Two-stage laparoscopic resection of colon cancer and metastatic liver tumour
A 70-year-old woman was admitted to our hospital with a diagnosis of cancer of the sigmoid colon. Barium enema showed an encircling mass in the sigmoid colon []. Computed tomography (CT) revealed a low-density area in the left lateral segment of the liver []. Liver function was normal, and the pre-operative carcinoembryonic antigen level was 6.2 ng/ml (normal range, < 5 ng/ml). The patient had no history of abdominal surgery. We planned two-stage procedure for the patient because it was considered to be a highly invasive treatment for this elder patient when both sigmoid colectomy and hepatectomy were performed simultaneously. In addition, interval hepatic resection for synchronous metastases of colorectal cancer, with a routine waiting period of 4–6 months, was recommended to improve the patient selection.[] Therefore, laparoscopic sigmoid colectomy was performed first. With the patient in the supine position, pneumoperitoneum of 8 mmHg was established, and trocars were placed in the right upper and lower abdomen []. After the sigmoid colon was mobilised from the surrounding tissues, a skin incision (6 cm) was made in the left lower abdomen. The sigmoid colon was exteriorised and resected through the skin incision after appropriate barrier protection of the wound edges was ensured. Operation time was 372 min, and estimated blood loss was 70 ml. The post-operative course was uneventful, first flatus was recognised on day 2, solid diet was started on day 3, the patient was discharged and directly went home on post-operative day 11.\nFive months after the first operation, CT scan revealed that the slight enlargement of the liver tumour (25–37 mm in diameter), but new lesions were not observed []. We performed laparoscopic partial S2/3 hepatectomy. After CO2 insufflation with a pressure of 8 mmHg, inspection of the peritoneal cavity revealed no remarkable adhesion. Four trocars were placed in the upper abdomen, as shown in . The falciform, left triangular and coronary ligaments were dissected, and the left hepatic lobe was mobilised. Hepatic resection was performed with an endoscopic autosuture stapler (EndoGIAII, US Surgical, Norwalk, CT, USA) under lower pneumoperitoneum pressure to prevent gas embolism. The resected specimen was removed from the port site, which was enlarged to 3 cm in the supraumbilical area with an EndoCatchII device (US Surgical). Operation time was 167 min, and blood loss was 20 ml. The post-operative course was uneventful and the patient was discharged and directly went home on day 14. She is currently doing well, with no evidence of disease recurrence during the 8 months since the procedure.