Department of Gastrointestinal Surgery, Kameda Medical Center, Kamogawa, Japan
KeywordsAdaptations for laparoscopic surgeryPreoperative settingLandmarks
2.1 Basic Approach for Colorectal Cancer
220.127.116.11 Colon Cancer
Factors considered contraindications in cases of laparoscopic resection for colon cancer surgery include advanced invasion to the other organs, bowel obstruction that cannot be decompressed, and larger-sized tumour; however, it is difficult to determine the contraindications for laparoscopic surgery noninvasively. An eventual adaptation of laparoscopic surgery should be determined based on intraoperative laparoscopic findings.
18.104.22.168 Rectal Cancer
Contraindications in cases of laparoscopic resection of the rectum (Laparoscopic low anterior resection [LapLAR] and laparoscopic abdominoperineal resection [LapAPR]) are advanced invasion to other organs with an insufficient circumferential resection margin (CMR), bowel obstruction that cannot be decompressed, and a larger-sized tumour in the pelvic space. Judgment relative to operative indications for laparoscopic resection of the rectum is determined based on many preoperative modalities including computed tomography (CT), magnetic resonance imaging (MRI), and rectal endoscopic ultrasonography (EUS). If the lower rectal cancer is in the advanced stage, preoperative chemoradiotherapy should be selected. Cases that are considered lateral lymph node-positive or having advanced lymph node metastasis are not indicated for immediate laparoscopic resection of the rectum but for chemotherapy and/or chemoradiotherapy.
2.1.2 Marking of the Lesion and Preoperative Treatment
If the lesion is difficult to identify during surgery, preoperative marking is essential. A clip method is carried out a few days before the surgery. It is important for the clip to hit the anal side of the lesion.
The dilatation of the small intestine and the colon significantly compromises the field of view of the laparoscopy, so it is important to perform adequate decompression of the intestinal tract. Although magnesium citrate formulations are prescribed the day before surgery, depending on the case and especially for obstructive type of cancer, fasting, nutrition management, and placement of a long intestinal tube from the anus may also be performed.
2.2 Basic Approach for the Operation
2.2.1 Patient Positioning
For the expansion of the intraoperative view in laparoscopic colorectal resection, the position of the trunk is important for removing the small intestine.
In the left side operation, the patient is placed in the head-down position on the operating table. Sometimes the table is tilted to the right in the left-side operation. The left hand of the patient is spread out and the right hand is attached to the trunk. In the lithotomy position with LevitatorTM stirrups the thighs are kept parallel to the trunk as much as possible to avoid interruption of the forceps and thigh. Also, plates are placed to protect the right side of the trunk, and shoulder protectors are attached on both shoulders to prevent the body from sliding head-down. In the left-side operation the operator and scopist are on the right side and the assistant is on the left side.