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A 51-year-old male patient with no relevant medical history or surgical history underwent a laparoscopic cholecystectomy in 2012.
After a positive occult blood dregs test, a study was initiated. The colonoscopy was performed, finding a colon neoplasm 8 cm from the anal verge. The pathology was compatible with adenocarcinoma.
An abdominal CT was performed as part of the extension study. It showed a intestinal malrotation as an incidental finding.
An MRI was performed to complete the study, which showed the rectal tumor to 10 cm from the anal verge,with an area of 5 cm, T3bN0 (same result in EUS)
The patient received neoadjuvant chemotherapy and radiotherapy. The control MRI was showed the lesion with an extension of 3 cm, yrmT3byrmN0 stage. Then it was decided to perform a 3D laparoscopic LAR by Cecil Approach within a suitable timeframe.
The patient was placed in the supine position with open legs. A total of 5 trocars were used. A 12mm trocar was placed in the umbilical position for a 30° scope, and three 5 mm served as working channels for the leading surgeon at the epigastrium, each flank, and right lower quadrant.
This video focuses on the abdominal approach and the resolution of the intestinal malrotation:
Once the surgery had started, we were able to objectify the sigma position on the right side of the patient and the cecum with the appendix in a medial position. The sigmoid colon ascended to the hepatic flexure, then the colon transverse went to the splenic flexure and finally we were able to see the cecum medially.
We proceeded to release of the cecum from the transverse colon in order to correct malrotation. The peritoneum was opened and blunt dissection was initiated; this maneuver was improved by the pneumo enhancing of the avascular plane.
Then we continued with the release of the transverse colon. We had to perform a very careful dissection to avoid damaging the mesocolon. We continued with the release of the left colon to correct malrotation and place it in its normal position.
Then we performed the dissection of the colon at the right parietocolic level. The right ureter can be seen to be in the retroperitoneal position.
The retroperitoneal structures should be taken into account to avoid vascular and ureteral injuries. It is important to be careful during these maneuvers.
Once the left colon had been mobilized, we identified the inferior mesenteric vessels which came from the right side due to the intestinal malrotation. We proceeded to meticulously dissect them. The LigaSure™ and clips were used to section the IVM and avoid bleeding.
Medial to lateral dissection was performed, leaving the posterior aspect of the colon free. Traction and countertraction movements are essential to perform this stage of the surgery.
Finally we had the sigma in its normal position, so we could complete the surgery.
We performed a Low anterior resection by Cecil Approach by means of a mechanical end-to-end anastomosis with no complications.
The surgery took 100 minutes. During the postoperative period the patient presented a paralytic ileus that was resolved through conservative treatment. The patient started oral intake and had a productive ileostomy with no other incidents. The patient was discharged after 10 days.
The pathological examination showed an adenocarcinoma ypT2N0.
We proceeded to close the ileostomy 10 months later. The patient currently has a good quality of life and correct fecal continence.
