Introduction

Large bowel cancer is the third most common cancer worldwide and the second leading cause of cancer-related deaths.1 It presents in multiple ways, and screening programs have been implemented in the Western countries to facilitate early detection and improve outcomes.2–4 Most of the large bowel cancers are treated surgically, with neoadjuvant and adjuvant chemotherapy and radiotherapy administered pre and post operatively depending on the tumor’s location and the stage.5,6

Laparoscopic left hemicolectomy is the standard procedure for the non-obstructive left side colonic cancers.7,8 Endoscopic tattooing is used to mark small polyps that might not be visible during surgery.9 Intraoperative colonoscopy is crucial in various situations, particularly in non-visible or non-palpable lesions.10,11 Here we report a case in which a laparoscopic camera was used as an intra-operative colonoscope in resource limited setting.

Case Presentation

A 55-year-old woman presented with intermittent left sided abdominal pain for two weeks. Colonoscopy showed a 2cm sessile polyp located 35 cm from anal verge. Histological analysis confirmed invasive adenocarcinoma. Contrast enhanced computed tomography (CECT) showed no evidence of tumor, nodal involvement or systemic metastasis. The patient underwent full bowel preparation and preoperative marking of the lesion was performed using methylene blue the day before surgery.

Laparoscopic left hemicolectomy was attempted but neither the lesion nor the marked site could be identified. The procedure was converted to a midline laparotomy; however, the lesion was not visible under the operating theater light nor was it palpable. Intraoperative colonoscopy was unavailable due to technical reasons. As an alternative, an enterotomy was performed in the descending colon -well away from the suspected lesion site, but within the planned left hemicolectomy specimen. A 10mm laparoscopy camera was inserted into the bowel successfully identifying the lesion. Left hemicolectomy was completed ensuring the specimen included the entire area through which the laparoscopic camera has passed. She had an uneventful recovery and histology revealed a pT2, N0 lesion and sent for surveillance.

Discussion

Screening for colorectal cancer by colonoscopy, fecal occult blood testing or sigmoidoscopy is recommended in an average risk person between the ages of 40 and 75 years.4 Although Sri Lanka does not have a well-established screening program for large bowel cancers, our unit maintains a low threshold for performing colonoscopy. A 2 cm sessile polyp with invasive malignancy requires staging with CECT and surgical excision as the primary treatment.5 Endoscopic Submucosal Dissection is an alternative option, but it is not widely available in our setting.12

Routine mechanical bowel preparation is not recommended for a left-sided colonic lesion as it does not significantly reduce the risk of anastomotic leakage or infective complications.13 However, in this case mechanical bowel preparation was done to facilitate preoperative lesion marking, in accordance with our unit protocol, although a rectal enema could have been an alternative.

Several agents can be used for preoperative colonic lesion marking, but we used methylene blue as it was the only available agent in our institution.9 It has been reported to fade early, but the exact time frame is not described for the colonic marking.14 When intraoperative demonstration of the lesion proved challenging, laparoscopic ultrasound or fluoroscopy could have been considered, neither necessary equipment nor experts were available at our center.15

Conversion to a midline laparotomy was the only surgical option available in our setting. In cases where a lesion is Impalpable during laparotomy, an intra-operative colonoscopy is the preferred localization method.10,11 At this point we faced the option of aborting the procedure and planning a second surgery with immediate pre-operative marking or using a more durable agent. However, abandoning the surgery would have resulted in a negative laparotomy for malignancy and necessitating a second operation in a field with multiple adhesions, both of which were deemed unjustifiable.

Laparoscopic camera was utilized because it was the only available device suitable for insertion into a hallow viscus. A previous report describes a technique to use a laparoscopic camera as an intraoperative colonoscope; however, in this case we used only the camera without a trocar or the gas insufflation.16 The camera lens is kept warm to prevent fogging and it could have adversely impacted the colonic mucosa upon insertion.17 To mitigate the risk, we ensured that the entire segment of the colon though which the camera passed (~10 cm) was included in the resected specimen.

In hindsight, if the laparoscopic camera failed to identify the lesion, we would have faced significant challenges as this approach is not standard practice. In such scenario we could have encountered complications associated with enterotomy in a negative laparotomy for malignancy, as well as potential adverse effects from the passage of warm laparoscopic camera through the colon. However, our approach was ultimately successful, and the safe use of a laparoscopic camera for intraoperative colonic visualization has been previously documented in the literature.16

Conclusion

In resource limited setting, unconventional methods may be necessary to facilitate intraoperative tumor localization. This case highlights the successful use of a laparoscopic camera as an intraoperative colonoscope enabling a successful completion of a left hemicolectomy in the absence of standard intraoperative colonoscopy equipment. While this technique proved effective in our case, further studies are needed to evaluate its safety and feasibility in clinical practice.

Acknowledgments

The subject gave informed consent, and patient anonymity was preserved. Authors wish to acknowledge the other medical staff who took care of the patient.