Preface
Colorectal cancer is one of the common malignant tumors in China, and its incidence is on the rise. The 5-year survival rate of colorectal cancer after radical surgery hovers between 50% (rectal cancer) and 70% (colon cancer). At present, the diagnosis and treatment of colorectal cancer still emphasize early diagnosis and comprehensive treatment based on surgery.
Radical surgery for colorectal cancer can choose between traditional open approach and laparoscopic-assisted radical colorectal cancer surgery. Laparoscopic colorectal surgery has been widely performed worldwide and is the most mature surgical procedure in laparoscopic gastrointestinal surgery. Existing clinical studies have shown that with the increasing proficiency of laparoscopic techniques and the shortening of the learning curve, the intraoperative and postoperative complications of laparoscopic colorectal surgery are not significantly different from those of open surgery, while the operative time and intraoperative bleeding are comparable or even better than those of open surgery; with the appropriate use of the hand-assist technique, the rate of intermediate open surgery has also been reduced. The feasibility and safety of laparoscopic colorectal surgery have been confirmed in terms of operation technique. In principle, laparoscopic gastrointestinal tumor surgery must follow the same principles of radical tumor treatment as traditional open surgery, including
(1) Emphasis on the removal of the whole tumor and surrounding tissues;
(2) Non-contact principle of tumor manipulation;
(iii) adequate margins;
④Thorough lymphatic dissection. The long-term follow-up has the same local recurrence rate and 5-year survival rate as conventional surgery.
Most rectal cancers in China occur in the middle and lower rectum. There are various surgical methods for radical rectal cancer treatment, but the classical procedures are still transabdominal anterior rectal resection (LAR) and combined abdominal perineal radical rectal cancer treatment (APR), and various other modified procedures are rarely used in clinical practice. Total mesorectal excision (TME) can significantly reduce the local recurrence of rectal cancer after surgery and improve the 5-year survival rate. Laparoscopic radical rectal cancer resection should follow the principles of TME.
① sharp separation in the anterior sacral space under direct vision;
②Keep the pelvic fascia intact;
Compared with open TME, laparoscopic TME has the following advantages: more accurate judgment of the pelvic fascial wall bilayer gap and more accurate choice of access; more accurate identification and protection of the pelvic plexus by laparoscopy; more complete resection of the rectal mesentery by sharp dissection with ultrasonic knife.
Laparoscopic radical colorectal cancer surgery is a safe and reliable way to cure colorectal cancer, but the surgeon must have experience in laparoscopic techniques and colorectal cancer surgery or be trained in laparoscopic colorectal cancer surgery.
Indications and contraindications for surgery
I. Indications
The indications for laparoscopic surgery are similar to those for traditional open surgery. They include benign and malignant colorectal tumors, inflammatory diseases, multiple polyps, etc. With the development of laparoscopic surgery techniques and instruments, as well as the improvement of anesthesia and systemic support, the indications for laparoscopic surgery have been greatly expanded.
Contraindications
1. Tumor diameter >6 cm and/or extensive infiltration with surrounding tissues; severe abdominal adhesions, severe obesity, emergency surgery for colorectal cancer (such as acute obstruction, perforation, etc.) and poor cardiopulmonary function are relative contraindications to surgery.
2. Poor general condition, which cannot be corrected or improved despite preoperative treatment; serious heart, lung, liver and kidney diseases that cannot tolerate surgery are contraindications to surgery.
Surgical equipment and instruments
I. Conventional equipment
Including high-definition camera and display system, automatic high-flow pneumoperitoneum machine, flushing and suction device, video and image storage equipment. Routine laparoscopic surgical instruments mainly include pneumoperitoneum needle, 5-12 mm trocar needle, separation forceps, non-invasive intestinal grasping forceps and holding forceps, scissors, needle holders, vascular clamps and applicators, retractors and laparoscopic hooks, specimen bags, etc.
Second, special equipment
Including ultrasonic knife (Ultracision), ligature bundle high energy electric knife (LigasureTM vascular closure system), bipolar electrocoagulator, various types of bowel cutting sutures and circular anastomoses.
Surgical modalities and types
I. Surgical methods of laparoscopic colorectal cancer
The surgical methods of laparoscopic colorectal cancer include
(1) Total laparoscopic colorectal surgery: the resection and anastomosis of intestinal segments are done under laparoscopy, which has very high technical requirements and long operation time, and is rarely used in clinical practice;
②Laparoscopic assisted colorectal surgery: the resection or anastomosis of intestinal segments is done through small incisions in the abdominal wall, which is the most used surgical method at present;
Hand-assisted laparoscopic colorectal surgery: During laparoscopic surgery, the hand is inserted into the abdominal cavity through a small incision in the abdominal wall to assist in the operation.
II. Types of laparoscopic colorectal cancer surgery
The main types of laparoscopic colorectal cancer surgery are as follows
① laparoscopic right hemicolectomy;
②Laparoscopic transverse colectomy;
③Laparoscopic left hemicolectomy;
④Laparoscopic sigmoid colectomy;
(⑤) laparoscopic anterior rectal resection (LAR); (6) laparoscopic perineal resection (APR), etc.
Basic principles of surgery
I. Scope of surgical resection
It is equivalent to open surgery. The resection margin of the colon should be at least 10 cm from the tumor, and the distal rectum should be at least 2 cm, together with the primary foci, mesentery and regional lymph nodes; the operation of the rectum should follow the principle of TME.
Principles of tumor-free operation
First ligate the artery and vein at the root of the vessel and clear the lymph nodes at the same time, then separate the resected specimen. Operate gently, use sharp separation and less blunt separation, and try not to touch the tumor directly to prevent the spread of cancer cells and local implantation. On the basis of radical treatment of cancerous tumor, the function (especially the function of anal sphincter) should be preserved as much as possible.
III. Tumor localization
Due to the lack of hand touch in laparoscopic surgery, certain lesions are not easily detected, so preoperative barium enema, CT, intraoperative colonoscopic localization and other examinations can help localization.
IV. Intermediate open surgery
In the process of laparoscopic surgery, those who really need to perform open surgery for patient safety reasons, or those who find that the tumor cannot be resected under laparoscopy or the tumor margin is not adequate, should be promptly transferred to open surgery.
V. Pay attention to protect the incision
When removing the specimen, attention should be paid to protect the incision to prevent the tumor cells from implanting in the incision.
Pre-operative preparation
Preoperative examination should be performed to understand the distant metastases such as liver and retroperitoneal and mesenteric lymph nodes;
②Control relevant diseases that may affect the surgery, such as hypertension, coronary heart disease, diabetes, respiratory dysfunction, liver and kidney diseases;
③ Correct anemia, hypoproteinemia, and imbalance of water-electrolyte acid-base metabolism, and improve the patient’s nutritional status; ④ Perform necessary intestinal and vaginal preparations.
Post-operative observation and treatment
① Closely observe the patient’s vital signs, the nature and quantity of drainage;
② Maintain water-electrolyte-acid-base metabolic balance and give antibiotics to prevent infection;
③Continue gastrointestinal decompression until the intestinal function is restored, and after the anal discharge, a liquid diet can be given, and gradually transition to a regular diet with low residue;
④Comprehensive anti-cancer treatment after surgery, according to the nature of the tumor, chemotherapy, radiotherapy and immunotherapy are given.
I. Laparoscopic colon cancer surgery
1.Laparoscopic radical surgery for right hemicolectomy: Applicable to treat malignant tumors of appendix, cecum, ascending colon and hepatic flexure of colon.
(1) The end of ileum 10-15 cm, cecum, ascending colon, right half of transverse colon and part of large omentum and gastric omentum vessels should be removed; the ileocolic vessels, right colic vessels and right branch of mesocolic vessels and their accompanying lymph nodes should be removed.
(2) General anesthesia with endotracheal intubation. The operating table was tilted 30° to the left after completion of pneumoperitoneum to avoid obstruction of the view by the small intestine. The operator stands in the middle of the patient’s legs, the first and second assistants stand on both sides of the patient, and the operator can also stand on the left side of the patient.
(3) The umbilical port is punctured and a pneumoperitoneum is established, which may also be open. The intra-abdominal pressure is maintained at 12-15 mm Hg. Usually, the lens is placed at the umbilical orifice by a 10 mm suprapubic poke, a 12 mm poke 5 cm to the left of the umbilicus as the main operating orifice, and 5 mm pokes in the right lower abdomen and left and right upper abdominal midclavicular line.
(4) Abdominal exploration: to determine the lesion site, the presence of lymph nodes and abdominal metastases. If necessary, laparoscopic ultrasound can be used to investigate the liver for metastases.
(5) The operation is often performed from the inside out, from the bottom up, dealing with the vessels and non-contacting the tumor first. The colonic mesentery is opened along the projection of the superior mesenteric vessels, and the ileocolic vessels, right colonic vessels and mid-colonic vessels are dissected out and clamped and cut with vascular clips, and the lymph nodes at the root of the vessels are cleared. The gastrocolic ligament should be separated and cut outside the gastroretinal arch, and the right vascular branch of the gastroretinal reticulum should be cut for transverse colonic tumor of the hepatic flexure of the colon, and the lymph node group below the pylorus should be cleared.
(6) along the lateral side of the colon from the iliac fossa to the hepatic flexure of the colon, cut the retroperitoneum and free the ascending colon from the posterior abdominal wall. Care should be taken not to damage the posterior duodenal peritoneum, ureter, kidney, and intra-seminal (or ovarian) vessels.
(7) A small incision corresponding to the size of the specimen is made in the upper abdomen or under the umbilicus, and a plastic sleeve is used to protect the incision. In vitro resection of the right hemicolectomy, including the tumor, colonic mesentery and sufficient intestinal segments (terminal ileum, cecum, ascending colon and right transverse colon). End-to-end ileo-transverse colon anastomosis is usually performed (end-to-side anastomosis is also possible). Dilute povidone-iodine (PVP-I) is first applied to both ends of the intestine and then anastomosed. The free edge of the transverse colonic mesentery and ileocecal mesentery can be closed with or without sutures.
(8) After closing the small incision, re-establish the pneumoperitoneum, flush the abdominal cavity, place drainage, and close the abdomen after checking that there is no bleeding.
2.Laparoscopic transverse colectomy: applicable to cancer of middle transverse colon.
(1) Adopt general anesthesia with endotracheal intubation. The patient is placed in supine position with legs separated by 30°~45°, head high foot low position 15°~20°, and the tilt direction and angle of the operating table can be adjusted according to the need of surgery. The operator stands on the left side of the patient when separating the right hemigastric ligament, and on the right side when separating the left hemigastric ligament, with the laparoscope holder standing between the patient’s legs and another assistant standing on the opposite side of the operator.
(2) A 4-hole approach is generally used. The lens is placed through a 10 mm subumbilical poke hole, a 10 mm poke hole in the right mid-abdomen, a 10-12 mm poke hole in the left mid-abdomen, and a 5 mm poke hole between the glabella and umbilicus. The puncture site can be adjusted according to the location of the tumor, and the position of the ultrasonic knife and operating forceps or even the laparoscope can be switched according to the actual situation.
(3) Exploration: 30° laparoscope is placed to explore the abdominal cavity to understand the location and size of the lesion and its relationship with surrounding organs, and to understand the metastasis of lymph nodes and other organs in order to determine the scope of bowel resection.
(4) Free the transverse colon: cut the right gastrocolic ligament along the great curvature of the stomach below the vascular arch of the omentum, loosen the hepatic flexure, and pay attention not to damage the duodenum and bile duct. Dissect the left gastrocolic ligament, loosen the splenic flexure, lift the transverse colon, identify the vessels of the transverse colonic mesentery, separate the root of the transverse colonic mesentery, cut the root of the middle colonic artery with a titanium clip, and cut the transverse colonic mesentery.
(5) Remove the diseased intestinal segment: enlarge the 4th hole to the appropriate size, protect the incision with a plastic bag and then remove the free diseased intestinal segment.
(6) Excisional anastomosis: excise the intestinal segment 10-15 cm away from the tumor outside the body, and perform end-to-end intestinal anastomosis, and close the mesenteric fissure with sutures.
(7) Suture poke: after the anastomosis, the intestinal segment is retracted into the abdominal cavity, the small incision is sutured, the pneumoperitoneum is reconstructed, the abdominal cavity is checked for bleeding, the abdominal cavity is flushed, drainage is placed, the trocar is removed, and the poke is sutured under the skin.
3. Laparoscopic left hemicolectomy: Applicable to malignant tumors of the splenic flexure of the colon, descending colon and sigmoid colon. The resection should include the left half of the transverse colon, splenic flexure, descending colon, sigmoid colon and the corresponding mesentery and blood vessels, if there are enlarged lymph nodes in the splenic portal, they should also be removed.
(1) Endotracheal intubation is used for general anesthesia, and the patient is usually placed in a lithotomy position with the head low and feet high to 15°-20° and tilted 15-20° to the right. The operator and the assistant holding the mirror stand on the right side of the operating table, and the first assistant stands between the patient’s legs.
(2) Poke hole selection: umbilical port for lens placement; a 5 mm poke hole on the midline of the clavicle 3-5 cm below the right and left rib margins; a 12 mm poke hole on the left side of the umbilicus at the external edge of the rectus abdominis muscle, which can be enlarged for specimen removal; and a 5 mm poke hole on the right lower abdomen.
(3) Open the right peritoneum of the colon in front of the abdominal aorta, separate the left colonic artery and vein as well as one or two branches of the sigmoid artery and vein, ligate them and cut them off, and separate the colonic mesentery, paying attention to preserving the blood supply of the intestinal segment.
(4) Cut open the descending colon and the lateral retroperitoneum of the sigmoid colon, and separate the left colon and its mesentery, taking care not to damage the ureter and the arterioles in the spermatic cord (or ovaries).
(5) Open the gastrocolic ligament and separate the splenic flexure of the colon. Separate and sever the left branch of the middle artery of the colon.
(6) Cut off the root of the transverse colonic mesentery attached to the body of the pancreas and the lower edge of the tail, taking care not to damage the mesocolic vessels.
(7) Ex vivo resection of the left hemicolectomy, including the tumor, sufficient intestinal segment and colonic mesentery, and end-to-end transverse colon-sigmoid anastomosis. Close the mesenteric foramen.
(8) After closing the small incision, re-establish the pneumoperitoneum, flush the abdominal cavity, check for no bleeding, place drainage and close the abdomen.
4.Laparoscopic sigmoid colectomy: It is applicable to cancer of the middle and lower sigmoid colon. The laparoscopic sigmoid colectomy is similar to laparoscopic low anterior rectal resection (Dixon surgery) in terms of position, poking hole and surgical steps. If the tumor is high or the sigmoid colon is free, the segment can be removed and anastomosed outside the abdominal cavity, simplifying the procedure and saving the cost of expensive anastomoses.