Laparoscopic anterior rectal resection for endometriosis using infrared stents

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Laparoscopic   anterior   rectal   resection   for   endometriosis   using   infrared   stents

Authors
J Leroy
Mots-clés
rectum,resection,stents,infrared,endometriosis,laparoscopy
Type de vidéo
Durée
23'00''
Publication
2003-11
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Nov 2003;3(11).
URL: http://www.websurg.com/doi-vd01en1515e.htm

Laparoscopic   anterior   rectal   resection   for   endometriosis   using   infrared   stents

1. Case presentation 00'23''
Exposure is not difficult in this case as you see, I am putting the small bowel on the right; there are no difficulties in doing so as you see, we have easy exposure. You see where the ureter is here. We have infrared detection of the ureter. That was an infrared technique using a probe introduced in the ureter just before the procedure and I have introduced the ureteral stent. Inside the stent, we have a specific probe and an infrared source. We have infrared detection during the procedure, so it is not necessary to switch off the light source of the system. First, I want to evacuate the cyst; you see the nodule is behind. The nodule is essentially on the rectum; this is the rectum and the nodule is on it. I feel the rectum and I imagine this female patient had pains and rectal symptoms too because it is a big nodule when we feel the rectum. We have more feeling in the rectum than in the vagina. It is an essentially rectal nodule. The uterus and the rectum are here. A small patch of vagina would be treated in the same time. What I will do, the infrared stent stops here, I pull on it inside the ureteral probe because it is only the 20 last centimetres of the device. You see the probe coming in the field, you understand why it is important and how we will gain time. I will begin by a rectal resection posterior (conventional) approach. I begin my incision of the peritoneum, the promontory is here I think. My goal is to dissect anteriorly to the vessels, the superior rectal vessel because it is a benign disease, but the danger is to keep endometriotic tissue and I prefer to have resection as for cancer. The vessels are here, I have to preserve perfectly the nerve. You see that we see the ureter very well, the right one, not sure if we see the left one, probably behind. We have a probe to locate the ureter if it is a sick patient. It is only to show you the ureter that is visible here behind. I am just anterior to the presacral fascia. I want to free laterally like this. See the advantage of the infrared. Other systems to detect require you to switch off the light to see, but with this system we can dissect and locate it at the same time. The light source is not so expensive, for the probe it’s probably around 100 Dollars for each kit, but I am not sure 10,000 dollars is for the light source. Those probes are interesting in complicated cases such as in this case because you know that with endometriosis, we sometimes have invasion of the ureter, we are very close to the ureter and we gain time. In a sigmoiditis, when it is really difficult, we can use it. I want to keep this. We change the trocar from a 5 to a 12mm. When we do a rectal resection, we don’t hesitate to do a first section of the sigmoid because we will have easier manipulation of the rectum. It is a 45. It is not routine but you see we will have a better vision of the pelvis. It is the 18th case we do; gynecologists don’t hesitate now to send their patients because they have seen that it is not so easy to do and it is a particular type of endometriosis: it is not a pelvic endometriosis but a rectal, rectovaginal endometriosis and it is completely different to classic endometriosis of the pelvis. We have to resect the rectum and the vaginal wall, it is why at the beginning of my experience I had 50% of resection but I can tell you now it is 99% of rectal resection. You see why it is important to see very well the ureter. We save a lot of time. We have different shapes for retractors, I know that Karl Storz develops this product too, this is a Genzyme product. It is not bleeding a lot. There are no nodules so we see better the limit to the left, the nodule is essentially to the right. I think it is a fantastic tool for the laparoscopic surgeon. See the nodule on the rectum, on the other side is the big nodule in the rectal wall, it is not in the vaginal wall. I am struggling now to find the vagina, that’s why it’s important to be able to see the ureter. If you don’t, it is necessary to dissect them. When it is difficult like this, particularly for endometriosis, I always dissect laterally to find the rectum, you see the rectum is lower. As a whole, our patients have had a lot of babies after this surgery, so it is one of the reasons why we operate the patients, because there is infertility. We have the possibility to place a bougie in the vagina and use infrared detection too. I see the cervix and I am dissecting just behind the cervix. One of the dangers is to enter the uterus too; this is why some authors propose to dissect first in the vagina, so it is a transvaginal approach, they remove the patch and close the vagina. This is a big nodule as you can see. The rectum is behind, this is the vaginal wall, I don’t know where the Denonvilliers’ fascia is. Can you see the bougie laterally to the left? see the vagina with the bougie here. You see the plexus trunk is here. You see we have different possibilities, when we opened the vagina, there was a leak so that it is more difficult to continue the dissection. It was offered by gynecologists to start with the vaginal step, we resect the patch, leave it stuck inside on the rectum and we close the vagina. We now have the rectum, I will transect at this level. We remove the specimen through this, we are removing the tumor. We want to check that there are no tensions for the sutures, there it is perfect. We pull this part of the sigmoid, we introduce the stump. We will do the anastomosis now, I will do the omentoplasty later. I have not mobilized the sigmoid more, I have kept all the movement left and back. We check there are no twists, that’s perfect.