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After placement of laparoscopic instrumentation, dissection was begun to identify the area of tumor. Mesentery was taken down using a medial to lateral approach and dissection continued protecting the ureter and iliac vessels. Dissection was carried to the sacral promontory and high ligation of the inferior mesenteric artery performed. Dissection continued, freeing adhesions, and the splenic flexure was taken down. The rectum was stapled across. The colon was eteriorized and a proximal resection point determined. An incision was made in the proximal bowel and the anvil placed. The proximal bowel was stapled across and the bowel with anvil replaced in the abdomen. After checking tension and doing a further release to gain more length, the stapler was connected to the anvil and orientation checked. The anastomosis was completed and a leak test performed before closure.
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General Surgery Specialty
Colorectal Surgery Subspecialty
Cedars-Sinai
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Past Notes
Good morning. My name is David
Magner, I'm the clinical chief
of colorectal surgery here at Cedars
Sinai Medical Center in Los
Angeles.
And this morning, we're gonna be
filming and going through a
laparoscopic low anterior resection.
That's just for some brief
background. The patient
is a 50 year old female who
first noted bright red blood
per rectum a couple of months
ago. This progressed and became
melancholic stool.
She was therefore referred for Colon
ASCAP and found to have
a large
rectal mass at about 12 centimeters
from the anal verge.
Further workup revealed normal seei
level and a
imaging reveals no distance
spread, but concerned for
peri clonic lymph lymphadenopathy.
So today we'll be going through a
Laboris copied Lonetree resection
with a end to end Anasta
Moses double stapled technique.
So this is a 50 year old female
who have some bleeding.
Several months ago, incorrectly,
she just got a call and ask me was
reveals a moderately
differentiated adenocarcinoma.
The rectal sigmoid.
This was tattooed.
Remainder of her staging workup
reveals likelihood of suspicious
nodes and the immediate peasantry
and no distant spread.
So we'll start by placing
the camera ports.
I do this as a modified Hassan
technique, beginning with the one
centimeter incision, and then I just
score
superficial most layer
to love purchase of the Army Navy.
I do a blunt dissection down to the
Fascher grasp the Fascher
with Cokers on either side.
That's you. That's your fascher.
And one more, Kelly, me
now reach in and grasp the
first name,
we insert the ten trocar.
That's a plate I use the balloon
trocar cause I just like that
trigger never comes out accidentally
during the case.
First thing we do is a quick survey
of the abdomen.
Now we're going to place our working
port and these I do the same for an
L.A. R and sigmoid ectomy
proximally to finger breast from the
as it in a hand's breath above
and a little offset towards the
midline upper is gonna be a five
millimeter port for my grasper
and the lower is a 12
millimeter that I use both for the
ligature and also for the stapling
device, Snel position, the patients.
Very important for these cases.
We'll do Trendelenburg X and left
side up.
She's had a cholecystectomy
and a appendectomy
and two C-section.
This looks like a scar to her
C-section.
Now we'll look for the test to
see where this is.
So this was initially described at
20 centimeters when I did my
measurements measure
here, which is at 12 centimeters.
So this will be a basically
an anterior resection.
But that's our target right there.
You can feel the tumor.
Look at our anatomy.
This is our vessel.
Here I am, a sweet,
small ball out of the way
to visualize the area.
OK, so we're going to start here.
Same thing we to move all way down
here so we can begin just
by scoring.
Sometimes you can do this just with
the vessel sealer itself.
Again, this is cancer.
Sure, you want to get low?
Well, we try to do is get right into
this area here, just Distel
or inferior to the vessel,
too.
And same thing we're doing here.
We're just going to look, keep
the vessels down, keep the ureter
down and make sure we're in the
right place. We're starting to see
it here prior to
dividing anything.
You want to make absolutely sure
that we're not pulling anything up.
So let's look in there.
We're starting to see our vessels, I
think, already right here.
So we're just developing this
potential space
between the Muslim and the
retroperitoneum.
You see what the technique is,
basically just gentle sweeps
as we work our way out to the
lateral side while this is a medial
to lateral approach.
Now come here and start identifying
to Aesir early x so
we know the ureter should be medial
to that and it should be
right here.
And there it is.
This is our year here.
We're going to look for that to
regulate.
And if it seems stubborn, you can
give it a little bump.
And generally will move it good.
So now we feel safe that the ureters
down in this position
and then the technique here is
just to test the mystery and the
aimé up trying to sweep
down any connections to the
retroperitoneum.
Basically as far several out as you
can go.
You want to free it up from the
from the kidney, from the
duodenum, and equally,
you want to start going down.
And same movement down here, just
keeping everything down.
Make sure that you're at or stay
down.
We're going to work our way all out
to the lateral wall here.
We just want to go all the way out
laterally and now see that
difference there. That's the lateral
side wall.
Everything's down.
We know you're down in good
shape.
Now, what we'll see is here should
be a fairly easy dissection
now to do the lateral take down
and create a starting point for
ourself.
And we'll see how this is all that
dissection is all done from the
medial side. This is all free now.
So now we're just moving up the
line at Tolt just to make sure
we have a tension free and ask
the Mozes
sometimes in Tennessee, here is a
dig into the sidewall because
you're afraid of getting into the
colon. But again, remember, the
metastatic cells don't spread.
They spread towards them.
Mesenteric. So we can stay fairly
close on the lateral side
of the colon.
Now let's look at our.
She the medications between the
colon and the ovary
here.
And again, we've already identified
that the order is down.
So if this were true sigmoid ectomy,
well, we would look for save for a
case of diverticulitis.
Well, we'd look for here is the
tinea coalescing
into the rectum, which is right
here. So they see this distinct
tinea here starting to coalesce.
And now there's no further Tinian
because you have a solid sheet.
This is a top of the rectum.
This case is actually a low anterior
resection for their tumor.
Read about 12 centimeters a
proportion of the rectum.
So we do have to continue down and
we're gonna do now is aim for
the sacral promontory and get into
the Temmy plane.
We're aiming for his base to this
kind of cul de sac here.
Helping them Circle Promontory.
And again, we're going to see where
the water is.
There it goes.
OK.
Come back up here so we know it's
going right here.
So this is one of those dangerous
front that's getting into our
plane there.
You start seeing that nice aerial
plane.
So now over the Circle Promontory
and we're coming down into this
plane that we see here.
Make sure you have good tension
upward. Still no where you're going,
which is going to be right there.
This being sidewall, this being what
we want. A
little reaction from the tattooing
here.
This is that plane. We want
to bulky tumer
look like it's through the walls
skin.
Take them lateral stock here.
Tumors up here.
Too is Distel, Toure
is here.
Bottom edge of the tumour is right
where this is.
Okay, so that's plenty of a margin.
That's probably about a seven
centimeter margin.
Now we just to make sure
everything's free. So.
Look at the other side.
And again. And just free up
laterally the lateral stocks down
the side. Here's our ureter.
Should be running up the side wall
here.
I guess we're just gonna go right
down to this and level
this side where here is all free.
Bottom to Reg is right here.
Tumer is right here.
So we've got plenty of it.
This is their analysis.
Look at our other
stuff. She's young and healthy,
so I don't think we need to staple
some.
So we do a highlight station here
of the I am
monkey.
So we took the vessel and
approximately.
Yeah. So I think I'll go right here.
Proximally this can be done.
Extra corporally or intercourse.
Really clean it up to the level of
the colon like we did before.
Think that's where we'll go now.
So make sure we have enough freedom.
Just going to free this laterally.
You'll see. This is a small ball
coming through our mesenteric
defect.
Rest of the mesenteric want to keep
it. We do want to get all these
sidewall adhesions down.
They're calling here.
The said.
I just want to create the space.
And there's our spleen right there.
Tip of the splain here.
There's a sulcus between the mystery
and this kidney
one, develop this plan,
and this allows a lot of reach.
You take down the splenic collection
and think.
Take down this one.
You see your edge here.
Come over the top and see the
backside.
Good.
Not a lot of blunt this section up
here by the spleen.
Now, come this way.
And I do think there is one more
band here that's holding us a little
bit stunned like this.
It's pretty good.
And this is all for you.
It should be nice.
Some moves coming down.
Laxity.
This is still a small
ball.
It's healthy. What do you think?
That's good. But down the bottom, do
a resection.
So any
Eskimos is below six centimeters.
Divert and then
anything.
And then any
one that's had radiation, chemo or
radiation or like rectal cancer,
we divert obviously
low albumin, steroids, things like
that.
Yes,
it is.
I was gonna take it down the
beginning and then the same thing.
This will just help us stay on.
We'll take a little little freedom
beyond where we're going to
go. So I think we can go right
here and do the same thing we did
before, which is get up to the
colon.
So this is an anterior resection
because we're not taking the entire
rectum and Muzo.
Measle reckoned he would want to
savor some capacity
if we can.
Let's try the echelon with the green
look. I'll probably need two firings
of it.
It looks like on the bottom when it
come in, lift us up
and then we're gonna clean out here.
Yeah, I'm going to clean up the
posterior wall.
Articulate then versus the wall.
We try to come in.
Here was our spot right there.
I think we a little more.
It's a little crowded in here.
Any lower than this is definitely
really benefited by the
Da Vinci robot system.
But at this level, you could see you
were coming across really low.
We tracked it to the patient left
just to straighten out a little bit.
And it will be a two by.
We're just trying to stay in the
same kraj without getting the
sidewall.
It looks good.
Good.
So think of the size of that tumor.
I think it's gonna be better to do
it. Take it up here.
We don't need it.
Good. So see how big the tumour
is. So depending on the size of the
tumor, we can extend this a little
bit more if need be.
But that's the only limiting factor
here.
Excellent.
Let's see how big this thing is.
Do you see that right there?
That is a nice Muslim there, in
fact, there
is a tumor right here.
Yeah, sure. Come on.
Thanks very much, company.
He was almost out.
Here we go.
Make sure you don't twist, it's the
other twisted on the way out.
Always check the Muslim theory.
Good.
So there's our tumer big
reveal, feel that response
from here to here.
So plenty. Twenty eight centimeter,
perhaps greater
good.
All right. So let's just decide on
our proximal resection point.
This is all gone.
Of amazing, Terry.
I'd say this is a nice vessel
here.
Right about here. We'll do the add
the double staple.
Don't you feel it right
there.
On the ball, do we need to get a
little closer, look closer right
now, what we do is
make an incision distal to her and
that's muscles is going to be.
So just use your Bovey.
Open this up.
Just big enough to get the M
to get the Antoin, like, right from
my finger down this way.
Yeah. Perfect.
Think the animal on a stick.
Grab that side.
Take one more.
Now you just run this proximally.
And now we go back and do our
decision point to get that cleaned
up.
Thank stapler right there.
Perfect. So we use green lows below
for the thicker bell and blue loads
up here.
And then I just bring this back up.
Grab your boogie.
I'll come out right over the staple
line. Just put a hole right down the
middle of the pipe.
So let's slam us out.
I'm sure that all your guests.
Okay, let's clean off a little bit
here.
Is there a specimen you can take
this colostomy is proximal
cause it looks nice and healthy
skin.
Put that back in there.
They just put a tight,
thick gloves here.
So now we go to check to think and
check the health, which we all
looked at, it looked nice and
healthy. We got a check.
Tension and actual
stuff is pretty low.
We're gonna need to do some more
words, see?
That's too tight. So we have to do
some more clarity.
Let's take a look up here.
We will have to do the entire
splenic flexure, which is OK.
For that, we will need another port.
So I'm going to pull one more for
them.
So I'll just make it equal distance
port on this side.
OK. So solve everything or see
what's holding us up.
Let's explain all the way down
there.
Let's come up here.
To take a little bit more here.
But we don't think many more
vessels.
That's better.
OK.
Let's look now right up the
road at the moment.
So here is
right up in this corner here.
And over the top, we just want to,
again, make sure nothing's almost to
go up the top.
That's that same vessel, right,
which we need to keep
should lay down nicely.
No, it's look under here.
So I'm going to go below and I just
want to see how far that comes
up, I think.
Always got a cell phone.
OK, so same thing we
did before. Let's just see how far
this comes up.
I want to make sure there's absolutely
no tension on this.
Yeah. So now.
Pretty good. She's got about eight
centimeters left.
What I like to do is you take the
call back up, out a little bit so we
can see what we have.
You grab it with the anvil grasper.
The anvil actually is perfect.
Just grab it there and really crank
it all the way close and then look
down into the pelvis.
And what I'm going to try to do is
come up with this and pick a good
spot to come up.
That's it. So Spike is coming out.
Yeah. And then just circlet with the
animal. Just put it straight down
here. Just want to see a little bit
of orange come out.
Yeah, that's pretty good.
And the key again is to lock
this anvil on the smooth
part of the column and not the
revoted part.
Fall her down.
I should be going soon.
Good. And I heard a click.
Good. Come on.
Now, before we lock it down, let's
take a look at the mesenteric.
So get your other big blue in there.
So it looks pretty. I'm going to
close down. But then we're going to
reach out. Once I have it closed.
OK.
OK. So Santa closed down.
Now take a look at the mesentery.
But physically, I want you to use
your big balloon.
Make sure it's straight
because that looks perfectly
straight forward all the way down.
Good. That's the monitor.
Nice and straight. Nice and
straight.
OK. Now we're going to do that leap
test again.
You didn't go across it with that.
That's fine.
That's good. That's about grasper.
Is that a. Oh.
Okay. I always look for bubbles.
Look down into the bottom.
So we do now as we clamp the bottle,
we fill the pelvis, are sailing,
submerged. The submerging
Nasta most of.
And now I'm doing a flex sig
directly directly.
Visualize the anastomosis and then
see if there's a leak.
So here's the Anasta Moses.
That's most of the intact certain
inferentially.
And there any leaking.
I see no bubbles are good.
Can you submerge. L push forward a
little bit. Submerge it.
Make sure you're completely submerged.
Good. That's a negative
sigmoidoscopy.
Good.
Oh. Before you get up and suck all
the fluid up.
All right. Good.
Does it look healthy?
No tension.
Oh, looks good.
Can make sure all the small balls on
the side. Which it is.
Yeah. Here again.
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