Hinchey IIa sigmoid diverticulitis: feasibility of the laparoscopic approach

作者群

摘要

The objective of this film is to demonstrate the possibilities of the laparoscopic approach during acute sigmoid diverticulitis partly responding to medical treatment. The sigmoid diverticulitis is accompanied by an important mesenteritis.

關鍵字

acute sigmoid diverticulitis, Hinchey IIa sigmoid diverticulitis, laparoscopy

媒體類型

期間

13'49''

刊物

2010-10

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, Oct 2010;10(10).
URL: http://www.websurg.com/doi-vd01en2965.htm

Hinchey IIa sigmoid diverticulitis: feasibility of the laparoscopic approach

1. Introduction 00'19''

2. Intraoperative view 00'36''

As can be seen on these images, the sigmoid mesocolon is retracted; it is the seat of an abscess, which will be sampled for bacteriological analysis. Attempts to find cleavage planes are made. These are not evident to find since the sigmoid loop is stuck to the posterior surface of the uterus and to the ovary. In this case, there is no obvious particular strategy –namely a medial or lateral approach. The intervention is begun in a healthy area by laterally freeing the attachments of the descending colon in order to find a posterior plane anteriorly to Toldt’s fascia.

3. Freeing of sigmoid colon 01'42''

The sigmoid colon fixed in the pelvis is then freed by sliding on the posterior surface of the uterus. The Ligasure® device is used like two fingers of one’s hand to progressively open the plane by dividing the adhesions at the posterior surface of the uterus. The procedure turns more delicate at the level of the sigmoid mesocolon’s root, as can be noted. The root is rigid. The ureters and the iliac vessels nearby represent a danger, so extra attention must be paid there. The left ureter is sometimes retracted in the mass.

4. Lateral freeing 02'40''

The lateral freeing is visible here as well as the opening of a pouch filled with probably infected mucoid fluid and attached to the left adnexa. The use of the Ligasure® Atlas device, not as a cutting system but as two fingers that perform a digitoclasia using the jaws of the device, helps to open the plane with no need for cutting, as this may be dangerous. Here the application of the Ligasure® device is well demonstrated as well as the jaws of this 10mm device that allow to open the plane. An additional trocar is used in order to suction out the blood resulting from the dissection, and to suction any digestive fluid that might come out after the opening of the colonic tube breaking down during traction.

5. Medial freeing 04'13''

The approach to the sigmoid mesocolon’s root is further continued medially, but not too much, bearing in mind that the ureter and the iliac vessels are close by. It is still risky to dissect way too posteriorly. The very inflamed tissues, when coagulated, give off a lot of smoke.

6. Dissection towards the pelvis 04'44''

Here the dissection towards the pelvis is visible anterior to the sacral promontory in the presacral space. It is almost impossible to perform a dissection in the sigmoid mesocolon and in the mesorectum. The ideal way is to find the presacral plane, which is an oncological plane. As mentioned earlier, there are no particular rules. One must not hesitate to navigate to the right, to the left. Here again, a mucoid collection can be observed. It may correspond to a mucosal secretion after perforation of the colon, which has become obstructed. It is accountable for all of these inflammatory lesions and the rarity of medical treatments for such a sigmoid diverticulitis. The lateral pelvic surface of the sigmoid colon is finally freed.

7. Identification of colonic perforation 05'48''

Here a colonic perforation can be seen. It originates from the different tractions and manipulations of a very inflamed colon. This may necessitate a conversion but there is no specific reason for doing so, and, notably in sigmoid diverticulitis, it may not be needed to envisage a conversion for such a small perforation, as would most probably have occurred in open surgery.

8. Upper rectum dissection 06'22''

The dissection is continued still staying away from the posterior plane in order to respect the nerve plexuses, but also the noble structures —and notably the vascular ones. A very compliant plane is reached by drawing nearer to the upper rectum on its posterior aspect. It will be the future division plane of the rectum, after having cleaned the rectal stump if necessary using a betadine solution, also allowing for an easier introduction of the circular stapler.

9. Rectal division 07'15''

Here a 45mm long Endo-GIA linear stapler, blue cartridge, is applied. It allows for the division of the rectum in a healthy area underneath the rectosigmoid junction, which will be excised as recommended in the diverticular disease of the sigmoid colon. The division is made close to Douglas’ pouch. It well demonstrates that the rectosigmoid junction has been resected.

10. Further mobilization of descending colon 07'52''

The descending colon is further mobilized until the splenic flexure. This mobilization will be more extensive with the complete mobilization of the splenic flexure and freeing of the posterior attachments of the transverse colon, if need be. However, it is not necessary to carry out a very extensive mobilization. The objective is to resect the inflammatory and diverticular part and to obtain a tension-free anastomosis at the level of the colon. The vascular network is preserved as much as possible when dividing the sigmoid mesocolon and the left mesocolon in a sufficiently large fashion away from the colon.

11. Proximal division 08'54''

The future zone of proximal division will be prepared laparoscopically as can be seen on these images. The pathological sigmoid colon that has been freed will be exteriorized via a suprapubic mini-incision through which a plastic drape is inserted. This drape is essential to protect the wall during the specimen extraction. The anvil of a circular stapler will be introduced into the proximal colon after application of a purse-string. The whole system will be reintroduced into the abdominal cavity, still through the suprapubic mini-incision, which will be temporarily closed to ensure a perfect air tightness.

12. Anastomosis 09'56''

Here the anvil that has been introduced into the proximal colon is clearly visible. And, as routinely performed, after controlling the perfect patency of the stapling line by means of a Betadine test, a PCEEA 28mm circular stapler is introduced to perforate the stapling line. One of the angles of the stapling line is resected and the crossing zone is removed in case of multiple stapling. Here the spike perforating the rectal stump close to the stapling line can be noted. This will help to remove the entire left part of the rectal stump. The anvil is introduced laterally into the proximal colon. It will allow to perform a tension-free side-to-end anastomosis, hence achieving a better vascularized anastomosis, rather than an end-to-end anastomosis with freeing of the meso to prepare the anastomotic area.

13. Air test 11'40''

Once the anastomosis is complete, an air test is carried out to rule out any leakage at the stapled area and to rule out any hemorrhage. As soon as this test has been performed and the control of colonic and rectal doughnuts has been achieved, the defect is closed using either staples or a running non-absorbable suture. A drainage is recommended in such infected situations. It will limit the risk of secondary abscess as a small blood oozing may persist and induce such abscess. This intervention demonstrated the possibilities of the laparoscopic approach even in severe forms of sigmoid diverticulitis. Caution is recommended and conversion is one potential option. Ureteral catheters may also be placed for identification purposes.

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