Retroperitoneal Approach to D3-Lymph Node Dissection With Left Colic Artery Preservation in the Treatment of Sigmoid Cancer.

IF 3.2 2区 医学 Q2 GASTROENTEROLOGY & HEPATOLOGY
Sergey K Efetov,Arina K Rychkova,Yaroslav P Krasnov
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引用次数: 0

Abstract

BACKGROUND Laparoscopic approaches and robot-assisted operations are used for colorectal cancer surgery because of their minimal invasiveness.1 However, changes in intra-abdominal pressure during laparoscopy can lead to cardiovascular complications in compromised patients;2 obesity and intraabdominal adhesions may further interfere with laparoscopic procedures. The retroperitoneal approach may facilitate minimally invasive surgery, even in patients with comorbidities. The technique for high ligation of the inferior mesenteric artery has been described in left colonic surgeries.3 However, complete termination of the blood supply through this artery may lead to a higher frequency of anastomotic leakage.4. IMPACT OF INNOVATION We present a novel retroperitoneal approach for D3-lymph node dissection with low ligation of the inferior mesenteric artery and preservation of the left colic artery. This method can reduce the duration of laparoscopic procedures for compromised patients and meet the standards for extended lymph node dissection with tumor-specific mesocolic excision.5,6. TECHNOLOGY MATERIALS AND METHODS The procedure started with the installation of a paraumbilical optical trocar to introduce a 30-degree optical system. The SILS™ Port (Covidien, Medtronic) was inserted into the retroperitoneal space via a 4-cm incision, made 2 cm below and parallel to the anterior superior iliac spine in the left flank under the control of the optical system. The horizontal aspect of the duodenum served as the cranial landmark during interfascial dissection, with the dissection proceeding in a cranial and medial direction. During the dissection, the left ureter was the primary landmark, passing medial to the gonadal vessels and Gerota's fascia.The aorta was exposed medially and the inferior mesenteric artery was identified. The inferior mesenteric artery was skeletonized from its origin until the branching of the left colic artery and the sigmoid artery. The left colic artery was skeletonized until the passage of the inferior mesenteric vein, and the apical lymphatic nodes with mesocolic tissue were mobilized and excised. The inferior mesenteric artery was cut below the left colic artery.The final step was performed laparoscopically. The parietal fascia along Toldt's line was cut laterally to complete the mesocolon excision. The parietal fascia was cut along the right side of the aorta to free the mesocolonic medial border. The sigmoid mesocolon was dissected at the proximal and distal resection margins.Following mobilization, the colon was cut 10 cm distal to the tumor margin using a linear stapler. The specimen was then extracted using an SILS incision. The sigmorectal anastomosis was made. Atypical hepatic resection was performed using two additional trocars. PRELIMINARY RESULTS The incidence of pain syndrome in the early postoperative period was low. Blood loss reached 100 mL. The duration of the surgery was 300 min. The retroperitoneal step took 63 min. Metastases were observed in 7 of the 41 harvested lymph nodes. The patient was discharged on the 8th postoperative day. CONCLUSIONS AND FUTURE DIRECTIONS The retroperitoneal technique can be safely performed. Anatomical structures are readily accessible and easily visualized with this approach after special training, enabling extended lymph node dissection.
保留左结肠动脉的腹膜后D3淋巴结清扫术治疗乙状结肠癌
背景腹腔镜方法和机器人辅助手术因其微创性而被用于结直肠癌手术1。然而,腹腔镜手术过程中腹腔内压力的变化可能会导致受损患者出现心血管并发症2;肥胖和腹腔内粘连可能会进一步干扰腹腔镜手术。腹膜后入路可能有助于微创手术,即使是有合并症的患者也不例外。3 然而,完全终止肠系膜下动脉的血液供应可能会导致吻合口漏的频率升高。4 创新的影响 我们提出了一种新型的腹膜后方法,用于肠系膜下动脉低结扎和保留左结肠动脉的D3淋巴结清扫术。该方法可缩短受损患者的腹腔镜手术时间,并符合肿瘤特异性结肠系膜切除术的扩大淋巴结清扫标准。在光学系统的控制下,通过一个 4 厘米的切口将 SILS™ Port(Covidien,美敦力)插入腹膜后间隙,切口位于左侧髂前上棘下方 2 厘米处,与髂前上棘平行。在筋膜间解剖时,以十二指肠的水平面为头颅标志,沿头颅和内侧方向进行解剖。在解剖过程中,左侧输尿管是主要标志,经过性腺血管和 Gerota 筋膜的内侧。从肠系膜下动脉的起始处到左结肠动脉和乙状结肠动脉的分支处对其进行镂空。将左结肠动脉镂空至肠系膜下静脉通过处,并移动和切除带有系膜组织的顶端淋巴结。最后一步在腹腔镜下进行。最后一步在腹腔镜下进行,沿托尔德线从侧面切开顶筋膜,完成结肠系膜切除。沿主动脉右侧切开顶筋膜,游离结肠系膜内侧缘。移动结肠后,使用线性订书机在肿瘤边缘远端 10 厘米处切开结肠。然后使用 SILS 切口提取标本。进行乙状结肠吻合术。术后早期疼痛综合征的发生率很低。失血量达到 100 毫升。手术时间为 300 分钟。腹膜后步骤耗时 63 分钟。41 个摘取的淋巴结中有 7 个出现转移。结论和未来方向腹膜后技术可以安全实施。经过特殊培训后,采用这种方法很容易接近和观察解剖结构,从而可以扩大淋巴结清扫范围。
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来源期刊
CiteScore
4.50
自引率
7.70%
发文量
572
审稿时长
3-8 weeks
期刊介绍: Diseases of the Colon & Rectum (DCR) is the official journal of the American Society of Colon and Rectal Surgeons (ASCRS) dedicated to advancing the knowledge of intestinal disorders by providing a forum for communication amongst their members. The journal features timely editorials, original contributions and technical notes.
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