Virtual laparoscopic imaging for performing central vascular ligation through laparoscopic surgery for transverse colon cancer

Abstract

The need for complete mesocolic excision (CME) in colon cancer is well recognized [1]. Achieving CME requires central vascular ligation (CVL) at the root of the feeding artery of the colon cancer [2]. However, in transverse colon cancer, the complex vessel anatomy surrounding the middle colic artery (MCA, often the feeding artery) makes CVL challenging. Therefore, we present a new technique, termed virtual laparoscopic imaging (VLI), developed from footage taken using a simulated laparoscopic exploration. The scope was inserted into and moved through the abdominal cavity via an umbilical surgical port in a manner similar to actual laparoscopic surgery. This procedure involved using a 64-row multi-detector computed tomography (CT) device (GE Healthcare, Little Chalfont, United Kingdom) to take 1-mm slice CT images once patients were injected with 600 mg/kg of iopamidol using an automatic syringe. These vascular data were loaded onto a three-dimensional (3D) image analysis workstation (system volume analyzer) (Synapse VINCENT, Fujifilm, Tokyo, Japan) that automatically removed data from bone tissue and irrelevant local organ tissue to preoperatively create all VLI footage. This footage is able to reproduce actual surgical views observed intraoperatively and allows surgeons to preoperatively simulate surgical procedures. In the video, we present a patient from our consecutive series of 26 patients who underwent laparoscopic surgery for transverse colon cancer (T2-T4a) between April 2014 and December 2017. The video shows a case where VLI proved particularly useful for CLV complicated by anatomical difficulties. The patient was a 64-year-old woman who underwent laparoscopic transverse colon resection for transverse colon cancer. Preoperative VLI was used to carefully examine the patient’s vessel anatomy and develop a thorough surgical plan, after which the surgery was performed. In this case, the root of the MCA was concealed behind the first jejunal vein, where it drained into the superior mesenteric vein from the left side, making CVL challenging. Hamabe et al. [3] reported such vessel anatomy in 10.5% of cases and noted that it places the first jejunal vein, located in front of the MCA, at risk of injury should a standard procedure be undertaken. Preoperatively created VLI allowed for a comprehensive reconstruction of the layout of the vascular anatomy present at this location. This facilitated dissection of the first jejunal vein, mobilization to the caudal side, and exposure of the root of the MCA while avoiding the risk of bleeding from the first jejunal vein, ultimately leading to a safe completion of CVL. One advantage of VLI is its capability to replicate actual surgical views. Studies have reported vessel anatomical images constructed from 3D CT data [4, 5]; however, in these studies, the images comprised two-dimensional (2D) depictions, which a laparoscopic surgeon then had to convert into 3D representations and align with the surgical views. During a surgical procedure, the surgical scope is inserted into the abdominal space through an umbilical surgical port where it moves away from its initial umbilical position through a combination of pivoting motions and rotations; this sequence of motions mimics the view experienced by the surgeon. The use of the endoscopic simulator mode of the Synapse VINCENT workstation allows VLI to faithfully replicate the actual movements of a surgical scope, preoperatively providing surgeons with a video composed of images identical to the surgical views. This enables a laparoscopic surgeon to craft a surgical plan using more precise information to undertake a delicate CVL procedure with greater confidence. The use of VLI when performing CVL through laparoscopic surgery for transverse colon cancer provides the surgeon a benefit of enhanced knowledge regarding vessel anatomy and enables a more accurate estimation of the location of vessels during surgery. * T. Ishizaki [email protected]