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Fully laparoscopic total coloproctectomy for intestinal polyposis

The objective of this film is to demonstrate a technique of coloproctectomy for disseminated polyposis in a young female patient who presented fairly massive bleedings. Her polyposis was discovered but did not have any known family history. Technical details and all steps of the dissection are clearly exposed.

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Fully laparoscopic total coloproctectomy for intestinal polyposis

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J Leroy, J Marescaux

摘要

The objective of this film is to demonstrate a technique of coloproctectomy for disseminated polyposis in a young female patient who presented fairly massive bleedings. Her polyposis was discovered but did not have any known family history. Technical details and all steps of the dissection are clearly exposed.

關鍵字

Laparoscopic full total coloproctectomy, intestinal polyposis

媒體類型

手術影片

期間

30'00''

刊物

2010-03

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Mar 2010;10(03).
URL: http://www.websurg.com/doi-vd01en2916.htm

Fully laparoscopic total coloproctectomy for intestinal polyposis

1. Introduction 00'20''

The objective of this film is to demonstrate a technique of coloproctectomy for disseminated polyposis in a young female patient who presented fairly massive bleedings. Her polyposis was discovered but did not have any known family history.

2. Exploration of abdominal cavity 00'42''

The procedure starts with the exploration of the abdominal cavity; all the colonic region is exposed. The surgeon stands between the patient’s legs and starts the intervention with division of the right colic vessels as close to the colon as possible in order to preserve the vascular network; this will allow to potentially lengthen the mesenteric axis with a correct preservation of the vascular supply of the ileal loops. This maneuver is facilitated by the use of specific instruments such as the Ligasure Advance® device or the new generation 5mm Ligasure®, which allows to seal the vessels and tissues before their division while staying in contact to the colonic wall.

3. Dissection of ileocaecal region 02'00''

The dissection starts close to the ileocaecal region to then proceed from caudally to cranially towards the hepatic flexure, then progressively on the right transverse colon. Before moving forward, it is useful to free the caecum on its posterior aspect. To do so, an upward traction is carried out and the freeing is continued by using the Ligasure Advance®’s monopolar electrode, which allows for a safe, precise and atraumatic division, especially when traction is combined with tension placed on the fibrous tracts.

4. Transverse mesocolon exposure and dissection 03'00''

The dissection of the transverse colon still needs to be carried on from right to left. As a result, the root of the transverse mesocolon is exposed. The surgeon always stands between the patient’s legs as when performing a right colectomy extended to the left. The transverse mesocolon is exposed once the omentum has been retracted above the transverse colon in the subphrenic region to the right and to the left. The root of the transverse mesocolon is searched for anterior to the pancreas until opening the lesser sac and dividing either the middle colic vessels or its branches if we want to stay away from the pancreas and avoid the risk of pancreatic injury. The greater omentum also needs to be detached from the superior border of the transverse colon if the greater omentum is not resected.

5. Splenic flexure mobilization 04'19''

The maneuver is carried on towards the splenic flexure always with the surgeon standing between the patient’s legs. And we can see that thanks to the laparoscopic approach, all the attachments of the splenic flexure (and especially the colo-omental ligament) can be divided with a clear view. To do so, a perfect exposure of the colon and omentum is achieved in order to divide the attachments as close to the transverse colon and the splenic flexure once these attachments have been sealed. We then gradually approach the phrenico-colic ligament and the suspensory ligament (also called sustentaculum tali) on which the spleen lies. This operative step is sometimes delicate to achieve since several attachments of the greater omentum may be found on the splenic capsule and the slightest traction can induce a splenic decapsulation with a risk of bleeding. It is often easier to carry on this freeing by a posterior medial approach and here we can see that the lesser sac has been opened as well as the gastrocolic ligament that is divided using a medial approach. This maneuver is carried on once the descending mesocolon has been exposed once more in order to pursue the division, still with the surgeon standing between the patient’s legs and using the 10mm Ligasure Atlas®, much more effective and rapid. And here, we can see the left colic vessels that will be divided following two or three applications of Ligasure Atlas®. As a matter of fact, the anterior aspect of the pancreas is identified in order to avoid injuring either the body or tail of the pancreas. Here we can see the danger of traction placed on attachments or adhesions to the spleen that may induce a splenic decapsulation with bleeding.

6. Left colon dissection 07'18''

The descending colon is further freed, this time no longer on its medial and posterior portion but on its parietal fold. The sigmoid colon is then approached. The best way to approach it is to change position and move to the patient’s right. This position is typical when performing sigmoid and rectal surgery. As this technique has been standardized for sigmoidectomies and rectal surgeries, it is relatively easy to carry out in a patient with no particular adhesions as in the current case. Here we use monopolar current as much as possible, with electronic control as when using the Ligasure Advance®. Thanks to traction, this instrument allows to achieve a very precise and atraumatic division. Once the sigmoid colon has been freed of its lateral attachments, it has to be freed medially, and here by always preserving the superior rectal vessels. That is why the sigmoid branches only will be divided since there is no degeneration and there is no reason to dissect in contact to the aorta; the risk of both neurological and ureteral lesion is not nil and it is preferable to preserve a correct innervation for sexual and functional urinary reasons. The divisions of nerve plexuses may cause retention problems, even neurogenic bladders if the dissection is performed much too close to the sacral region.

7. Rectal dissection 09'45''

The other benefit of carrying out a dissection as close to the rectal wall as possible is to preserve an adipose bed that will prevent too important a tilt of the genital organs to the back; it will also help to keep a reservoir position anteriorly and not too posteriorly with such a tilt in the presacral space. This was facilitated by the use of instruments such as the Ligasure Advance® as in the present case; other experts will use ultrasonic scissors, which have the drawback of presenting depots of particles that may impair the sight. Here we can see that we can play with different current types using the scissors’ mode without using energy, be it bipolar or monopolar. The dissection is continued until the pelvic floor staying in contact to the rectal wall, not only on the posterior aspect of the rectum but also on its anterior and lateral aspects. The dissection is gradually brought down on to the pelvic floor. The meso is still vascularized since the rectal vessels and the inferior mesenteric vessels have been preserved. The dissection is gradually pursued and it must be understood that this is a painstaking, delicate operative step that must be performed anteriorly, posteriorly, laterally, always staying in contact to the rectal wall. The objective is to perform a cylindrical dissection in contact to the rectum since there is no tumoral lesion. Here the vaginal wall and the Denonvilliers’ fascia can be seen; they are retracted anteriorly. The dissection of the lower rectum is progressively continued by exerting an anterior traction and retracting the rectum posteriorly and always using the Ligasure® to stay in contact and ensure hemostasis as close to the rectal wall as possible. Any bleeding can be immediately controlled by hemostasis as can be seen here using the Ligasure® device. The dissection is performed anteriorly, laterally and posteriorly, by navigating on each side as it is exceptional to be able to perform a complete one-step dissection on one of the surfaces. It is essential to navigate around the rectum to gradually uncover the planes and approach the pelvic floor with the help of the traction that is exerted and the dissection that gradually lowers, thus approaching the pelvic floor and the external sphincters. At this moment in the procedure, we will continue this step by a transanal approach after having checked the distal part of the dissection, but before that, it is preferable to continue the dissection in contact to the rectum to join the pelvic floor. To facilitate the extraction, the colon’s position must be checked, along with the absence of rectal twists and complete the ileum’s terminal small bowel mobilization by dividing the attachments up to the Treitz’s flexure, and even until the posterior surface of the pancreatic head is visible, or more if necessary depending on the meso’s thickness. Here we see the end of the terminal small bowel’s freeing. This freeing will carry on until the duodenojejunal flexure in order to have a good mesenteric motility. If required, we may have to divide the mesenteric vessels away from the network of marginal arteries. Indeed, as we have preserved the ileocolic vessels and a well-vascularized network of marginal arteries, we can gain a few centimetres by performing a division of the superior mesenteric vessels. We can see the third duodenum being dissected and we will be able to see the pancreas’ posterior surface, which will provide greater motility to the pancreas’ head.

9. Transanal dissection and specimen extraction 16'30''

The transanal dissection now remains to be performed; this is identical to conventional surgery, as we install an Endo-anal Lonestar® retractor first, then the lower rectum is divided, here by keeping around 1cm of mucosa of the anal canal above the pectinate line to preserve a good continence, and especially have a good differentiation between gas and stools. We then pull the entire colon and bring it through the anus up to the ileum that was divided with a stapler. We then return to the abdominal cavity and in this case, after having performed a temporary closure of the anus with a gauze introduced transanally, we check how the ileum can be lowered to then perform a reservoir laparoscopically. This dissection is performed following a complementary mobilization in order to gain the few centimetres that will allow a tension-free lowering with no need for traction on the vessels.

10. J pouch creation 18'40''

Once this has been done, we identify the bowel’s extremity by fixing the two flaps to perform a 15cm high reservoir. This ileal reservoir will be shaped as a J. A landmark stitch allows to fix the two flaps, keep a hold of the reservoir’s extremity to measure its length and fix the extremity using a 2/0 Ethicon needle that will allow to see the reservoir’s extremity and prepare its making. We open the reservoir’s extremity using the monopolar tip. This opening is easy to make; we then introduce the anvil of an Endo-GIA linear stapler. Due to the reservoir and the trocar’s proximity, the cartridges used are 30mm long; it will therefore be necessary to apply several cartridges. We push the Endo-GIA step by step in the reservoir, which also allows to control the efficiency of the hemostasis, and we gradually perform a reservoir that gets longer. It will measure around 15cm long upon completion, as can be seen on these pictures. The proximal portion of the reservoir remains to be checked, and excess bowel will need to be resected with a stapler before extracting the intestinal segment. The reservoir is then closed using a quite loose stitch, which is a landmark stitch that will be used to place traction transanally via a grasper introduced transanally while we control the lowering and avoid any twist. Indeed, a twist would reduce the course and could cause ischemia in the long run. We check that the reservoir is perfectly positioned in relation to the meso. We can see here that it is positioned perfectly. The mesentery is situated more anteriorly and the reservoir posteriorly, which will allow to provide it a good curve following the sacral concavity, along with a good angle in relation to the anal canal and the reservoir to reproduce the anorectal angle that allows to improve the continence. Excessive rectitude and traction on the reservoir could lead to a disappearance of the anorectal angle, and the risk of incontinence would be greatly increased.

11. Ileostomy 23'00''

The mesenteric defect is closed using a suture or a stapler. We then identify the bowel segment 30cm from the anus to perform an ileostomy in the left iliac fossa in this case, as the bowel is better positioned at that level. We then check the position of the reservoir and its color before performing the stomy on lateral diverting ileostomy. The patient is controlled 15 days later, with a left ileostomy and a scarring of the various trocar sites. This patient will benefit of the stomy’s closure on the 15th day. Before doing so, we explore the reservoir endoscopically to evaluate its vascular quality, its compliance and make sure that there are no leaks at the level of the anastomosis. We see here the posterior and anterior stapling areas, and by backing the endoscope, the suture area at the level of the anal zone. The laparoscopic exploration is performed via the stomy’s orifice following its integration. The abdominal cavity is free of adhesions; the bowel is not inflamed and compliant. The pelvis is not inflamed and we can see the reservoir in the back, which presents no important adhesions.