title: En bloc laparoscopic sigmoidectomy, left adnexectomy, small bowel loop and piece of urinary bladder resection for advanced sigmoid tumor.
abstract: The laparoscopic surgery of colon increasingly replaces the conventional surgery of colon on a global and regional scale. Many randomized studies demonstrate the advantages with regard to the shorter postoperative hospital stay, faster recovery, and identical results of the indexes of survival and frequency of relapses. The en bloc resection in cases of locally advanced colon cancer is the most secure method for achieving of R0 resection . The growth of the tumoral mass towards the adjacent structures manifests with histological tumor invasion in approximately 50% of the cases. The cases of laparoscopic en bloc resection for the treatment of colorectal cancer, which are described in the literature, increase. In this report we present a clinical case of substenotic sigmoid colon cancer and perioperative finding of infiltration towards a small intestinal loop and part of the urinary bladder, as well as towards the left uterine tube and the left adnex. In the case of this patient laparoscopic en bloc resection of the tumor formation was performed according to the so called "laparoscopic no touch technique". Approximately 15-20% of the cases of colorectal cancer are still in T4 stage, with involvement of the adjacent organs (1), despite the advance of the examination methods.
  
  
  METHODS
  A 67 year old female was admitted to the hospital for a substenotic sigmoid colon lesion, syndrome of anemia, resulted adenocarcinoma at colonoscopy. Endoscopy showed an endoluminal tumor at 25 cm from the anal margin and preoperative work-up did not evidence any secondary lesions or invasion of other organs.
  
  
  METHODS
  Four abdominal trocars were placed. The laparoscopic exploration of the abdominal cavity showed the presence of a colic mass with suspected invasion of a small bowel loop and part of the urinary bladder, the left uterine tube, and the left ovary. The tumor formation was dissected en bloc with resection of the left uterine tube and ovary, the urinary bladder, and a small bowel loop. Colorectal anastomosis with laparoscopic manual technique was performed. The anastomosis was tested for leak-tightness. The specimen was removed by enlargenemt of the 5 mm. suprapubic trocar.
  
  
  RESULTS
  The mean operative time was 285 minutes with blood loss of 300 ml. Patient was discharged on Postoperative Day 5. The histological result verified tumoral invasion towards the urinary bladder, the small bowel, and the ovary. The final staging according to the TNM classification is pT4N0Mx.
  
  
  CONCLUSIONS
  The en bloc laparoscopic resection for the treatment of sigmoid colon cancer, engaging the adjacent organs, is indicated and feasible, with surgical results, comparable with a conventional surgical intervention at the same volume.
authors.affiliation: Clinic of Surgery & Department of Surgery, Alexandrovska University Hospital, Sofia, Bulgaria.
authors.forename: G
authors.initials: G
authors.lastname: Velev
authors.forename: P
authors.initials: P
authors.lastname: Gribnev
authors.forename: G
authors.initials: G
authors.lastname: Todorov
authors.forename: G
authors.initials: G
authors.lastname: Dapri
mesh_terms: D000368:Aged; D012809:Colon, Sigmoid / Q000473:pathology* / Q000601:surgery*; D003110:Colonic Neoplasms / Q000473:pathology* / Q000601:surgery*; D005187:Fallopian Tubes / Q000473:pathology / Q000601:surgery; D005260:Female; D006801:Humans; D007421:Intestine, Small / Q000473:pathology / Q000601:surgery; D010535:Laparoscopy / Q000379:methods; D009361:Neoplasm Invasiveness / Q000473:pathology; D010053:Ovary / Q000473:pathology / Q000601:surgery; D001743:Urinary Bladder / Q000473:pathology / Q000601:surgery