Minimally invasive surgery for colorectal cancer emergencies

Table 1 Surgical strategies in dealing with obstructed colon cancer

Challenges	Mitigation strategies
Limited working space	Consider proximal decompression at site of intended proximal transection
	e.g., in the case of right-sided cancer with significantly dilated small bowel loops from an incompetent ileocecal valve, an extended periumbilical incision can be made to first perform decompression via a controlled enterotomy extracorporeally at the site of the planned proximal transection (Figure 2), before proceeding with MIS surgery
	Use gauzes to pack small bowel away and minimize accidental thermal injury to surrounding structures
Limited exposure	Adjust patient’s positioning to displace distended bowel away and maximize exposure
	(Consider the use of a surgical table with greater articulating range and patient secured to the table with a surgical bean-bag)
Limited access to target anatomy	Work from different approaches (lateral/medial/inferior/supra-colic) and extrapolate from known planes
	Perform dissection distal to obstruction where tissue planes are normal with collapsed bowel. Subsequently perform early distal bowel transection to gain better exposure, before working more proximally

MIS: Minimally invasive surgery.