Table of Contents
Colonic polyps are projections from the surface of the colonic mucosa. Most are asymptomatic and benign. Over time, some colonic polyps develop into cancers. Colorectal polyps are classified as non-neoplastic and neoplastic. Non-neoplastic polyps include hyperplastic, inflammatory, and hamartomatous polyps. They are typically harmless and do not become cancerous. Neoplastic polyps include adenomas and serrated polyps. They are premalignant lesions that may progress to colon cancer over time. In general, the larger the polyp, the greater the risk of cancer, especially with neoplastic polyps. Polyps are diagnosed using colonoscopy and are removed via polypectomy if they are small and pedunculated. If the polyps are too large or cannot be removed safely, they may be removed by colonic resection.
Carcinoid tumors develop from cells in the submucosa. They are slow-growing neoplasms. Carcinoid tumors of the colon are rare, comprising less than 11% of all carcinoid tumors and only 1% of colonic neoplasms. The majority of patients diagnosed with carcinoid tumors have no symptoms, and their tumors are found incidentally during endoscopy. Treatment of these tumors depends on the size, location, and presence of metastatic disease. Tumors less than 1 cm can often be excised locally either by endoscopy or for rectal lesions via a transanal approach. Carcinoid tumors larger than 2 cm require formal oncologic resection.
Here we present a middle-aged male who had an unresectable polyp in the ascending colon and a carcinoid tumor in the ileocecal valve. The patient underwent laparoscopic right colectomy with ileocolic anastomosis to remove both lesions.
This patient underwent a laparoscopic right colectomy with ileocolic anastomosis as a curative procedure that removed both an unresectable polyp that was found in his ascending colon as well as a carcinoid tumor that was incidentally found at his ileocecal valve. In this case, the patient required surgery because the mass in his ascending colon was too large to be resected by endoscopic means, and carcinoid tumors of the ileocecal valve are also not suitable for endoscopic resection. This procedure allowed the patient to have both tumors removed in one surgery and required only one anastomotic connection between his small and large intestine, lowering the chance of postoperative complications. By doing this procedure with a laparoscopic approach the patient is able to have a shorter and easier recovery with a more cosmetic outcome. The surgeons were able to resect both of the patient’s abnormal growths because the patient’s colonic polyp was located in his ascending (right) colon, just distal to the ileocecal valve, and had a blood supply that originated from the same major blood vessel. This approach allowed the surgeon to resect both growths in the same operation and reconnect the patient’s small intestine to his remaining large intestine, eliminating the need for an ileostomy and helping the patient to retain much of his large intestine for normal functions.
A middle-aged white male was found to have an unresectable polyp in his ascending colon on colonoscopy. Incidentally, on further work-up, the patient was found to have a carcinoid tumor at the ileocecal valve. Due to the nature of these two masses, a laparoscopic right colectomy with ileocolic anastomosis was performed.
Aside from the detection of occult blood on a digital rectal exam, the physical examination is usually not helpful in the diagnosis of colon cancer.
Colon masses may be picked up on screening colonoscopies or incidentally on other abdominal imaging a patient may receive. However, when a colon mass is suspected or identified a further work-up should be performed including a CT chest, abdomen, and pelvis with both oral and IV contrast. This imaging modality allows for the estimation of the preoperative staging and helps determine the best surgical approach. This modality of imaging offers an accuracy of 73-83% for determining the T stage, a 59-71% for determining the N stage, and an 85-97% for determining the M stage of the disease.1
Most colon cancers are asymptotic in their early stages, which is why the United States Preventive Services Task Force recommends all adults to begin screening colonoscopies at age 50 and continue them every 10 years if no pathology is found.2 A general rule of thumb is that colonic cancers located in the right (ascending) colon tend to slowly bleed leading to signs and symptoms of anemia including but not limited to fatigue, low energy, pallor, shortness of breath, and/or elevated heart rate. Colon cancers located in the left (descending) colon, sigmoid colon, or rectum tend to alter the diameter of a person’s stool as the mass narrows the lumen in which the stool passes.3 Carcinoid tumors tend to be completely asymptomatic until widespread metastasis has occurred. The neuroendocrine function of carcinoid tumors means that they produce hormones, mainly serotonin, a monoamine hormone. Since the venous blood supply from the gastrointestinal tract flows first into the liver through the portal system, excess serotonin produced from the tumor is broken down by the enzyme monoamine oxidase found in the liver and the patient remains asymptomatic. Once the carcinoid tumor has metastasized to or beyond the liver, excess serotonin can enter the circulation and leads to signs and symptoms referred to as Carcinoid Syndrome. These symptoms include diarrhea, cutaneous flushing, wheezing, and right-sided heart strain.4
Colon cancers originate as either polyps or flat adenomatous lesions. The natural progression of colon cancer ranges from asymptomatic in early stages to complete obstruction and potential perforation in later stages. As a mass in the colon continues to grow it can grow into adjacent structures and/or into the lumen of the bowel leading to obstruction of bowel contents. Once enough tissue disruption has occurred due to cancer, patients may present with an acute abdomen due to perforation of the bowel.5
As stated above, small growths that arise in the colon can often be removed during the colonoscopy and be sent to pathology to confirm if the growth was cancerous or not, as well as if the mass was removed entirely. In this case, the patient’s colonic mass was too large to be removed during colonoscopy; therefore, he required surgical colonic resection. In addition, the patient was able to have his carcinoid tumor removed during the surgery before it had the chance to grow and metastasize to the rest of his body. Given the fact that this patient had both a large colonic polyp as well as a carcinoid tumor, his only option was to have his right colon and a small portion of terminal ileum removed.
One goal for the treatment of this patient was to remove the two masses in question. By removing these masses in their entirety, a pathologist is able to study them in further detail and determine the extent of the patient’s disease. In addition, they are able to assess the lymph nodes that are resected within the mesentery of the specimen for any spread of the disease. The second goal of this procedure was to reconnect the patient’s small intestine to his remaining large intestine to avoid the creation of a diverting ileostomy. With the help of this, the patient was able to retain normal bowel functions including the absorptive function of the large intestine and the continence that comes with having a fully-connected gastrointestinal tract. This surgery was successful in removing the patient’s masses allowing for further analysis, which will help to determine if further treatment is necessary.5
An adequate lymphadenectomy is critical for accurate staging of both adenocarcinomas and carcinoid tumors of the bowel. A minimum of 12 lymph nodes should be examined to achieve accurate staging. In the case of carcinoid tumors, the primary lesion is often small and may even present with lymph node metastases. Hence a thorough lymphadenectomy is especially important in this patient.
The goal of a surgical right colectomy in this patient is to remove the mass with at least 5-cm margins on both the proximal and distal ends of the mass and a 1 mm circumferential margin. In addition, the ideal resection for possible cancers is to remove 12 or more lymph nodes that are found within the mesocolon that is transected during the dissection process. To do this resection, the ileocolic vascular pedicle is identified, dissected, and transected near its origin. This allows access to the retroperitoneum. The mesentery is dissected away from the retroperitoneal tissue and duodenum and then the lesser sac is entered. This allows the division of the attachments of the hepatic flexure to occur to complete the mobilization of the entire right colon, hepatic flexure, and proximal transverse colon. After the mobilization and division of the vascular pedicle, a transversus abdominis plane nerve block is performed, and the colon is externalized through a periumbilical mini-laparotomy. The bowel is then resected, anastomosis created, and then returned to the abdomen. The procedure is completed by closing the mini-laparotomy.
This presentation of a colonic mass is unusual because it was located adjacent to a carcinoid tumor found at the ileocecal valve. Due to the proximity of these lesions and the fact that the colonic mass was too large to be removed by colonoscopy alone, the patient opted to undergo a right colectomy in which the ileocecal valve was also removed, and primary anastomosis was created between his remaining ileum and transverse colon.
Large masses in the colon are presumed to be cancerous until proven otherwise and must be taken out for further pathological examination and to prevent further spread of disease. Colon cancer affects around 150,000 Americans per year, with approximately a third of patients dying as a result of the disease.6
While some advanced centers can offer endoscopic resection for low-grade tumors (i.e. carcinoma in situ in a sessile polyp), it is not widely available, and the mainstay of treatment for patients with non-metastatic colon cancer is surgical resection. Neoadjuvant chemotherapy has no role in the primary treatment of localized colon cancers.
Many randomized clinical trials including the COLOR, CLASSIC, and COST trials have shown that laparoscopic-assisted colectomy surgery has the same outcome (69%) as open surgery (68%) in terms of 5-year survival. In addition, retrospectively it has been found that open surgery resections have a higher positive margin rate at 5.3% with a hazard ratio of 3.39, 95% CI 2.41 – 4.77.7 The usual length of hospitalization following laparoscopic right colectomy is 2-3 days. The use of enhanced recovery after surgery (ERAS) protocols has been an essential component of post-operative care, shortening hospital stay, and reducing complication rates. Most patients with node-negative colon cancer ( i.e. Stages I-II) are cured by surgery alone. Some patients with Stage II adenocarcinoma that has aggressive histologic features (such as lymphovascular invasion) may benefit from adjuvant chemotherapy. The risk/benefit ratio is such that decision making should be individualized. However, adjuvant chemotherapy is clearly indicated for those with Stage III tumors. Treatment of patients with isolated liver metastases needs to be individualized and should be discussed by a multidisciplinary tumor board to optimize treatment planning.8
No special equipment used.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Cappell M. Pathophysiology, clinical presentation, and management of colon cancer. Gastroenterol Clin N Am. 2008; 37: 1-24. https://doi.org/10.1016/j.gtc.2007.12.002
- Whitlock E, Lin J, Lines E, Beil T, Fu R. Screening for colorectal cancer: a targeted, updated systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008 Nov; 149(9):638–58. https://doi.org/10.7326/0003-4819-149-9-200811040-00245
- Recio-Boiles A, Cagir B. Cancer, colon. In: StatPearls [Internet}. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: http://www.ncbi.nlm.nih.gov/book/nbk470380/
- Ito T, Lee L, Jensen R. Carcinoid-syndrome: recent advances, current status, and controversies. Curr Opin Endocrinol Diabetes Obes. 2018 Feb; 25(1): 22-35. https://doi.org/10.1097/med.0000000000000376
- Kijima S, Sasaki T, Nagata K, Utano K, Lefor A, Sugimoto H. Preoperative evaluation of colorectal cancer using CT colonography, MRI, and PET/CT. World J Gastroenterol. 2014 Dec;20(45):16964-75. https://doi.org/10.3748/wjg.v20.i45.16964
- Jemal A, Siegel R, Ward E, et al. Cancer statistics. CA Cancer J Clin. 2007;57:43-46. https://doi.org/10.3322/canjclin.57.1.43
- Yozgatli TK, Aytac E, Ozben V, Bayram O, Gurbuz B, Baca B, Balik E, Hamzaoglu I, Karahasanoglu T, Bugra D. Robotic complete mesocolic excision versus conventional laparoscopic hemicolectomy for right-sided colon cancer. J Laparoendosc Adv Surg Tech A. 2019 May;29(5):671-676. https://doi.org/10.1089/lap.2018.0348
- Cascinu S, Poli D, Zaniboni A, Lonardi S, Labianca R, Sobrero A, Rosati G, Di Bartolomero M, Scartozzi M, Zagonel V, Pella N, Banzi M, Torri V. The prognostic impact of primary tumor location in patients with stage II and stage III colon cancer receiving adjuvant therapy. A GISCAD analysis from three large randomized trials. Eur. J. Cancer. 2019 Apr; 111:1-7. https://doi.org/10.1016/j.ejca.2019.01.020
- Portal Placement
- Mobilize Right Colon
- Identify Ileocolic Vascular Pedicle
- Dissection to Isolate Ileocolic Vascular Pedicle
- Transection of Ileocolic Vascular Pedicle
- Develop Retroperitoneal Space
- Take Down Hepatic Flexure
- Take Down Remaining Lateral Peritoneal Attachments of Ascending Colon and Terminal Ileum
- Resection and Anastomosis
- Transversus Abdominis Plane (TAP) Block
- Externalize Right Colon
- Divide Mesentery of Terminal Ileum to Harvest Lymph Nodes
- Prepare Transverse Colon for Anastomosis
- Construct Anastomosis
- Transverse Stapler to Resect Right Colon
- 5. Closure
- 6. Discussion
I am Dr. Rattner. Today we're going to do a laparoscopic right colectomy on a middle-aged man who was found to have a large unresectable polyp in his ascending colon and incidentally also had a carcinoid tumor at the ileocecal valve. The way we're going to go about this is to position him so that his left arm is tucked in. Both myself and my assistant will stand on the patient's left side. We will place the four trocars in standard position.
And I - generally, we do this in the medial to lateral fashion, so we try to identify the ileocolic pedicle to suck it out at its - close to its origin, transect it, and then develop the retroperitoneal space, elevating the right colon in this mesentery off of the duodenum, and then take down the hepatic flexure. Mobilize lateral attachments is our last step. Once we have everything free, I usually do an extracorporeal anastomosis. I don't really find there's much difference between intra- and extracorporeal in terms of either function, pain, or anything else. We do give a tap block before making an incision. This really helps with the post-operative pain control. We use an E-Ras pathway post-op, and once all that’s done, we’ll exteriorize the fully mobilized and devascularized colon, construct a stapled anastomosis, put the bowel back into the abdomen, close the incision, and then we're done. Generally, the patient will go home in a couple of days afterwards.
12 mm trocar please. Okie dokie. Okay, might want to switch to the - if you're getting all the footage, it should be fine. So let’s just take a look around. Okay, let’s have a knife please. 5 millimeter trocar - Steven put a trocar right here. And we’re going down there. Vertical incision. 5 millimeter trocar. Do you know if - that's perfect - if it doesn’t go through, we’ll put the 12 in. Leave that there for just a second. That's a good illustration. Okay, knife please, and a 12. Okay, knife please and the five. Put that right out here - maybe a little bit more central in here - probably fine in there somewhere. The room lights out or go green please.
Switch places from a minute. Rotate the table all the way towards me. It’s actually unusually high for me to put that port as high as I put the left one, and then use that one to help. Now trying to see if you can get this. There's a terminal ileum right here. When it's - let's go over this way for just a second here, and let’s grab this and put this on a stretch here. You need to pull the - I’m not used to being the surgeon here - I’m used to a system of you guys. I’ll switch hands. Let’s get this up on a stretch. A little more - like that. Let's just get all the stuff out of the way down here. Open - it’s the duodenum right there - transverse colon right here. Let’s get this down and out of the way. Find ileum - make sure that’s free, which it is. Okay, we need to find stretch like that, so you need to re-grab see right here. Good. Now look down at 6 o'clock - more, more. That’s good down there. I’ll take a regular blank grasper. And open up the endo-GI white 45 please.
Okay so we're going to start by just taking the ileocolic vascular pedicle, open the peritoneum overlying it, identify the border of the duodenum.
Let’s get this up again. Just working up in here. Let go for just a sec. Stretch this out - there’s a little redundant right colon. Why don’t you grab over by the flexure. Here's the tattoo. Grab that - stretch that up towards the ceiling or - good just like that. That’s excellent. Let’s see if you can’t get this right colic on stretch here. Good here.
This is all retroperitoneal fat down here. Come in a little bit closer. Let’s keep coming up - freeing up the duodenum in here. Can I have a harmonic please?
Is that the - hollow grasper again please. Okay - this looks like a distal vessel - we’re going to have to take this or not. We want to save that. Where’s the tattoo? Tattoo is way over here, right? Yeah, it’s way back there, so we don’t have to take it out. That's nice, shiny mesentery right there, so all this little fun right here can go. This should all be mesentery. Famous last words. Okay, harmonica again.
And now I think we’ve reached the point where we can just come through. I've got a few little strands right there and this is a clear spot. So should be able to come through Steven right here right. Don't you think? I think. Just stay where you are - great exposure. Beautiful. Alright good. Move to the other side. Okay, this way. I’m going to give you this. Let’s trade. I am going to give you the harmonic, and you’re going to take down the hepatic flexure. Almost done.
So let’s see here - this is my hole. Right here - come in closer. See this clear stuff right up here?Go right through that. Hemostasis is next to godliness - in laparoscopic surgery anyways. So see this stuff right down in here? You’re gonna have to roll a little bit to - pull back and let me just see the duodenum for sure. Duodenum is there - okay, yes. And all this stuff underneath here has got to go.
Let’s take the lateral attachments first and then all we’ll be left with is the stuff underneath. You can go right underneath there, and then go to that clear area. Let’s stay a little bit further away from the colon wall - right there, good. All through all that stuff - perfect. Move this hand up. Back up a little bit. Let’s see what we are held on here. All this filmy stuff in there - yeah. Just work your way through that. Even all the way down to the bottom of the screen where the Xenon 300 is. It’s all - that’s all got to go. Yeah down at the bottom there’s another. We’ll get back to that in a minute. We just have to connect the dots from - and make sure we are in the same plane as the other dissection or we’ll be in two different planes. Let's finish bringing this up here, and then all we’ll have left is that stuff there. There's your appendix. You’re all the way down to the secum over there. Let me get that out of your way. That’ll be the innominate vein right underneath you. Close to the appendix okay. Close to the appendix.
Let’s switch to the other way now cause your angle’s bad. There’s the vessels. Get the colon back up here. Okay, switch. You’re going to take this now. Take this one here. I think. So you want to free up the terminal ileum right now and then come back up to the appendix, okay? If you get this stuff down here. So if you roll that over this way, you should start seeing the other dissection up in here, right? So those are going out also. You're just going to be just medial to that. Come back down this way for a minute - move this up - better. So there’s your ureter right there. So this is safe to take up here. Really nice illustrations of stuff. So we should finish up right in here. Famous last words, as we should be completely free now. So let’s just clean the scope for a second - get that smudgy spot off of it.
Alright, let’s lift this thing up and get it up in the air and make sure that there's nothing that’s still intact - we should be able to see completely through to the other side. Can I have that other bile grasper for just a second? So you want to grab up in here. I haven’t had to do one of these by myself in quite some time - it’s kinda fun. I almost forgot how to do it. Can you pull on this for me? That’s good. I think we got what we need here. Why don’t you go to the other side of the table.
And let's do the tap lock on your side before we rotate. So let’s have the tap lock stock. Remember how to do this? Did we do these together? So this is the 12th rib - is right here, okay. So we go right up the tip of the 12th rib. Let me have a grasper please? Can you see okay? Tap your finger for me for a minute. Can I have the zero vicryl and the suture passer - get a blank grasper please.
So you can see the valve right there. Fat pad right there. Okay. Turn everything off except the laparoscopic stuff please. Skin knife please. There’s our pedicle. Do you have a couple of towels please - blue towels? It’s right here - feel it - it's right there. Clean off the mesentery - say up in here somewhere.
So this is where the carcinoid is - right here. So we can come maybe right to - here is fine. And you want to go radially back this way. There might be a node right there, so we’re going to go right to my fingers as the target. Preserve it - yep. Yeah, let's put that other thing underneath here - just lay that in there Steven. It will look nicer. I usually tie the muscles - share this with you. Schnip please. Let’s make a hole right here - see this little arcade vessel here. We’re just going to look at the arcade - you can see that there's a vessel - see this this loop is all coming up here, so you want to save that. Make a hole right in here. Okay, bovie. We’ll take this little vessel - this branch - this vessel - just clean this perineum off first - Make it much easier. Metz. Do you want 2-0 or 3-0? Either. 2-0 is fine.
Okay, take a harmonic or whatever - just keep going down right through here now. Come right to here, okay? We’ll tie that big vessel in there. K - schnip to me please. Tomorrow. Switch sis. So this is the stuff you want, right there, so we can finally go right through this with the harmonic.
Okay, alright, so that's good there. Now the colon side. We want something… Blood supply, which is not twisted. So all looks good through here. So should we clean off somewhere in here - let’s see. Let’s get this so that it's not all contorted - wants to go this way I think - I thinks. Or not. It goes like this. So here’s the tinea, coming along here, so that's perfect. And so here's the vessel right down here. That you want to leave. So I would say anywhere in here is going to be a-okay, so how's this going to lie. Just want to suture staple to staple. Why don’t we clean off right about here? Let’s clean that up - that will be where we’ll come across. I’ll need 100 times 2. K, let’s clean this up a little bit please - schnip please. I thought she had that open. I thought I saw that at the beginning of the case. Crystal, we just need the cartridges. Okay, schnip schnip. Nets please and a 2-0. Five. We’ll take 3 silk pops next please. So this can go - where did we clean up the the small bowel, right here. So want the two fork holes to match, or this is where we’re going to ultimately fire this transverse stapler, so it'll go from clear spot to clear spot.
So put a stitch there to line that up. Right here to the tinea. Good. Another stitch please. Snap these. Snap these. Times two. That’s good - that’s all we need. Okay, now let's make our fork holes. So this is where we're going to come across, so let's make the fork holes right about here, okay? That’s in - let’s do the same thing right about here. Pull right in - straight down. That’s in. One more. Yeah - that in. Let’s have the stapler now please. Take it apart and just put the big boy in the colon. You're definitely in - yeah, good. That’ll be fine - now looks lot better, good.
Let me just lift this up for a second. Make sure this is flat so you get a double layer there. I’m going to make sure there's nothing - get this fat out of this corner right there, and get the tinea going in the right direction - so it's not twisted. That looks pretty good to me. Matthew - not happy. Hold on. Yeah. That looks - that’s better. Let’s look at our staple line. Make sure nothing’s bleeding in there - he’s not bleeding at all. Okay. 3 Alices please. So this is going to go to this. She gets serosa - all layers are big bite, chunky bite. Good - another one. Should get this picked up to here. One more in the middle. And another load of the stapler. I thought we had this clean - where’s our clean off spot here? Is it back there? We had this all cleaned off. Everything get this side? Let’s divide all that - get that clean. Back in here - that’s bowel wall. Just don’t want to have any bleeding from anything else - just come right in though here. We should be fine there. So we can come straight across here and our staples in where - the staple line ends right about here. So we're in great shape - plenty of length. That's good there.
Okay now, we just want to check one more time here. Make sure we got all of everything out, which we do. Okay go ahead and fire. Let's have one more silk stitch please. Actually staples go all the way down there, so we have plenty of room. So stitch from right - see where that last staple is? Right underneath it. Come over to the side right there probably. That’s too far back - just right where the hole that you’re holding up is fine. Perfect.
Now we’re going to change our gloves. There’s bleeding right here on the corner. Coming right out of here. Just right there. Now that should take care of it - all the staples pretty well formed. Do you have a clip there by chance or no? Yeah, yeah. That's what I want. Let’s just put that on - right through there okay. Let’s see if I can just identify it fully. Good just straight - right at the tip of your clip. You probably got it. Mhmm yeah. Clip please. Well least we know the colon - good - blood supply is good huh. Fine. Yup. Loving it.
Can I get the local now rather than -let me just do this now - I see it so well. Bonnie please. Bonnie. Can I have more please. Can I have a rich please? Such a nice operation. Are you going to take another one? I’ll just put a few stitches in just to get to the umba level - a little bit past it. Run one down from the top. Close the skin. Start on your side. And lock.
Case is all finished. Everything went smoothly. Nothing particularly unusual about the anatomy or the procedure itself. Expect the patient to do really quite well. We were able to palpate the carcinoid tumor and the terminal ileum when we exteriorized it. I didn't see any lymphadenopathy, and we know the adenoma was at the site marked by India ink, which we saw well laparoscopically.