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Ileorectal fistula after open total colectomy: laparoscopic re-operation

Total colectomy with an ileorectal anastomosis (IRA) is a commonly performed operation. Postoperative mortality and morbidity are reported to be low and functional outcome is generally rated as good to excellent. When a postoperative fistula occurs, the surgical management is very complex. The purpose of this video is to demonstrate the laparoscopic approaches available in a patient who has had multiple interventions via laparotomy and who may be prone to having numerous adhesions.

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Ileorectal fistula after open total colectomy: laparoscopic re-operation

作者群

J Leroy, J Marescaux

摘要

Total colectomy with an ileorectal anastomosis (IRA) is a commonly performed operation. Postoperative mortality and morbidity are reported to be low and functional outcome is generally rated as good to excellent. When a postoperative fistula occurs, the surgical management is very complex. The purpose of this video is to demonstrate the laparoscopic approaches available in a patient who has had multiple interventions via laparotomy and who may be prone to having numerous adhesions.

分類

clinical cases

關鍵字

Ileorectal fistula, open total colectomy, laparoscopic re-operation

媒體類型

手術影片

期間

13'00''

刊物

2009-06

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Jun 2009;9(06).
URL: http://www.websurg.com/doi-vd01en2603.htm

Ileorectal fistula after open total colectomy: laparoscopic re-operation

1. Introduction 00'11''

The purpose of this video is to demonstrate the laparoscopic approaches available in a patient who has had multiple interventions via laparotomy and who may be prone to having numerous adhesions.

2. Adhesiolysis 00'33''

The protective ileostomy is left in place and following a mini-open laparoscopic approach to the abdominal cavity, a selective adhesiolysis is carried out towards the pelvis. In order to do so, we use monopolar scissors with a low and elective voltage, along with scissors at the level of non-inflammatory areas. Gradually, the various spaces are opened as we search for the anatomy of the distal bowel loop that was left in the pelvis and that is responsible for the fistula.

3. Pelvic dissection 01'18''

We free the pelvis from left to right before identifying the distal blind loop in relation to the ileostomy which, as a reminder, is located in the left iliac fossa. The blind loop is gradually freed from the pelvis while in contact to what we suppose to be the fistula tract and the rectal stump that we still haven’t identified at this moment of the procedure. The bowel loop is very long and dilated on its distal extremity. It is freed on its posterior surface towards the distal segment of the ileostomy. The dissection is continued anterior to the sacral promontory in order to find the blind loop’s extremity: this one appeared to be very dilated on the preoperative CT-scan. It is critical to identify all the anatomy of this very long blind loop, a size that probably explains the local over-infection and the fistulization towards the rectal stump.

4. Fistula isolation 02'47''

The extremity has just been freed and the blind loop as well as the fistula tract have been isolated. Here we can see the aspiration cannula penetrating through the fistulous orifice, who was itself in contact with the rectal stump in the pelvis.

5. Rectal stump dissection 04'07''

We now have to better isolate the rectal stump situated in a very fibrotic area.

6. Bougie introduction 04'14''

This rectal stump is easier to identify thanks to a bougie that we will introduce in the rectal stump. This bougie can also be luminous, but a mere Hegar’s dilator or a bougie allows to manipulate this rectal stump. The dissection is performed with monopolar scissors, but we can also perform this dissection while keeping in contact to the rectal stump with ultrasonic scissors. The dissection in contact to the presacral area is quite tricky so that we don’t hesitate to use cold scissors and the monopolar electrode as it performs better thanks to the stump’s manipulation with the bougie, leading to tension being placed on the tissues that we wish to dissect.

7. Mesorectum dissection 05'20''

We continue the dissection with monopolar scissors deeper and get closer to the rectal wall. By doing so, we gradually approach the mesorectum, followed by the lateral surface of the rectum in order to perform a new resection in a perfectly vascularized and compliant area. We can see here the importance of the bougie that had been introduced through the rectal stump to place tension on the latter. The division is performed with cold scissors before we transect the rectal stump while resecting the fibrotic zone, but especially the area that had a fistula on the back of the rectal stump.

8. Rectal stump transection 06'50''

The transection is performed with a 30mm Endo-GIA linear stapler, blue cartridge, as there is not much space in the pelvis.

9. Rectal stump test 07'28''

Once the transection has been performed, we check the air tightness of the rectal stump through an air test or by injecting a Betadine solution.

10. Anvil introduction 07'47''

The anvil of a DST EEA 28mm circular stapler is then introduced through the 12mm trocar incision’s site situated in the right iliac fossa in order to avoid another abdominal incision. We push the anvil through the ileal fistulous orifice and perforate the small bowel more proximally to exteriorize the shaft of the anvil. We then divide the mesentery until we have resected the excess of distal loop in order to perform a side-to-end anastomosis on the small bowel segment distal to the ileostomy. The division of the mesentery with the LigaSure Atlas® device is then quite easy. We complete it by the division of the small bowel with an Endo-GIA linear stapler. The bowel and the rectal stump now remain to be connected. To do so, we introduce the DST EEA 28mm circular stapler in the rectal stump and connect the anvil to the tip of the stapler.

11. Anastomosis 09'36''

The anastomosis will be performed according to the stapler’s protocol. The postoperative CT-scan performed 2 months after the procedure reveals a good anastomosis that will allow to close the ileostomy.