Hand-assisted sigmoidectomy for sigmoidovesical fistula

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摘要

This video shows the positioning and use of a handport for taking down a colovesical fistula. This patient had diverticular perforation complicated by a colovesical fistula. The handport is placed in the right subcostal area.

分類

basic techniques

關鍵字

hand-assisted sigmoidectomy, position of Hand-port

媒體類型

期間

24'00''

刊物

2004-09

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1099e.htm

Hand-assisted sigmoidectomy for sigmoidovesical fistula

1. Case demonstration 00'21''

This is the case of a patient with a vesical sigmoidovesical fistula ongoing for 2 years and we decided to do a hand-assisted laparoscopic surgery for this type of procedure. The main point is the location of the mini lap, these are different devices for hand-assisted laparoscopic surgery. The one we use, which is called the Hand-port system, needs some place at the level of the abdominal wall, so the location of the mini-laparotomy must be well chosen and is an important point of the procedure. The hand needs to be able to sweep the whole abdominal cavity from the pelvis to the left hypochondrium to take down the colonic flexure if necessary. Where does the wrist go through the abdominal wall, how long and where is the incision? How many centimetres from the symphysis? The incision is in the right hypochondrium; it is located at some distance to the port, it must not interfere with the telescope, which is placed on the left hypochondrium so there is no interference between the scope and the Hand-port. In this way, the hand is able to go through the structure to operate in a good way. You have to operate with this device while respecting the principles of triangulation and this is nothing else than a big port through which my hand goes. How many centimetres from the costal margin? The distances to the costal margin depends on the type of port you use, this one needs some place and must not be placed near the bone, either the pubic bone or the costal margin. These are other devices that need less place but this one you have to be careful and you can’t use it near the bone. That is your left hand and you are right-handed. It must be the surgeon’s non-dominant hand and not the assistant’s. Hand-assisted laparoscopy enhances coordination and provides direct tactile sensation and you must keep that by introducing your hand inside the cavity. The location by a split muscle incision in the right hypochondrium is the choice we made when starting this procedure, but when starting we had experience with laparoscopic surgery. So the risk of conversion is far lower and we prefer this location because we felt it was the right place to be comfortable with the hand. But other teams did not make the same choice and used other locations for their mini-laparotomy in order to be compatible for a conversion. This is another thing you can do with hand-assisted laparoscopic surgery, you can do swabs of considerable size pre-shaped by the non-dominant hand in the abdominal cavity and you can dissect these types of adhesions. This there is small bowel, this is the bladder, this is the sigmoid and this is the fistula. This is the sigmoid and I suppose that the fistula is there. I did an adhesiolysis before you came, this is the right iliac artery, this is still some small bowel, which is fixed in the pelvis but I think that the liberation of the small bowel is going to be done this way. Yes, the patient is in a Trendelenburg position with a slight tilt. Usually in pure laparoscopy the bowel is sometimes difficult to push away from the operative field, this is not the case at all for the hand-assisted technique. This is the rule; this is the mesosigmoid, this is the small bowel. This seems a very good reason to have a hand in there, seems like a very precise way of dealing with this particular area and have the advantage of feel in this particular spot seems quite important. This kind of hybrid surgery combines the advantages of both techniques, you have magnification of the picture, I was told that in laparoscopy (I was taught by Philippe Mouret) when you work on one centimetre of a structure, you have an enlargement of the structure by 10. This patient weighs over 90 kilos, we are deep in the pelvis, you have got the structure that you see well and the hand, which is the visceral surgeon’s best tool. We used to say that the left hand is the brain and the right hand is the monkey hand. Usually sigmoidovesical fistula for diverticulitis are in this area and don’t interfere with the trigone and the ureter, it is not the same thing as sigmoidovesical fistula when dealing with cancer. I take a different view point, if anything bad is going to happen it will happen in my patient and the peri-diverticular abscess can necessitate to any viscus in a way that makes no sense at times, the fistulas have gone in to virtually all intraperitoneal organs. You are right that the dome of the bladder is far more frequently the side of the fistula, but it is possible that the fistula is in the trigone, close to the trigone and there are times when you can’t be certain whether you are dealing with peri-diverticulitis or a tumor or you haven’t been able to make that distinction, I find it helpful in all instances of complicated diverticulitis to have a ureteral catheter in place. I was present when a secondary ureter, a duplicated ureter was transected when the catheter was in the other ureter, you can still do it, you have to be careful, there are certain safeguards but it is very helpful. The small bowel is free all right, this is the sigmoid, we entered this plane, located the posterior aspect of the fistula, which is here and then we can have the fistula pediculated between the thumb and the index. The fistula is here and we are going to cut it right now. You need the fingers for this kind of inflammatory adhesion, the fingers are really a very important part of safely separating such things but maybe some laparoscopic surgeons would disagree. I think the fingers are useful but we have done some of these cases with pure laparoscopy, I find it impossible to work with a hand-assisted port system because after a few minutes I loose vascular supply in my hand and it makes it a terrible operation. It depends on which type of device it was you used I guess, depends where the mini-lap is compared to the location of the structure that you operated, it depends on how you made the size of the laparotomy in comparison to the size of the wrist. There are many factors to appreciate before having a formal judgement on this, we did a prospective randomized trial comparing pure laparoscopy to hand-assisted laparoscopy for sigmoiditis and we did not observe this type of inconvenience in 20 cases. Do you feel induration in the bladder with that left hand of yours? No, not at all, in fact I am going to finish the freeing now. I think you have to be selective, there are times when you can just finger fracture it and you may not see a hole, you may just reinforce it. Look at that, that is done, this is the bladder, this is the colon, I suppose there is nothing at all. Anyway, I agree with what was previously said by one of the speakers; we are just going to take a few minutes to do a blue methylene test via the bladder catheter and there will probably be nothing at all. We will leave the bladder catheter in place for a little more than a week. You are putting methylene blue in the bladder? There you go, a little hole. Some blue is coming out. The feeling of surgeons is also a question of his personal history, in Germany the divisions between the urologist and the general surgeon are very sharp and if you go through this frontier, you are more anxious than if you stay on your colon and you cannot compare the colon to the bladder and I think that the bladder is much more benign than the colon. I think it is important to remove the inflamed tissue as much as possible. So the difference would mean that maybe there was a complication, I don’t know in the literature or in my experience of any bladder complication after any type of bladder suturing as long as you leave the urinary catheter in place for a good time. We have just done a new test with the methylene blue and with the same quantity as before the stitch and there is no more leak. So we are going to place the drain this way and leave the bladder catheter for one week. The next step is the mobilization of the sigmoid itself.

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