Explorative laparoscopy: resection of small bowel for vascular tumor

The management of patients with small bowel bleeding remains a diagnostic and therapeutic challenge. In about 5% of cases, upper endoscopy and colonoscopy are nondiagnostic, and the small intestine is the site of bleeding, This is the case of a 55-year-old patient admitted to the emergency department for a digestive hemorrhagic syndrome. The patient’s hemoglobin levels dropped to 6 grams per 100mL. The patient’s resuscitation allowed for the stabilization and restoration of blood volume. Gastroscopy and colonoscopy did not demonstrate any etiology of bleeding. An emergency CT-scan found a suspected lesion at the level of the small bowel with contrast medium extravasation. A video-endoscopic capsule was administered to the patient. It helped to identify the presence of a bleeding polypoid lesion on the middle portion of the jejunum. This video shows the laparoscopid resection of the lesion.

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Explorative laparoscopy: resection of small bowel for vascular tumor

Authors

M Vix, J Marescaux

Abstract

The management of patients with small bowel bleeding remains a diagnostic and therapeutic challenge. In about 5% of cases, upper endoscopy and colonoscopy are nondiagnostic, and the small intestine is the site of bleeding,
This is the case of a 55-year-old patient admitted to the emergency department for a digestive hemorrhagic syndrome. The patient’s hemoglobin levels dropped to 6 grams per 100mL. The patient’s resuscitation allowed for the stabilization and restoration of blood volume.
Gastroscopy and colonoscopy did not demonstrate any etiology of bleeding. An emergency CT-scan found a suspected lesion at the level of the small bowel with contrast medium extravasation.
A video-endoscopic capsule was administered to the patient. It helped to identify the presence of a bleeding polypoid lesion on the middle portion of the jejunum. This video shows the laparoscopid resection of the lesion.

Mots-clés

Explorative laparoscopy, resection, small bowel, vascular tumor

Type de vidéo

Vidéo chirurgicale

Durée

14'00''

Publication

2011-12

Popularité

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Audio

Sous-titres

E-publication

WeBSurg.com, Dec 2011;11(12).
URL: http://www.websurg.com/doi-vd01en3435.htm

Explorative laparoscopy: resection of small bowel for vascular tumor

1. Clinical case 00'15''

This is the case of a 55-year-old patient admitted to the emergency department for a digestive hemorrhagic syndrome. The patient’s hemoglobin levels dropped to 6 grams per 100mL. The patient’s resuscitation allowed for the stabilization and restoration of blood volume. Gastroscopy and colonoscopy did not demonstrate any etiology of bleeding. An emergency CT-scan found a suspected lesion at the level of the small bowel with contrast medium extravasation. Further to the patient’s acute episode, a video-endoscopic capsule was administered to the patient. It helped to identify the presence of a bleeding polypoid lesion on the middle portion of the jejunum. An explorative laparoscopy is decided upon.

2. Lesion identification 01'04''

It will help to rapidly identify the features of a lesion on the anti-mesenteric border when the omentum is lifted up. This lesion is identified by means of a thread.

3. Small bowel exploration 01'14''

The entire small bowel is then unrolled in order to rule out the possibility of there being other lesions to the small bowel. Here visualization of the jejunum and of the ileum is achieved until the last ileal loop. The entire small bowel is unrolled until the caecum becomes visible. Our attention is then turned to the lesion, which is easily identified thanks to its landmark thread. This thread is used for traction purposes in order to present the small bowel. Three ports are used in the present case, one 5mm port is used to accommodate a grasper and two 12mm ports, one to accommodate the optical and the other to introduce the automatic staplers.

4. Meso opening 02'30''

The meso is opened caudally to the lesion. A 60mm linear stapler with white cartridges is used. A landmark thread is placed on the distal portion of the bowel.

5. Small bowel exposure using a Berci needle 03'16''

A 1.5mm Berci needle grasper (Karl Storz™) is introduced transcutaneously in order to expose the distal loop.

6. Resection 03'32''

The small bowel is then controlled on its superior portion and a mesenteric opening is carried out so as to allow for the total resection of this lesion. The mesentery is opened. A 60mm white linear stapler is used once again. When the bowel has been resected, the mesentery can then be divided using a 5mm Ligasure® vessel-sealing system. Tension is placed using the Berci needle grasper (Karl Storz™) on the pulley thread, which serves as a landmark, placed at the beginning of the intervention. The resection of the mesenteric window is completed.

7. Specimen extraction 04'50''

The specimen is placed into a bag. It is immediately extracted through the umbilical opening.

8. Isoperistaltic anastomosis 05'12''

In order to prepare for the anastomosis, the distal loop is exposed once again. The proximal loop is brought in apposition with it. An isoperistaltic anastomosis is carried out. A stitch made of absorbable monofilament is placed to approximate the two loops. Traction is exerted on this thread at this moment. The two loops are then opened using the hook in order to allow for the introduction of the linear staplers. A 60mm long white linear stapler is used. The stapler’s introduction site is closed using a running absorbable monofilament suture. To do so, a first stitch is placed at the lower part of the anastomosis. It will serve as a pulley thread. It will also represent the final stitch of the anastomosis. This stitch facilitates mobilization and handling maneuvers. An absorbable monofilament suture helps to achieve an adequate and complete closure of the jejunal defect from cranially. The closure is achieved with extramucosal stitches. Five stitches are necessary.

9. Mesenteric defect closure 09'10''

Once the anastomosis has been completed, the mesenteric defect still needs to be closed. Here it will be closed on each side using a 3/0 Polysorb™ purse-string. The posterior part of the mesenteric defect will also be closed so as to avoid any bowel loop incarceration into the hiatus. This closure is also carried out by means of an absorbable braided suture. Here the suture is used first to approximate the 2 loops and then to close the mesenteric defect on the lateral aspect of the proximal loop.