Synchronous laparoscopic right colectomy and rectal resection – a video vignette

Synchronous colorectal carcinoma is defined as the presence of two or more primary invasive adenocarcinomas identified in an individual at the time of first diagnosis [1]. A common question on intra-operative surgery that is posed to surgical trainees during colon and rectal procedures is whether or not it is safe to perform synchronous colonic resection and an anastomosis [2]. The laparoscopic approach is feasible in double colonic resection and may always be considered to improve postoperative outcomes [3]. We present a laparoscopic approach for synchronous caecal and rectal carcinoma, using a three-trocar technique, in an 82- year-old male patient with CT-confirmed absence of the left branch of the middle colic artery. The aim of the didactic Video S1 was to demonstrate a feasible technique for laparoscopic right colectomy and rectal resection, using a primary vascular approach. Video S1 concentrates on the key vascular steps needed to perform a radical lymphadenectomy safely. The first step of our technique is identification and sealing of the ileocolic pedicle using the energy device Ligasure AdvanceTM (Coviden, Mansfield, Massachusetts, USA; which combines monopolar tip dissection and a vessel sealer divider and is associated with reduced blood loss and operative time [4]), dissection of the duodenum and the pancreas with high sealing of the right branch of the middle colic vessels, then medial to lateral dissection of the right retrocolic space along Toldt’s fascia. According to the principles of the ‘no touch’ technique, the right colon is only mobilized laterally after the vascular supply has been interrupted, which also facilitates retraction during the medial to lateral dissection. After right colonic resection, we perform a primary anastomosis with a completely intracorporeal side-to-side stapled isoperistaltic anastomosis between the distal ileum and transverse colon, and finally a laparoscopic hand-sewn double-layer closure of the enterotomy. Rectal resection is conducted using the same principles of ‘medial to lateral’ shown above, with a stapled end-to-end colorectal anastomosis; the specimens are extracted through a 4-cm minilaparotomy incision, as shown at the beginning of Video S1. The patient’s postoperative course was uneventful, and the results of the histology performed on the specimens extracted during the procedure was ypT3N0R0 for the caecum and ypT2N0R0 for the rectum. The laparoscopic approach for synchronous colonic cancer is safe and effective, but careful patient selection with accurate preoperative staging is paramount. A major vessel sealing device, used as reported in our previous study may reduce the operative time, number of surgical instruments and cost.