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Laparoscopic Hartmann procedure for Hinchey III diverticulitis

Guidelines for the treatment of complicated sigmoid diverticulitis recommend Hartmann's procedure. The surgical approach is changing from the current standard of laparotomy to a minimally invasive technique. The objective of this film is to demonstrate the potentials of laparoscopy to manage a sigmoid abscess associated with a Hinchey III diffuse peritonitis.

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Laparoscopic Hartmann procedure for Hinchey III diverticulitis

作者群

J Leroy, C Callari, J Marescaux

摘要

Guidelines for the treatment of complicated sigmoid diverticulitis recommend Hartmann's procedure. The surgical approach is changing from the current standard of laparotomy to a minimally invasive technique. The objective of this film is to demonstrate the potentials of laparoscopy to manage a sigmoid abscess associated with a Hinchey III diffuse peritonitis.

關鍵字

Laparoscopic Hartmann procedure, Hinchey II-III diverticulitis

媒體類型

手術影片

期間

06'48''

刊物

2009-10

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Oct 2009;9(10).
URL: http://www.websurg.com/doi-vd01en2743.htm

Laparoscopic Hartmann procedure for Hinchey III diverticulitis

1. Introduction 00'08''

The objective of this film is to demonstrate the potentials of laparoscopy in the management of a sigmoid abscess associated with a Hinchey III diffuse peritonitis.

2. Introduction of first trocars and abdominal cavity exploration 00'20''

After introduction of a 12mm optical port in a supra-umbilical position and of an operating port in the right iliac fossa, exploration of the abdominal cavity begins. We can identify the presence of diffuse false membranes as well as the edematous aspect of the sigmoid loop. Exploration of the abdominal cavity is continued and sequels of inflammatory process with false membranes, especially at the level of the last bowel loop, of the appendix, of the right iliac fossa, and of the pelvis. Once bacterial samples have been taken, the colon is further explored. The condition of the descending colon is assessed searching for any diverticula that may be situated higher up.

3. Lateral freeing 01'13''

We start with the lateral freeing of the sigmoid colon. It helps to better visualize the sigmoid mesocolon using a medial approach. The incision is pursued cephalad along the parietocolic gutter. Caudally, the root of the sigmoid mesocolon is freed, and especially the inflammatory attachments on the lateral aspect of the pelvic wall and iliac vessels as can be seen here on these pictures. This maneuver induces a few bleedings related to the inflammatory process. Here we can identify the left adnexa, which is immersed in pus and inflammatory areas.

4. Division of the colon 02'15''

Once the colon has been freed laterally, a rapid division is carried out in a somewhat healthy area using the Endo-GIA linear stapler, blue cartridge. Then the sigmoid mesocolon is divided using the Ligasure Atlas® device. This division is extended caudally while staying proximal to the colon and distal to the superior rectal vessels.

5. Left flank trocar introduction 02'53''

Where the colostomy site will be located on the left flank, a trocar is introduced. This trocar helps to exert traction on the sigmoid colon and to better expose the root of the sigmoid mesocolon. Division of the mesentery can then be continued using the Ligasure Atlas® device, always staying anterior to the rectal vessels in order to preserve the vascular supply of the rectal stump. This is carried out, and especially so, as it is a benign condition. Division of the meso is then pursued caudally until the colorectal junction.

6. Division of the upper rectum 03'36''

The upper rectum is divided using the Endo-GIA linear stapler, blue cartridge, 60mm. Tissues are still inflammatory. Once the sigmoid colon has been divided both proximally and distally, we look into the possibilities of mobilizing the descending colon to perform a colostomy without any traction and without any risk of ischemia. This is a direct colostomy since this patient will further benefit of the restoration of the colorectal continuity. The vascularization of the lowered colon is preserved. Here a few adhesions of the omentum to the descending mesocolon are divided. In order to avoid any tension, division of the meso is completed while preserving the network of marginal arteries. Distally, and after shelving the sigmoid colon into the left iliac fossa and after pelvic lavage to prevent any fluid collection, the stump is identified using a colored, non-absorbable thread (Ethibond 2/0). This thread is knotted and kept sufficiently long in order to facilitate the identification of the stump during the re-intervention. This thread is knotted either intracorporeally or extracorporeally and kept sufficiently long. Naturally the stump could be fixed in order to facilitate its identification. In order to complete this maneuver, a silicone drain is placed coming out of the right iliac fossa trocar site.

7. Specimen extraction 05'59''

The bowel segment specimen is extracted through a small incision situated in the left iliac fossa at the trocar site. Once the sigmoid segment has been taken out, the left colon is brought into the left iliac fossa to perform the colostomy.