical presentation. Biventricular involvement, which is a rare and severe manifestation of TC, has been reported frequently among pTC patients. To date, due to the lack of a systematic review, there is little knowledge about potential risk factors, prevention strategies and management of pTC. Conclusions Despite multiple cases of pTC have been reported, several characteristics of this entity are not fully understood. However, it must be considered as a part of differential diagnosis in patients with anaesthesia-related decompensation. Biventricular involvement represents an infrequent presentation and its commonly associated with life-threating hemodynamic impairment.

A novel knotless hand-sewn end-to-end anastomosis using V-loc barbed suture vs. stapled anastomosis in laparoscopic left colonic surgery: A propensity scoring match analysis.

Laparoscopic colectomy is widely practiced for colon cancer, but many variations exist for anastomosis after laparoscopic colon cancer radical resection. We retrospectively analyzed 226 patients who underwent laparoscopic-assisted radical resection for left colon cancer with knotless hand-sewn end-to-end anastomosis (KHEA) technique with barbed V-loc™ suture material and compared perioperative outcomes, safety, and efficacy to those undergoing stapled anastomosis from 2010 to 2021. After the 1:2 propensity score matching, 123 participants with similar preoperative characteristics (age, body mass index, TNM stage, and tumor location) were enrolled in the study: 41 in the KHEA and 82 in the stapler group. Statistically significant differences were found in time to accomplish the anastomosis (mean 7.9 vs. 11.9 min, p < 0.001) and hospital costs (mean 46,569.71 vs. 50,915.35 CNY, p < 0.05) that differed between the KHEA and stapler group, respectively. No statistically significant difference was found in the mean delay to bowel function recovery (2.6 vs. 2.7 days, p = 0.466), duration of hospital stay (8.6 vs. 7.9 days, p = 0.407), or rate of postoperative complications (14.6% vs. 11.0%, p = 0.563). Anastomotic leakage occurred in 11 patients: 5 (12.2%) vs. 6 (7.3%) (p > 0.05) in the KHEA and stapler group, respectively. KHEA is feasible and safe for anastomosis after laparoscopic left hemicolectomy. The KHEA technique could reduce operation time and hospital costs with complication rates comparable to stapling.

Emergency Laparoscopic Left Hemicolectomy for Tubercular stricture of descending colon presenting as massive haematochezia: A Rare Case Report

Emergency Laparoscopic Left Hemicolectomy for Tubercular stricture of descending colon presenting as massive haematochezia: A Rare Case Report

Comparison of short-term and medium-term outcomes between intracorporeal anastomosis and extracorporeal anastomosis for laparoscopic left hemicolectomy

BackgroundFew studies have evaluated the feasibility and safety of intracorporeal anastomosis (IA) for left hemicolectomy. Here, we aimed to investigate the potential advantages and disadvantages of laparoscopic left hemicolectomy with IA and compare the short- and medium-term outcomes between IA and extracorporeal anastomosis (EA).MethodsWe retrospectively analyzed 133 consecutive patients who underwent laparoscopic left hemicolectomies from July 2016 to September 2019 and categorized them into the IA and EA groups. Patients with stage 4 disease and conversion to laparotomy or those lost to follow-up were excluded. Postoperative outcomes between IA and EA groups were compared. Short-term outcomes included postoperative pain score, bowel function recovery, complications, duration of hospital stay, and pathological outcome. Medium outcomes included overall survival and disease-free survival for at least 2 years.ResultsAfter excluding ineligible patients, the remaining 117 underwent IA (n = 40) and EA (n = 77). The IA group had a shorter hospital stay, a shorter time to tolerate liquid or soft diets, and higher serum C-reactive protein level on postoperative day 3. There was no difference between two groups in operative time, postoperative pain, specimen length, or nearest margin. A 2-year overall survival (IA vs. EA: 95.0% vs. 93.5%, p = 0.747) and disease-free survival (IA vs. EA: 97.5% vs. 90.9%, p = 0.182) rates were comparable between two groups.ConclusionsLaparoscopic left hemicolectomy with IA was technically feasible, with better short-term outcomes, including shorter hospital stays and shorter time to tolerate liquid or soft diets. The IA group had higher postoperative serum C-reactive protein level; however, no complications were observed. Regarding medium-term outcomes, the overall survival and disease-free survival rates were comparable between IA and EA procedures.

Robotic-Assisted versus Laparoscopic Left Hemicolectomy-Postoperative Inflammation Status, Short-Term Outcome and Cost Effectiveness.

Robotic-assisted colon surgery may contain advantages over the laparoscopic approach, but clear evidence is sparse. This study aimed to analyze postoperative inflammation status, short-term outcome and cost-effectiveness of robotic-assisted versus laparoscopic left hemicolectomy. All consecutive patients who received minimal-invasive left hemicolectomy at the Department of Surgery I at the University Hospital of Wuerzburg in 2021 were prospectively included. Importantly, no patient selection for either procedure was carried out. The robotic-assisted versus laparoscopic approaches were compared head to head for postoperative short-term outcomes as well as cost-effectiveness. A total of 61 patients were included, with 26 patients having received a robotic-assisted approach. Baseline characteristics did not differ among the groups. Patients receiving a robotic-assisted approach had a significantly decreased length of hospital stay as well as lower rates of complications in comparison to patients who received laparoscopic surgery (n = 35). In addition, C-reactive protein as a marker of systemic stress response was significantly reduced postoperatively in patients who were operated on in a robotic-assisted manner. Consequently, robotic-assisted surgery could be performed in a cost-effective manner. Thus, robotic-assisted left hemicolectomy represents a safe and cost-effective procedure and might improve patient outcomes in comparison to laparoscopic surgery.

Laparoscopic versus open left hemicolectomy for left-sided colon cancer: protocol for a systematic review and meta-analysis

IntroductionLaparoscopic colectomy has been widely used clinically due to its minimally invasive advantages, and many studies have also demonstrated its safety and efficacy. However, the efficacy of laparoscopic left hemicolectomy...

Synchronous \u201cskip\u201d facial metastases from colorectal adenocarcinoma: a case report and review of literature

BackgroundSkin metastases from colorectal adenocarcinoma are rare conditions that are metachronous in most of cases and may represent the first sign of a recurrence. These lesions are usually located to the abdominal wall on postoperative scars, perineum and chest due to direct spread from the tumor or to the lymphatic and venous dissemination. We describe a rare case of synchronous skin metastases in a patient affected by sigmoid adenocarcinoma with no sign of liver and lung repetitive lesions.Case presentationWe admitted a 59 years old male, with no relevant medical history. He was evaluated by our tertiary center of colorectal surgery complaining diarrhoea and abdominal pain. The physical examination revealed a palpable mass in left flank of the abdomen. The colonoscopy showed a sub-stenosis of the sigmoid colon (G2 adenocarcinoma). No repetitive lesions were detected by the preoperative CT scan. The patient reported a rapid grow of a soft supralabial and chin nodules in the last 2 months, which he believed to be related to the use of the mask due to COVID-19 pandemic. A laparoscopic left hemicolectomy with complete mesocolic excision and a local excision of both facial nodules were performed. The histological examination revealed a poorly differentiated signet ring cell colorectal adenocarcinoma with metastases in seven pericolic lymphonodes. The excisional biopsy of the skin nodules revealed a subcutaneous metastases from primary colorectal tumour.ConclusionsAs far as we know, synchronous facial metastases from colorectal cancer in the absence of any other metastases has never been described before. The onset of new skin nodules in patients affected by colorectal cancer should raise-up the clinical suspicion of metastatic lesions even when repetitive lesions are not detected in the liver or lungs.

Clinical Benefit of Preserving Inferior Mesenteric Vein in Laparoscopic Curative Resection for Descending and Splenic Flexure Colon Cancer: A Comparative Study of CT-based objective Evidence

Background: Although the presence of remnant long sigmoid colon after left hemicolectomy with inferior mesenteric vein (IMV) ligation is a major risk factor for venous ischemia, there is insufficient objective evidence to support the clinical benefit of IMV preservation in curative resection for distal transverse, descending and splenic flexure colon cancer. This study was to confirm the patency through CT after IMV preservation in laparoscopic left hemicolectomy for distal transverse, descending and splenic flexure colon cancer, and to analyze the clinical outcomes compared to the IMV ligation group.

Comparison of clinical efficacy between bursa omentalis approach and medial-to-lateral approach in laparoscopic left hemicolectomy: a propensity score matching analysis

Objective: Splenic flexure mobilization is technically difficult during the resection of left hemicolon cancer. This study aims to compare the safety and effectiveness between the bursa omentalis approach (BOA) and medial-to-lateral approach (MTLA) in laparoscopic radical resection of left-sided colon cancer. Methods: A retrospective cohort study was conducted. Inclusion criteria: (1) patients underwent radical resection of left hemicolon cancer; (2) the postoperative pathological result was adenocarcinoma; (3) patients aged 18-80 years old; (4) no liver, peritoneal or other distant metastasis. Exclusion criteria: (1) poor physical condition with serious heart, brain, lung, liver, kidney and hematopoietic system diseases; (2) unable to tolerate laparoscopic surgery; (3) history of other malignancies simultaneously, or multisource tumors; (4) emergency operation due to bleeding, obstruction, perforation, etc. Clinical data of 189 patients who underwent laparoscopic left hemicolectomy in the Guangdong Provincial Hospital of Chinese Medicine from 2014 to 2020 were retrospectively analyzed. According to surgical approaches, patients were divided into the BOA group (52 cases) and MTLA group (137 cases). The whole group of patients were matched by propensity score matching (PSM) according to the nearest neighbor matching method. The caliper value was 0.01. The matching variables included gender, age, American Society of Anesthesiologists (ASA) score, body mass index, tumor location and tumor stage. After PSM, 47 patients were included in the BOA group and MTLA group, respectively. There were no significant differences in baseline data between the two groups after PSM (all P>0.05). Paired t-test, paired rank sum test and paired Chi-square test were used to compare intraoperative and postoperative paramether between the two groups. Kaplan-Meier method was used to draw the survival curve, and log rank test was used for inter group comparison. When the two survival curves intersect, the two-stage method and restricted mean survival time (RMST) were further performed. Results: Both groups of patients successfully completed the operation without conversion to laparotomy or intraoperative death. No combined splenectomy or pancreatectomy were performed in the two groups. There were also no significant differences in intraoperative blood loss, number of harvested lymph nodes, time to the first flatus and the length of hospital stay between the two groups (all P>0.05). However, the median laparoscopic dissection time in the BOA group was shorter than that in the MTLA group, and the difference was statistically significant (median: 56 minutes vs. 65 minutes, P=0.032). No entry to posterior pancreatic space was recorded in the BOA group but wrong entry to posterior pancreatic space happened to 6.4% (3/47) of patients (body mass index >25 kg/m(2)) when dissecting left Toldt's fascia in the MTLA group. The 3-year disease-free survival rate in BOA group and MTLA group was 90.2% and 86.1%, respectively (P=0.909) and the 3-year overall survival rate was 85.6% and 94.4%, respectively (P=0.532). Conclusions: BOA is safe and feasible in laparoscopic left hemicolectomy, especially for inexperienced surgeons. For obese patients, BOA facilitates the entrance into the correct anatomical level and avoid entering the retropancreatic space.

304 First Reported Case of Metachronous Tumours With Delayed Recurrence from The Neuroendocrine Tumour Arising in A Tailgut Cyst

Abstract Background Malignant transformation of tailgut cysts (benign retrorectal cysts) into Neurodendocrine tumours (NETS) is extremely rare with less than 30 reported cases in the literature. A tiny proportion of these cases report early recurrence (within 2 years) and to our knowledge none have reported delayed recurrence 6 years after primary resection. Case history We report a 55-year-old male who underwent laparoscopic excision of a 5 cm presacral tumour found incidentally and confirmed histologically to be a G1 NET (WHO Classification) arising from a pre-existing tail gut cyst, with no evidence of metastasis.16 months later the patient presented with bowel obstruction secondary to adenocarcinoma of the colon at the splenic flexure. The patient underwent laparoscopic left hemicolectomy; histology confirming a moderately differentiated adenocarcinoma (TNM stage pT3pN0). The patient underwent adjuvant chemotherapy post-operatively based upon immunohistochemistry. The patient was followed up for both tumours with CEA, serum chromogranin A, colonoscopies, and CT scans. At 5th year post hemicolectomy, CT scan revealed a new asymptomatic 18 mm left internal iliac lymph node which was avid on octreotide scan consistent with metastasis secondary to NET resected previously. He, therefore, underwent 30Gy sabre radiotherapy. Conclusions There is no consensus regarding follow up duration post early NET resection. The recurrent NET was picked up incidentally as part of the 5-year colorectal adenocarcinoma follow up at our unit. The recurrent NET would not have been identified had this not been a metachronous case. Thus, consideration must be given to both radiological and biochemical follow up post NET resections.

Transrectal natural orifice specimen extraction in left hemicolectomy for tumours around the splenic flexure: Old wine in new bottles

Laparoscopic anterior resection with natural orifice specimen extraction (NOSE) has favourable short-term outcomes. However, NOSE is rarely adopted for left hemicolectomy procedures. This study aimed to review the feasibility, safety and short-term outcomes of transrectal NOSE in patients undergoing laparoscopic left hemicolectomy. All consecutive patients who underwent laparoscopic left hemicolectomy surgery with transrectal NOSE in a single institution between January 2018 and December 2020 were reviewed. Transrectal NOSE was performed with an enterotomy at the upper rectum. The specimen was brought out via a transanal endoscopic microsurgery scope inserted through the anus. A supplementary video demonstrates this technique. Surgical outcomes, including complications, postoperative short-term recovery and the level of pain intensity, are presented. Twenty patients were reviewed. There were no immediate postoperative complications and no wound infections in these patients. The average time to tolerate a soft diet was 3.6days, and the average postoperative hospital stay was 4.5days. The average score on the numerical rating scale of postoperative pain was 3.0 on postoperative day 1. The median follow-up time was 23.5months. Laparoscopic left hemicolectomy with transrectal NOSE is a safe and feasible procedure that leads to early postoperative recovery and a short hospital stay.

S1881 Colonic Intussusception From a Necrotic Giant Lipoma

Introduction: Lipomas are the most common benign subepithelial lesions (SEL) of the colon. They usually originate in the submucosa, however, could rarely be found within muscularis propria or subserosa. Although usually asymptomatic, lipomas can become symptomatic depending on their size and/or location. Herein we present a case of colonic intussusception secondary to a necrotic giant lipoma. Case description/methods: Patient is a 58 year old woman with past medical history of uncontrolled hypertension resulting in two cerebrovascular accidents without residual deficits (currently on clopidogrel) and uncontrolled insulin dependent diabetes type 2 with nephropathy resulting in stage 5 chronic kidney disease leading to iron deficiency anemia (IDA) who presented to ambulatory surgery unit for colonoscopy for further evaluation of IDA. Colonoscopy revealed a 5 cm nearly obstructing ulcerated and necrotic SEL in distal transverse colon. Procedure was complicated by transient desaturation and patient underwent post-procedural computerized tomography (CT) scan to rule aspiration pneumonia as patient was found to have a pieces of ginseng root within the oral cavity. CT scan revealed a 4.8 cm predominantly fatty mass-like lesion at splenic flexure with edematous fat and mild circumferential thickening of wall of proximal descending colon possibly suggesting colocolic intussusception without evidence of bowel obstruction. The patient was admitted to surgical service and taken to the operating room for laparoscopic left hemicolectomy. Pathology revealed a partially necrotic submucosal lipoma with acute inflammation, fat necrosis, ulceration and granulation tissue. Discussion: Colonic lipoma leading to intussusception is a rare complication of otherwise benign SEL. They are typically asymptomatic but can present with obstruction, bleeding, intussusception, and/or abdominal pain. CT scan is the preferred imaging modality for diagnosing aforementioned complications. The differential diagnosis for incidental lesions identified on imaging includes malignancy, large pedunculated polyps or liposarcomas. Management for symptomatic colonic lipomas can be either endoscopic or surgical. Size, location and presenting symptoms are the determining factors for deciding on type of management. Endoscopic ligation (“Loop-And-Let-Go”) technique was contemplated, however, due to finding of intussusception and the fact that patient had to resume clopidogrel, a decision was made to proceed with surgical resection.Figure 1.: A. Image from CT scan revealing a mass in the colon B. Imaging from colonoscopy depicting large lesion nearly obstructing with intussusception C. Microscopic Appearance: Necrotic mucosa and fat globules with foamy macrophages consistent with necrotic lipoma.

Management of postoperative complications after laparoscopic left hemicolectomy: an approach in modern times after incorporation of indocyanine green and full mobilization of the splenic flexure.

The aim of this study was to report our experience in the management of complications after laparoscopic left hemicolectomy (LLH) after the incorporation in our clinical practice of intraoperative indocyanine green (ICG) fluorescence angiography (FA). In our last period after incorporation of ICG-FA, 277 unselected consecutive patients underwent laparoscopic colorectal surgery with this technology. Ninety-seven (35%) right hemicolectomy, 19 segmental resection of the splenic flexure (6.9%), 54 anterior resection of the rectum (19.5%) and 107 LLH (38.6%) were performed. Complications were graded according to Clavien-Dindo classification, and anastomotic leakages (AL) were graded according to Clavien-Dindo classification and to International Study Group of Rectal Cancer (ISGRC) classification. Eight surgical and one medical complications (8.4%) were observed. Two AL occurred (1.9%). One drained spontaneously by drainage placed intraoperatively (Clavien-Dindo I, ISGRC A) and one treated by laparoscopic peritoneal lavage, leakage suture and ileostomy (Clavien-Dindo III-b, ISGRC C). Other complications were: wound infection (Clavien-Dindo II) (2); postoperative anemia caused by rectorrhagia (Clavien-Dindo II) (2); pelvic abscess between bladder and uterus (Clavien-Dindo III-a) (1); hemoperitoneum secondary to inferior mesenteric artery bleeding treated with peritoneal lavage and hemostasis (Clavien-Dindo III-b) (1); atrial fibrillation (Clavien-Dindo II) (1). All complications have been resolved. The complication rate after LLH after the incorporation of ICG-FA is low, since the number of AL have dramatically decreased in comparison to our previous experience. The management of these patients proved to be safe and effective due to in all cases the complication has been resolved. Further studies are required to standardize the management of these patients.

Long splenic flexure carcinoma requiring laparoscopic extended left hemicolectomy with CME and transverse-rectal anastomosis: technique for a modified partial Deloyers in 5 steps to achieve enough reach and preserving middle colic vessels

IntroductionThis How-I-Do-It article presents a modified Deloyers procedure by mean of the case of a 67-year-old female with adenocarcinoma extending for a long segment and involving the splenic flexure and proximal descending colon who underwent a laparoscopic left extended hemicolectomy (LELC) with derotation of the right colon and primary colorectal anastomosis.BackgroundWhile laparoscopic extended right colectomy is a well-established procedure, LELC is rarely used (mainly for distal transverse or proximal descending colon carcinomas extending to the area of the splenic flexure). LELC presents several technical challenges which are demonstrated in this How-I-Do-It article.Technique and methodsFirstly, the steps needed to mobilize the left colon and procure a safe approach to the splenic flexure are described, especially when a tumor is closely related to it. This is achieved by mobilization and resection of the descending colon, while maintaining a complete mesocolic excision to the level of the duodenojejunal ligament for the inferior mesenteric vein and flush to the aorta for the inferior mesenteric artery. Subsequently, we depict the adjuvant steps required to enable a primary anastomosis by trying to mobilize the transverse colon and release as much of the mesocolic attachments at the splenic flexure area. Finally, we present the rare instance when a laparoscopic derotation of the ascending colon is required to provide a tension-free anastomosis. The resection is completed by delivery of the fully derotated ascending colon and hepatic flexure through a suprapubic mini-Pfannenstiel incision. The primary colorectal anastomosis is subsequently fashioned in a tension-free way and provides for a quick postoperative recovery of the patient.ResultsThis modified Deloyers procedure preserves the middle colic since the fully mobilized mesocolon allows for a tension-free anastomosis while maintaining better blood supply to the mobilized stump. Also, by eliminating the need for a mesenteric window and the transposition of the caecum, we allow the small bowel to rest over the anastomosis and the mobilized transverse colon and reduce the possibility of an internal herniation of the small bowel into the mesentery.ConclusionsLaparoscopic derotation of the right colon and a partial, modified Deloyers procedure preserving the middle colic vessels are feasible techniques in experienced hands to provide primary anastomosis after LELC with improved functional outcome. Nevertheless, it is important to consider anatomical aspects of the left hemicolectomy along with oncological considerations, to provide both a safe oncological resection along with good postoperative bowel function.