Complicated colonic diverticulitis (Hinchey IIb): is there a limit for a totally laparoscopic resection?

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摘要

This video presents the case of a sigmoidectomy in a female patient with a complicated diverticulitis treated in the beginning with a conservative management. A detailed description of the altered anatomy and dissection is given.

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10'00''

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2008-06

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最愛

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WeBSurg.com, Jun 2008;8(06).
URL: http://www.websurg.com/doi-vd01en2322.htm

Complicated colonic diverticulitis (Hinchey IIb): is there a limit for a totally laparoscopic resection?

1. Case presentation 00'09''

This is the case of a 79-year-old patient with a complicated diverticulitis compromising the left ovary. First off, a conservative treatment was performed but led to no clinical improvement. We can quickly see the perisigmoid abscess delimited by the uterus, the left ovary and the small intestine. Dissection of the sigmoid colon begins through the medial plane. We can observe that the uterus is retracted due to the inflammation and that the left ovary is part of this inflammatory mass. Dissection quickly brings out the purulent liquid so that we therefore decide to extract it and take samples for laboratory analysis. With the aid of the Ligasure, we begin to gently separate the elements included in the inflammatory abscess. Once the sigmoid colon is totally free, we obtain good retraction for a better exposure. In this case, because it is a benign pathology; it is advisable to preserve the vascular supply of the left colon and rectum in order to improve short- and long-term results. Dissection is started from the promontory and extended just below the third portion of the duodenum. Especially in cases of severe mesenteric inflammation, the identification of the inferior mesenteric artery is mandatory in order to identify the arterial branches that must be preserved. Once vascular control has been achieved, the sigmoid loop is retracted and lateral mobilization is performed. This lateral dissection is basically realised with traction and counter-traction and monopolar cautery. The objective is to open the left parietal gutter and the dissection is continued caudally, passing through the inflammatory mass. The inflammatory mass is very important and wide, this is why we have to divide the left trump to complete the colonic mobilisation. It is necessary to identify the left ureter as it can be retracted by the inflammation. We know that if we respect the embryological planes of dissection, we should not encounter any particular problems. We look for the ureter just before the crossing with the iliac artery. When identifying the left ureter is difficult, it is preferable to pursue its dissection higher up in a non-inflamed area and to follow it caudally into the operative field. The ureter is next to the abscess, we perform the dissection of the inflammatory tissue surrounding the ureter; this dissection is performed with monopolar cautery. Dissection is continued with monopolar dissection and we manage to partially evacuate the inflammatory abscess. We pursue the dissection on the same plane but the inflammation no longer allows us to recognise the anatomy. Due to the associated inflammation, we decided to continue dissection next to the round ligament to then join the plane of the previously performed dissection. A total resection of the sigmoid colon is performed including the rectosigmoid junction. The mesorectum is divided first anteriorly and then posteriorly; the distal division of the sigmoid colon is performed below the rectosigmoid junction in a healthy, non-inflamed colon. Division of the rectum is performed using 3 linear staplers Endo-GIA (blue cartridges). We can observe the final linear stapler Endo-GIA (blue cartridge). After the distal resection, the proximal division is performed on a portion of the colon that is supple and without diverticula. The extraction is performed through a mini-incision while protecting the abdominal wall. The suprapubic incision is widened and protected with a plastic-coated drape with a ring. The bag is twisted on itself to reseal the peritoneal cavity in a reversible fashion. The sigmoid is placed in a plastic bag, and extract the proximal part of the colon through the abdominal suprapubic incision. Performing the anastomosis includes an extra-abdominal step. An anvil is introduced into the colonic lumen in a healthy and well-vascularized zone. After completing this, the proximal colon is reintroduced into the abdominal cavity. A circular stapler is introduced into the rectum. The rectal stump is transfixed with the tip of the head of the circular stapler. Before closing the stapler, the surgeon should check for any incarcerated organs or any twisted colon. Finally an air test is performed, which in this case is negative. Mesenteric closure is performed and a drain is left in place for 48 hours.

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