Difficult case of ureteral identification during laparoscopic sigmoidectomy: interest of augmented reality

The aim of this video is to show the benefit of imaging when faced with anatomical abnormalities to avoid incidents during the surgical procedure. In this case, it is the left ureter that is abnormal, passing behind a section of the left iliac ureter, the latter being in fact an abnormally long left iliac artery and its course partially hiding the ureter. The procedure is a sigmoidectomy for cancer of the sigmoid colon in an averagely obese patient.

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Difficult   case   of   ureteral   identification   during   laparoscopic   sigmoidectomy:   interest   of   augmented   reality

Authors
J Leroy, L Soler, J Marescaux
Abstract
The aim of this video is to show the benefit of imaging when faced with anatomical abnormalities to avoid incidents during the surgical procedure. In this case, it is the left ureter that is abnormal, passing behind a section of the left iliac ureter, the latter being in fact an abnormally long left iliac artery and its course partially hiding the ureter. The procedure is a sigmoidectomy for cancer of the sigmoid colon in an averagely obese patient.
Mots-clés
Difficult case, ureteral identification during laparoscopic sigmoidectomy, interest of augmented reality
Type de vidéo
Durée
15'25''
Publication
2010-03
Popularité
Favoris
Favorites Media
Audio
en fr es
Sous-titres
en
E-publication
WeBSurg.com, Mar 2010;10(03).
URL: http://www.websurg.com/doi-vd01en2890.htm

Difficult   case   of   ureteral   identification   during   laparoscopic   sigmoidectomy:   interest   of   augmented   reality

10. Ureter identification using augmented reality 07'05''
Using augmented reality, we will highlight the ureter that is in fact hidden by the iliac loop. Here we see the iliac loop, we think it is the ureter but it still isn’t. The ureter is still not properly identified and we therefore think that we have divided the ureter that has remained stuck to the peritoneum. We therefore decided to use augmented reality and we can see that the ureter is much more medial that we would have thought as it is hidden by the iliac loop. The ureter is usually located at the bisection between the genital vessels and the aorta. The ureter is searched for using the augmented reality’s image and then we understand why we do not see the ureter at this time in the procedure since it is hidden by the iliac vessels. The retroperitoneal space is opened to find the ureter on the posterior aspect of the artery. Very rapidly, here we can see that the ureter is well visible; we do not try to dissect it completely. We only demonstrate its location to prevent any risk of ureteral division and/or resection that might have gone unnoticed. Here it is understood that the ureter is hidden posteriorly. More cranially above the iliac loop, the same maneuvers are performed and we can use augmented reality to re-identify the ureter, which lies much more medially than initially thought since we are dealing here with genital but not ureteral structures. Indeed, the ureter lies much more medially. These are genital vessels. Thanks to lateral traction, it soon becomes evident that the ureter has been moved laterally since it was situated more medially and we can see it pulse with reptation movements highly representative of the ureter. In this very precise case, the augmented reality helped to perfectly identify the structures avoiding any excessive dissection even if the dissection was fairly moderate here. Indeed, relatively fixed structures have been identified easily through the use of augmented reality. Augmented reality uses a combination of real video images and reconstructed images, which are elaborated using digital images such as the ones obtained by CT-scan or MRI; here CT angiography was used to perfectly demonstrate this vascular anomaly along with others since there were several renal arteries, and more particularly 3 renal arteries to the left kidney. The procedure is further continued once we have made sure that the ureter has been preserved by resecting the sigmoid colon. Its proximal division is carried out following division of the meso and ‘en bloc’ removal of the vascular package to isolate the bowel segment containing the tumor.
13. Intracorporeal proximal colon division and anastomosis 12'28''
The anvil will have been pushed in the proximal colon from externally in this somewhat morbidly obese patient. The colon is then divided under laparoscopic control without extracting it suprapubically using a stapler. The stapler will trap the suture thread holding the anvil’s extremity. On the antimesenteric side, close to the stapling zone, at the level of the stapling line, a small incision is performed with a hook until opening the bowel lumen. The thread is searched for to be hooked according to a “fly fishing” technique. This is achieved in order to exert traction on the anvil’s shaft, which will be exteriorized on the antimesenteric side. This offers the benefit of better closing the opening site. This must be preferred over the division on the stapling area, which tends to open more widely. Doing this on the antimesenteric side offers many advantages: indeed, the anastomosis is performed in a “racquet handle” fashion by resecting a part of the stapled area; as on the rectal stump, this triple stapling technique is only partial since a full resection of the two stapled angles is achieved, one antimesenteric on the colon and the other on the right part of the rectum. The integrity of the doughnuts is controlled. An air test is performed before re-approximating the mesenteric defect using a stapler; here an Endo-universal stapler, green cartridge (with longer staples) is used. No drainage is used. The mesenteric closure should be meticulous enough as to avoid any risk of internal hernia, especially in the immediate postoperative period as this risk cannot be overlooked.