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 postoperative 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. doi: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. doi: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. doi: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. doi:10.3748/wjg.v20.i45.16964.
- Jemal A, Siegel R, Ward E, et al. Cancer statistics. CA Cancer J Clin. 2007;57:43-46. doi:10.3322/canjclin.57.1.43.
- Yozgatli TK, Aytac E, Ozben V, et al. 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. doi:10.1089/lap.2018.0348.
- Cascinu S, Poli D, Zaniboni A, et al. 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. doi:10.1016/j.ejca.2019.01.020.
Cite this article
Harkins JM, Rattner D. Laparoscopic right colectomy with ileocolic anastomosis. J Med Insight. 2023;2023(125). doi:10.24296/jomi/125.
Table of Contents
- 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
- 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
Hi, I'm Dr. Rattner. Today we're going to do a laparoscopic right colectomy on 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 generally, we do this in the medial to lateral fashion, so we try to identify the ileocolic pedicle, dissect it out close to its origin, transect it, and then develop the retroperitoneal space, elevating the right colon and its mesentery off of the duodenum, and then take down the hepatic flexure. Mobilize the 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 postoperative pain control. We use an ERAS pathway post-op, and once all that’s done, we’ll exteriorize, fully mobilize and devascularize the 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.
Can I get a 12-mm trocar, please? Okie dokie. Let's go. So let's just take a look around. Okay, let’s have a knife, please. 5-mm trocar. Steven, put a trocar right here. Midline down there. Vertical incision. Oh yeah, vertical incision, 5-mm trocar. Do you know if - yeah, that's perfect right there, and if it doesn’t go through, we’ll put the 12 in. And just leave that there for just a second. That's a good illustration. Okay, knife please, and a 12. Right there. Okay, knife please and a 5. Put that right out here, yeah. Maybe a little bit more central, you know, it's probably fine in there somewhere. Okay, room lights out or go green, please. Steven, let's switch places from a minute, okay? Rotate the table all the way towards me. Actually usually how I put that port when I have it, is I put the left one, and use the bowel grasper. Yeah, and use that to sort of help, yep.
Okay, let's see if we can get this. There's the terminal ileum right here. When it's - let's go over this way for just a second here. Grab this and put this on a stretch here. You need to pull the - actually, I’m not used to being the surgeon here. I’m used to assisting you guys. Put this up on a stretch. Is that enough stretch? A little more - like that. Let's just get all this stuff out of the way down here. Open a - oh, it’s the duodenum right there. Yep. Transverse colon, right here. Let’s get this down and out of the way. Assess our terminal ileum for a second, 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. Yeah, sure. Push that. Right there? Good, now look down at 6 o'clock - more, more. That’s good down there. I’ll take a regular, or a blank grasper, something. And open up the endo-GIA, white 45, please. White 45, please, now. 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's get started here.
Let go for just a sec. Stretch this out a little - there’s quite a bit of a 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. Yeah. Let's go there. This is all retroperitoneal fat down here. Come in a little bit closer. Let’s keep coming up and freeing up the duodenum up in here, okay? Do you have a harmonic, please? Where's that bowel grasper again, please? Okay. This looks like a - this vessel right here - do we need to take this or not? Do we want to save that? Where's the tattoo? The tattoo is way over here, right? Yeah, it’s way back there, so we don’t have to take that. This is what you want to see - this nice, shiny mesentery right there. So all this little flim flam in here can go. And that should leave us only mesentery. Famous last words. Okay, Harmonic, again. Right 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? Sure. Don't you think? I think. Stay where you are. This is just great exposure. It's beautiful. Lift the duodenum. I think you're okay. Okay, good. Let's go to the other side.
This way. I’m going to give you this. Let's trade. So I'm going to give you the Harmonic, and you’re going to take down the hepatic flexure. And we're 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 is gonna have to roll a little bit too, I think, pull back and let me just see the duodenum for sure. Duodenum is there. Okay, yes. So this has got to go - all this stuff over in here has got to go.
Yep, let’s take the lateral attachments first, and then all we’ll be left with is the stuff underneath. Let's see if I can make this happen. All right in here, or do you wanna? Yeah, you can go right underneath there, yep. Come up this way? Yep. And then go to that clear area, okay? Let’s stay a little bit further away from the colon wall. Yeah, right there, good. All through all that stuff - yep, perfect. Move this hand up. Back up a little bit. Let’s see what we're held on here. See 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, All that’s got to go, yep. Looks good. Then down at the bottom there's another. Yeah, 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. So you’re all the way down to the cecum over there. Okay? Let me get that out of your way. Good. That’ll be the gonadal vein, right underneath you. Get close to appendix, okay. What's that? Close to the appendix. Close, yep. All right, 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. You take this one. This one here. So you want to free up the terminal ileum right now and then come back up to the appendix, okay? Still have to get this stuff down here. So if you roll that over this way, we should start seeing our other dissection up in here, right? Right there. So those are gonadals, so the ureter's going to be just medial to that. Yep. Looks pretty good there. Let's come back down this way for a minute, clean this up a little bit better. So there's you ureter right there. Yep. Whic means this is safe to take up here. Really nice illustrations of stuff. Okay, this should finish this up right in here, right? Famous last words. Okay, we should be completely free now. All right, so, let’s just clean the scope for a second and get that smudgy spot off of it. Yeah, sure. Okay, 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. So you want to grab up in here. I haven’t had to do one of these myself in quite some time, it’s kind of fun. I almost forgot how to do it. Can you pull on this for me? Good. Yeah, that’s good. I think we got what we need here. All right, okay. All right, why don’t you go to the other side of the table.
And let's do the TAP block on your side before we rotate. So let’s have the TAP block stuff. Do you remember how to do this? Did we do these together? Yeah. Okay. 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? Bounce your finger for me for a minute. I'm right here. Let me have the 0 Vicryl on the pass, and let me get a blunt grasper, please.
That's the ileocecal valve, right there. Ileocecal fat pad, right there. Okay. Turn everything off except the laparoscopic stuff, please. Skin knife, please. Bovie. There’s our pedicle. Do you have a couple of towels please - blue towels? Can you feel the lesions? It’s right here - feel it - it's right there. Oh yeah, yeah, for sure.
We'll clean off the mesentery, say up in here, somewhere. Okay. So this is where the carcinoid is, right here. So we can come maybe right to here is fine. 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, the target. Preserve it, yep. Do you want another? Yeah, I do. Let's put that other thing underneath here, just lay that in there, Steven. It will look nicer. I'm on it I usually tie the vessels to be honest with you. Schnidt, please. Let’s make a hole right here. See this little arcade vessel here? Yeah, not even... We’re going to just 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. We'll make a hole right in here, okay? Bovie. We’ll take this little vessel - this branch, this vessel - just clean this peritoneum off first, make it much easier. Schnidt, please. Metz. And then do you want 2-0 or 3-0? Either. 2-0 is better. 2-0 tie, please, free. Take a Harmonic or whatever, and just keep going right down through here now. Come right to here, okay? Sure. We’ll tie that big vessel in there. Okay. Okay, Schnidt to me, please. 2-0, please. Suture scissors. So this is the stuff you want, right there, so we can finally go right through this with our Harmonic.
Okay, all right, so that's good there. Now the colon side. We want something... Good blood supply, which is not twisted. This 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 - just wants to go this way, Steven, 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. Yep. Okay? Which we want to leave. So I would say anywhere in here is going to be a-okay, let's see, hows this gonna lie? Just want to suture staple to staple. Why don’t we clean off right about here? Sure. Okay? Let’s clean that off - that will be where we're gonna come across, yep. Yep. ILA 100 times 2. Okay, let’s just clean this up a little bit, Schnidt, please. I thought she had that open. I thought I saw that at the beginning of the case, Crystal, we just need the cartridges? Yeah. Yeah, okay. Okay, Schnidt, Schnidt. Metz, please, and a 2-0. Tie. We’ll take 3-0 silk pops next, please. So that's gonna go - where did we clean up the small bowel, right here. Just want the two fork holes to match, or this is where we’re going to ultimately fire the transverse stapler, so it'll go from clear spot to clear spot.
So put a stitch there to line that up. From here to the tinea? To the tinea. Good. Another stitch, please. Do you wanna snap these, or just like...? Snap them. Okay, snap please. Times two. Keep going through there. That’s good there - 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 hole right about here, okay? Sure. Okay, that’s in. That's in, okay, let’s do the same thing right about here. Still not in. Stroll right in, straight down. Good, good, that’s in. A little more. Yeah, that in. Okay, let’s have the stapler now, please. Take it apart and just put the big boy in the colon, and the... You're definitely in, right? Yeah. Yeah, okay, good. That’ll be fine - now looks lot better, good. Let me just lift this up for a second. Just pick that up, yeah. Make sure this is flat so you don't get sort of a double layer there. Okay, good. Let's make sure there's nothing - yeah, 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. Down there, yeah. Yeah, exactly. That's - that's better. That looks better, yeah. Okay. Yep, good. All right, do you want to close it? Yep. Let's look at our staple line. Make sure nothing’s bleeding in there. No blooding at all. Okay, 3 Allises, please.
So this is going to go to this - this. Right. Make sure you get serosa - all layers with a big bite, chunky bite. Good - another one. Make sure you get this picked up to here. One more in the middle, yep. Allis, please. And another load of the stapler. I thought we had this clean - where’s our clean off spot here? Is it back there? Let's have this all cleaned off. Think we can get this side? Let’s do this - divide all that - get that clean. There you go, back in here - that’s bowel wall, right? Just don’t want to have any bleeding from anything else. You want to just come right in through here, you know. Sure, medially. Yep. Sure. Am I...? That should be fine there. Okay, so we can come straight across here. And our staples end where? The staple line ends, right about here. So we're in great shape - plenty of length. That's plenty of length. Yeah, that's good there. Okay, now I just want to check one more time here. Make sure you 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? Yep, just right underneath it. Come over to the side right there. That’s too far back, just right where the hole that you’re holding up is fine. Yep, that's fine, good. Needle. Perfect. Now we’re going to change our gloves. Let's just look and see what's bleeding right here on the corner. Coming right out of here. Just right there. Seems to take care of it, all the staples, pretty well formed. Do you have a clip there by chance or no? Laparoscopic? Yeah, yeah. That's what I want. Let’s just put that on right - right through there, okay? Yep. Let’s see if I can just identify it fully. Good, straight, yep. It's right at the tip of your clip. You probably got it. Good. You need another one?Yeah. One more clip. Well at least we know the colon blood supply is good, huh? Fine. Yep. Loving it.
Can I get the local now rather than - you know, let me just do this now while I see it so well. Bonnie, please. I'll take one as well. Local or Bonnie? Bonnie. Can I have more, please? Let's have a Rich, please? Such a nice operation. Yeah, it is nice. Nice and quick. Are you going to take another one for the top? Yep, yeah, I’ll just put a few stitches in just to get to the umbo level, a little bit past it. Then I'll have you run one down from the top, and close the skin. Let's start on your side, I think.
Case is all finished. Everything went smoothly. Nothing particularly unusual about the anatomy or the procedure itself. I expect the patient to do really quite well. We were able to palpate the carcinoid tumor in 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.