En Bloc Laparoscopic Sigmoidectomy, Left Annexectomy, Partial Small Bowel Plus Partial Urinary Bladder Resection For Advanced Sigmoid Tumor

Introduction: The authors report a clinical case operated for substenotic sigmoid colon tumor, discovered perioperatively locally advanced because adhering to a small bowel loop, urinary bladder dome, left tube and ovary. Clinical Case: A 67 years old female was hospitalized for a substenotic sigmoid colon lesion resulted adenocarcinoma at colonoscopy, localized at 25 cm from the anal margin. Preoperative work-up did not show the presence of secondary hepatic lesions, and did not evidence an invasion of other abdominal organs. The patient was scheduled for laparoscopic resection using 4 trocars, and specimen removal by enlargement of the 4th trocar placed in the suprapubic area. Perioperatively, a small bowel loop, the left tube and ovary, a partial dome of the urinary bladder were evidenced as attached and involved in the tumoral mass. The procedure started with the isolation of the small bowel loop from the lesion, and realization of the jejuno-ileostomy by linear stapled technique. The inferior mesenteric artery and vein were sectioned between clips at their roots. The tumor, the left tube, the ovary and the dome of the urinary bladder was resected en bloc by the coagulating hook. The urinary bladder was closed by two converting running sutures. The left colon and splenic flexure were freed from lateral to medial, and the left colon as well as the superior rectum was transected by firings of linear stapler. An end-to-end colo-rectal anastomosis was fashioned by handsewn technique, using two absorbable running sutures. The specimen was removed by enlargement of the trocar placed in the suprapubic area, after have inserted a plastic protection at the access-site. Results: Operative time was 285 minutes, and perioperative blood loss 300 cc. The patient was discharged with the urinary catheter on the 5th postoperative day. The catheter was removed after 3 weeks. Pathologic report confirmed the tumor invasion of the small bowel loop, of the left tube and ovary, and of the urinary bladder wall; the final TNM stage was: pT4N0Mx. Conclusions: En bloc sigmoidectomy with adhering visceras is feasible and safe to be performed by laparoscopy. Intracorporeal sutures permit to solve some difficulties discovered perioperatively.