laparoscopic assisted colectomies ( lac ) for colon and rectal cancer have recently become more common in japan .
this procedure minimizes surgical stress and has been recognized as acceptable treatment for colorectal cancer based on long - term outcome studies and a low complication rate .
long - term survival after lac is similar to survival after conventional surgery , but it is more expensive in terms of surgical instruments and surgical staff .
we have developed a colon - lifting method using a suture that requires only 2 operators and 3 trocars .
a 12-mm trocar is inserted below the navel through a small incision and pneumoperitoneum is created .
two additional trocars are placed superior and inferior to the lesion and serve as the working ports ( figures 1 and 2 ) .
a 10 nylon suture is introduced into the lower abdominal cavity with a grasping needle ( granee needle , r - med , inc . ,
oregon , oh , usa ) and passed through the mesocolon ( figure 3 ) .
the point of penetration of the mesocolon must be at least 10 cm from the edge of the tumor to avoid tumor implantation ( figure 2 ) .
the colon is retracted anteriorly using the suture , exerting slow and steady pressure to avoid injury to the vessels in the mesocolon .
lymph node dissection is performed easily because countertraction can be applied at the point of incision .
the stability of the working space is achieved by fixing the colon to the abdominal wall .
the main nutrient vessels are divided at their origin to facilitate lymph node dissection ( figure 5 ) .
one port site for the trocars is enlarged , and the lesion is removed through it .
the reconstruction is intracorporal for left - sided lesions and extracorporal for right - sided lesions .
this method requires only a scopist in addition to the operator . in some cases ,
an extra traction suture is needed for lesions of the right colon or when the left or sigmoid colon is redundant .
the open circles are manipulation ports . schematic diagram showing technique for resecting a rectal cancer . the inferior mesenteric artery is divided .
the sigmoid colon is lifted using the suture at least 10 cm from the edge of the tumor .
a 10 nylon suture is inserted into the abdominal cavity and passed through the mesocolon .
the colon is retracted anteriorly by pulling on the 10 nylon suture , placing traction on the main nutrient artery in the mesocolon ; lymph node dissection is easily performed near the inferior mesenteric artery ( arrow ) .
from april 2000 to august 2002 , 52 laparoscopic colectomies were performed with this method .
thirty - one patients had colon cancer in the following locations : cecum , 2 ; ascending colon , 5 ; transverse colon , 3 ; descending colon , 1 ; and sigmoid colon , 21 .
twenty - one patients had rectal cancer , 17 in the upper rectum and 4 in the lower .
the mean operative time was 27850 minutes ( range , 115 to 380 min ) .
the mean blood loss was 137158 ml ( range , 10 to 800 ml ) .
the disease stage of primary cancer was as follows : tis , 13 ; t1 , 20 ; t2 , 9 ; and t3 , 10 .
the mean number of dissected lymph nodes was 16.99.0 ( range , 5 to 41 ) .
thirty - three lesions were well - differentiated adenocarcinoma , 17 were moderately differentiated adenocarcinoma , and 2 lesions were carcinoid .
all patients are alive , and one patient has experienced a hepatic recurrence during a mean follow - up of 16.08.4 months ( range , 4 to 33 ) .
since lac for colon cancer was first reported in 1991 , its use has increased worldwide .
one long - term follow - up study of lac for stage 3 colon cancer reported results comparable to those of open colectomy ( oc ) .
this study found that lac was superior to oc in terms of morbidity , length of hospital stay , incidence of recurrence , and cancer - related survival . in economic studies of diverticular disease and cancer , the total hospital costs were similar to or less than those for lac than for oc , although the operating room charges were greater for lac due to the need for many disposable items .
therefore , reducing the amount of instrumentation will increase lac 's attractiveness as a surgical option . in most reports ,
in our technique , only 3 trocar sites were needed , and one surgeon was able to perform the laparoscopic procedure assisted only by a scopist .
we selected nylon suture for the lifting tool because there are advantages in terms of medical costs and cosmesis ; nylon is a very inexpensive tool , and wound to the abdomen is very slight .
our method saves 1 or 2 trocar implements , so the difference is 13,640 yen ( about 114 us dollars ) per operation . in japan ,
the surgeon 's cost is inexpensive ; it is about 3,500 yen ( about 29 us dollars ) per hour .
the length of time for a laparoscopic procedure is about 2.5 hours , so this method saves about 8,750 yen ( about 73 us dollars ) per operation .
a similar method has been reported previously , but our method is different in that the colon is elevated using a ligature .
this method allows the beginning lac surgeon to easily understand the operative anatomy . because of suspension and fixation of the colon , the surgical field becomes stable , and the colon and mesocolon are on the same plane .
the dissection line was easily placed under tension by using the grasping forceps because the colon was fixed to the abdominal wall .
another concern is the risk of tumor implantation of lymph node metastasis from the mesocolon to the abdominal wall .
in fact , this method seems to be more of a nontouch technique than other procedures because the colon is manipulated only at points far from the cancer .
but the learning curve has become shorter lately ; it was about 180 minutes for colon cancer and 240 minutes for rectal cancer in the last 10 cases .
we performed 80 traditional laparoscopic procedures that required 4 or 5 ports and 3 surgical personnel between 1993 and 2001 .
the mean time of all cases was 33675 minutes . from 2000 , it has been 29041 minutes in the last 25 cases .
so , the time of our lifting method is the same as that of the traditional laparoscopic method .
a unique advantage of this method is that the operator is much less dependent on the assistant 's laparoscopic skills , giving the surgeon greater control over the operation .
it is likely that the introduction of robotics to handle the laparoscope will make it possible for a single operator to perform this procedure in the future .
lifting the colon using a ligature is a useful technique for performing lac with lymph node dissection .
 background and objectives : laparoscopic - assisted colectomy for colon and rectal cancer causes less surgical trauma than does open colectomy . however , current methods are more costly and require highly skilled staff . 
 in addition , the technique for lymphadenectomy has yet to be standardized . 
 we developed a technique that uses a nylon suture to elevate the colon . 
 this method reduces costs without compromising the completeness of the resection.methods:three trocars are introduced and a 10 nylon suture is passed into the abdominal cavity and through the mesocolon . 
 the colon is retracted anteriorly and is fixed by this suture to the abdominal wall . 
 the main mesenteric vessels are under tension , and lymph node dissection is performed easily . 
 this method requires only 2 surgeons , an operator , and a scopist , because the colon is fixed to the abdominal wall . 
 in addition , the working space is more stable because the colon is fixed to the abdominal wall . 
 the procedure is relatively independent of the skill of the first assistant.results:from april 2000 to august 2002 , this method was performed in 52 patients . 
 the mean number of dissected lymph nodes was 16.99.0 ( range , 6 to 41 ) . 
 nine patients had lymph node metastases ( 17.3% ) . 
 one patient developed hepatic recurrence ; all patients are alive . 
 no complication occurred that was related to lifting the colon.conclusions:using a suture to lift the colon is a useful method for performing laparoscopic - assisted colectomy with lymphadenectomy . 
 this method reduces the number of surgical staff and the expense of the procedure . 
INTRODUCTION
SURGICAL TECHNIQUE
INDICATIONS
RESULTS
DISCUSSION
CONCLUSION