Puchkov D.K.

Laparoscopic anterior resection with D3 - lymphadenectomy, preserving of the left colic artery, transvaginal specimen extraction (N.O.S.E.S. technique)

Laparoscopic anterior resection with D3 - lymphadenectomy, preserving of the left colic artery, transvaginal specimen extraction (N.O.S.E.S. technique)
Surgeon D.K. Puchkov (2020y.)

This film shows the technique of performing laparoscopic anterior resection with D3 - lymphadenectomy, preserving of the left colic artery, transvaginal specimen extraction (N.O.S.E.S. technique).

Patient B., 49 years old, was treated with the diagnosis: Cancer of the upper third part of the rectum fT2N2M0, G2. During the preoperative examination, according to MRI of the small pelvis in the rectum about 11 cm from the anal verge was found a formation 2 cm in diameter. According to CT-scans along the upper rectal artery, in the area of the origin of the inferior mesenteric artery were found a few enlarged lymph nodes.

A 10 mm trocar, endoscope were introduce above the umbilicum. In the right and left mesogastrium region 5 mm trocars were introduced; in the right iliac region a 10 mm trocar was introduced. Firstly, the patient was transferred to the Trendelenburg position. The tumor was not visually defined; intraoperative colonoscopy was performed to determine the border of the resection.

The parietal peritoneum was dissected along the IMA, medial-to-lateral mobilization was performed, the left ureter was visualized, then the IMA was mobilized, the superior rectal artery and the first sigmoid artery were selectively crossed with the 5mm LigaSure device. The left part of the colon was mobilised using a Harmonic scalpel (Ethicon).

The mobilisation of the rectum to the level of resection within the mesorectal fascia was performed.

A colpotomy was performed, a plastic sleeve was inserted into the abdominal cavity to prevent tumor contamination of the vagina. The colon was removed, the proximal resection border was visualised (the demarcation line), the specimen was cut off extracorporeally. The head of the CDH-29 device was inserted into the proximal part of the colon and fixed with a purse string suture (thread “Vicryl 2.0”), immersed in the abdominal cavity. The colpotomy opening was intracorporeally sutured. Leak control - no air intake.

The CDH-29 device was transanally introduced. The head was adapted with the device; the device was removed. The trocar wounds were sutured and the skin was trimmed with OmniStrip stripes. Operation time 145 minutes.

This film shows the technique of dissecting of the left parts of the colon, modified combined approach for splenic flexure mobilization for cancer of the descending colon.

This film shows the technique of dissecting of the left parts of the colon, modified combined approach for splenic flexure mobilization for cancer of the descending colon.
Surgeon D.K. Puchkov (2019y).

This film shows the technique of dissecting of the left parts of the colon, modified combined approach for splenic flexure mobilization for cancer of the descending colon.

Patient M., 62 years old, was treated with a diagnosis of cancer of the descending colon fT3N0M0, G2. During the preoperative examination, RCT of abdominal organs in the descending colon was found a volumetric formation ~ 4 cm in diameter, no enlarged lymph nodes in the abdominal cavity were detected.

A 10 mm trocar, camera were introduced in the umbilical area. In the mesogastrium, in the right and left iliac regions three 5 mm trocars were introduced. The tumor was located in the proximal third of the descending colon, mobile, dense, the serous layer was not involved.

The parietal peritoneum was dissected along the IMA, the IMA was mobilized at the origin of its bifurcation. IMA branches were skeletonized, the left colon artery was selectively cut with a 5mm Ligasure device, and then the IMV was transsected. The left parts of the colon were mobilized with the Harmonic device in medial-to-lateral (inframesocolic) approach in the interfascial layer with visualization of the pancreatic tail.

An entrance to the omental bursa was made through the mesentery of the transverse colon, the mesentery was separated from the pancreas to the splenic flexure. The peritoneum was dissected along the left lateral canal to the splenic flexure.

Dissection of the gastro-colon ligament was performed, the splenic flexure of the colon was mobilized. The operation stage time was 65 minutes.

Laparoscopic right hemicolectomy

Laparoscopic right hemicolectomy.
D-r Puchkov D.K. (CMS) is performing an operation (2018).

• In this video the technique of laparoscopic right hemicolectomy is presented. A 53 year-old female patient was operated with diagnosis: Cancer of the hepatic flexure of the colon fT3N0M0, G2. During preoperation investigation of the abdominal cavity according to RCT, was found extensive formation about 5.5 cm in diameter and multiple increased lymphatic nodes along the artery ileocolica, without symptoms of their metastatic lesion. The first stage of operation: a 10 mm troacar was placed above the umbilicus, 10 mm optic was introduced. Then a 5 mm troacar was introduced in epigastrium along the midline of abdomen under the guidance of optic, 5 mm troacars were introduced into the right and left iliac areas. During revision of the abdominal cavity where was not found any sings of metastases in liver. The tumour was found in the cecum, movable, firm, does not involve the serous layer. Increased lymphatic nodes of the first priority were visualized. Intraoperatively surgeons decided to perform a right hemicolectomy with the high ligating of artery and vein ileocolica. Artery and vein were visualized, skeletonized, transected near the area of its origin with 5 mm LigaSure (“Medtronic Covidien”) device. The right part of the large colon was mobilized from “downwards-to- upwards” within the boundaries of Toldt’s fascia with Harmonic (“Ethicon”) scalpel, the descending part of duodenum was visualized, the head of pancreas, infrapyloric lymphatic nodes are intact. The abdomen of the right lateral canal was transected, resection of gastrocolic ligament up to the level of middle one-third of the transverse colon was done. Mesentery of the colic colon was mobilized up to the level of middle one-third of the transverse colic colon. Mesentery of the iliac colon was transected at the distance of 15 cm proximally to Bauhin’s (ileocecal) valve. Middle minilaparotomy was performed. Latex ring “Dextrus” was placed into the wound to restrict tissues of the anterior abdominal wall from the colon with tumour, the colon is exteriorized into the wound, resection of the right parts of the colon and iliac colon was done. Bistapler ileotransversoanastomosis “side –by-side” was performed. Edges of anastomosis were additionally stitched by “Vicryl” 3-0 thread. The abdominal cavity was drained via troacar incision in the right iliac area. Minilaparotomic and troacar wounds were stitched layer by layer. Aceptic bandage was applied. Operation duration is 80 minutes.

Laparoscopic anterior resection of rectum

Laparoscopic anterior resection of rectum
D-r Puchkov D.K. (CMS) is performing an operation (2018).

In this video the technique of performing the anterior rectal resection for chronic diverticular disease of the sigmoid colon is presented. A 58 year-old female patient was treated, having the diagnosis: Diverticular disease of the sigmoid colon, relapsing diverticular without complications. Within the last 5 months a patient thrice was hospitalized for acute complications of diverticular disease. During preoperation investigation according to fibrocolonoscopy, had found multiple diverticula with the symptoms of inflammation in the sigmoid colon, and in rectum on the border of middle ampullar and upper ampullar parts and proximally thickening and rigidity of rectal wall had been found out. RCT of abdominal cavity had shown multiple diverticula in the sigmoid colon, some indirect symptoms of presence of “chronic” abscess in Douglas cul-de-sac.
“Classical” scheme of positioning of troacars had been used: in the right iliac area, the right and left mesogastric area. The operation was started from rectum, identification of interfascial layer with help of Harmonic scalpel (”Ethicon”) device. In case, if it is not possible clearly visualize the layer between Toldt’s fascia and fascia Gerotae distally to the inferior mesenteric artery, the layer could be visualized under the inferior mesenteric vein. Transection of the inferior mesenteric artery was done near at the origin with LigaSure instrument (“Medtronic”). The next stage was exposure of the inferior mesenteric vein, identification of embryologic layer of the large colon, we use from media-to-lateral direction towards splenic flexure. For safe mobilization of the splenic flexure of the colon was dissected in inframesocolic way. Preliminarily dissection of pancreas should be done, then opening of omentum sac, after that the abdomen of the left lateral canal was incised, then mobilization of the descending part of colon and of splenic flexure of the colon took place. Then exposure of rectum along the posterior wall with the identification of the left ureter took place. Exposure of rectum is up to the infiltrate level along the posterior wall, then – along the right and left half - curcumference, and only after at the end-along the anterior wall. Transection of the large colon in the distal part was done with EcheloFlex-60 (a blue cassette) device (“Ethicon”). Then minilaparotomy was performed (about 5 cm), a latex ring “Dextrus” was placed in the wound to restrict tissues of the anterior abdominal wall from the colon. The colon was exteriorized, resection of specimen was done, the head of CDH-29 device (“Ethicon”) was inserted into the proximal end, it was fixed by purse-string suture, “Vicryl” 2-0 thread was used, then, it was immersed into the abdominal cavity. CDH-29 device was introduced transanally, created an anastomosis. Operation was finished by draining the small pelvis. The duration of operation was 130 minutes.

Laparoscopic D3 lymphadenectomy for right-sided colon cancer

Laparoscopic D3 lymphadenectomy for right-sided colon cancer.
D-r Puchkov D.K. (CMS) is performing an operation (2018).

In this film the technique of performing D-3 lymphadenectomy (operation stage) for right-sided colon cancer is presented. A 50 year-old male patient was treated with diagnosis: Cancer of hepatic flexure of colon fT3N1M0, G2. During preoperation investigation, on RCT research a few findings was detected: a big formation in the transverse colon, closer to the hepatic flexure about 5 cm in diameter, there were multiple increased lymphatic nodes in the mesentery of the ascending colon, without sings of metastatic lesion. There is no RCT information about local spreading of tumour. The first stage of operation: a 10 mm troacar was placed above the umbilicus and then 10 mm optic was introduced. Then a 5 mm troacar was introduced into epigastrium along the midline of abdomen under the guidance of optic and then 5 mm troacars were introduced into the right and left iliac area. During the revision of the abdominal cavity where was no evidence for liver metastases. The tumour was located in the proximal one-third of the transverse colon, is movable, firm, does not invade the serous layer, increased paracolic lymphatic nodes. Taking into consideration the intraoperation situation of the patient, we decided to perform a right hemicolectomy with D3 lymphadenectomy, high ligation of main arteries and veins. V.ileocolica was visualized, skeletonized and transected at the origin into the superior mesenteric vein with a 5 mm LigaSure (“Medtronic Covidien”) device, a. ileocolica is ligated in the origin of the superior mesenteric artery. Then the right part of the colon was mobilized from “downwards-to upwards” within the Toldt’s fascia by Harmonic Scalpel (“Ethicon”) device, a descending part of duodenum is visualized. The head of pancreas, infrapyloric lymphatic nodes were intact. Lymphatic nodes along the superior mesenteric artery and vein were removed. The operation is continued. Mesocolonectomy has been performed. The duration of this stage was 50 minutes.

Laparoscopic right hemicolectomy

Laparoscopic right hemicolectomy
D-r Puchkov D.K. (CMS) is performing an operation (2018).

A 61 year-old female patient was treated with diagnosis: Cancer of the hepatic flexure of the colon fT2N0M0, G2. During preoperation investigation of the abdominal cavity an extensive mass about 3.5 cm in diameter had been found out in the hepatic flexure of the colon according to the results of RCT. No lymph nodes were involved. The first stage: incision was done in paraumbilical area-3 cm. Platform QuadroPort+ (“Olympus”)was introduced into the abdominal cavity for performing one-port operation, CO2 gas was used for peritoneum. A 10 mm laparoscope, a 5 mm soft straight forceps and 5 mm curved forceps (“Medtronic Covidien”) and Harmonic scalpel device was introduced into the port. Firstly adhesion was separated. A. ileocolica was visualized, skeletonized and transected at the origin with 5 mm LigaSure (“Medtronic Covidien”) device. Then right part of the large colon was mobilized “downwards-to-upwards” within the boundaries of Toldt”s fascia with Harmonic Scalpel (“Ethicon”) device, descending part of duodenum and the head of pancreas were visualized. The peritoneum of the right lateral canal was transected, the gastrocolic ligament was resected up to the level of middle one-third of the transverse colon. Mesentery of the colon was mobilized up to the level of middle one-third of the transverse colic colon. Mesentery of the iliac colon was transected at the 10 cm proximally to Bauhin’s valve. The platform QuadroPort+ was removed from the abdominal cavity, resection of the right parts of the iliac and colon was done. Bistapler ileotransversoanastomosis “side-by-side” was formed. Anastomosis edges were additionally stitched by “Vicryl” 3-0 thread. The abdominal cavity was drained. Minilaparotomic wound was stitched layer by layer. Aceptic bandage was applied. Operation was about 145 minutes.

Anterior resection of rectum with the expanded D4 lymphadenectomy

Anterior resection of rectum with the expanded D4 lymphadenectomy
D-r Puchkov D.K. (CMS) is performing an operation (2017).

In this film the technique of performing the anterior resection of rectum with the expanded D4 lymphadenectomy is demonstrated. A 51 year-old female patient was treated, having the diagnosis: Cancer of upper third of rectum f T3N2M0, G2. During preoperation investigation of abdominal cavity organs by RCT multiple increased (up to 1.5-2 cm) lymphatic nodes along the inferior mesenteric artery, aorta, in the area of aorta bifurcation have been found out-mass of lymphatic nodes with the diameter up to 4 cm. The “classical” scheme of positioning of trocars had been used: to the right of the iliac area, and in the mesogastric area –to the left and right. The operation was started with aortocaval lymphadenectomy by a 5 mm Harmonic Scalpel instrument (“Ethicon”). Transection of the inferior mesenteric artery took place at the origin with LigaSure device («Medtronic Covidien»). Then dissection of peritoneum took place to the right of rectum, exposure of rectum along the posterior wall with the identification of the left ureter. The next stage was exposure of the inferior mesenteric vein, identification of embryologic layer of the large colon, its exposure in medialateral direction towards the splenic flexure. Then peritoneum of the left lateral canal was dissected, and mobilization of descending part of the colic colon took places. Exposure of rectum was done in 5 cm lower than the distal border of tumour along the posterior wall and then along the right and left semicircumference and only at the end-along the anterior wall. Transection of the large colon in its distal part was done with the EchelonFlex-60 (a blue reload) device (“Ethicon”). Then midline minilaparotomy was performed (approx. 5 cm), the latex ring “Dextrus” was placed into the wound to restrict tissues of the anterior abdominal wall from the colon with tumour. Colon was exteriorized, resection of specimen was done, CDH-29 device head (“Ethicon”) was inserted into the proximal end, it was fixed by purse-string suture, using ‘Vicryl” 2-0 thread and immersed into the abdominal cavity. CDH-29 device was inserted transanally, stitching was done. The operation was finished by placing drainage transabdominally via trocar wound in the right iliac area. Operation time was 140 minutes.