Laparoscopic proctocolectomy in Crohn's disease with complete mesocolic excision and total mesorectal excision

Abstract

Background

Total mesorectal excision, involves the resection of an intact tumor specimen with its full lymphatic drainage and blood supply within a predefined plane. This technique resulted in significantly better oncological outcomes in rectal cancer surgery. Hohenberger described the Complete Mesocolic Excision, comprising sharp dissection of the mesocolic visceral plane avoiding tumor spread within the peritoneal cavity. Several studies have since demonstrated superior long-term oncological outcomes in colon carcinoma.

Case Presentation

A 22-year-old woman with Crohn's disease since the age of 4 years presented with several nodules along the entire colon on colonoscopy. Biopsies evidenced high grade dysplasia in the rectum and a carcinoma in the sigmoid colon. Preoperatively, no distant metastases were found. Laparoscopic proctocolectomy with Complete Mesocolic and Total Mesorectal Excision was performed. Multiple foci of carcinoma were identified and a yield of 312 lymph nodes, 102 positive, was achieved.

Results

This video shows a systematic approach to laparoscopic proctocolectomy with simultaneous with Complete Mesocolic and Total Mesorectal Excision, which includes medial to lateral colon mobilization, central vascular tie and lymph node dissection, with accurate dissection of the complete mesocolon leaving its surfaces intact. The same principles were used distally in continuing the dissection around the mesorectum.

Conclusion

Proctocolectomy with Complete Mesocolic and Total Mesorectal Excision combines two gold standard techniques in the surgical treatment of colon and rectal cancer. Both techniques have been shown to benefit patients with improved oncologic outcomes. The technique demonstrated here could become the standard oncologic procedure for patients with synchronous colon and rectal cancers.