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World J Clin Oncol. Aug 24, 2025; 16(8): 107757
Published online Aug 24, 2025. doi: 10.5306/wjco.v16.i8.107757
Table 1 Surgical strategies in dealing with obstructed colon cancer
Challenges
Mitigation strategies
Limited working spaceConsider 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 exposureAdjust 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 anatomyWork 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
Table 2 Surgical strategies for perforated colorectal cancer
Challenges
Mitigation strategies
Limited working space, exposure and access to target anatomyAs per Table 1
Difficulty in identifying critical structures and less obvious anatomical planesExtrapolating from normal tissue planes and known anatomy – there may be a need to start dissection away from the target pathology to identify normal anatomical structures first, before working back towards the pathology by extrapolating from known tissue planes
Use of adjuncts such as use of lighted ureteric stents or indocyanine green can be helpful
Poor optics from surgical smoke and plume generationUse of intraoperative smoke evacuation systems, or continuous smoke evacuation and carbon dioxide recirculation devices (e.g., AirSeal iFS [CONMED Corp., Largo, FL United States]) to provide more stable pneumoperitoneum pressures and faster clearance of plume
Reduction of plume generation by keeping dissection planes dry with gauze and frequent suctioning
Concerns of adequate decontamination/Lavage in contaminated casesUse gravity to bring contaminated fluid to more accessible areas with systematic changes to patient positioning
Use of laparoscopic gauze as a wick when performing suctioning in regions that are harder to gain full exposure
Consider the use of laparoscopic suction/irrigation powered pump devices to improve surgical efficiency
Friable and inflamed tissueHeighten awareness on tactile and visual feedback when handling tissues to avoid excessive traction
Distributing force applied on tissues over a larger surface area by pushing tissues with an open grasper or using a gauze to aid in this. Avoid direct grasping or pulling of tissues as this can easily result in inadvertent injuries
Inflamed tissues are more susceptible to bleeding. Performing meticulous hemostasis at all times during the surgery to keep planes dry
Control of further intraoperative spillageProximal control with laparoscopic bulldog clamp to prevent continued downstream contamination
Pack defect with gauze
If tissue quality is suitable, perform primary closure of the site of perforation as a temporizing measure if added operative time is short