Laparoscopic approach for symptomatic benign stricture following laparoscopic sigmoid resection

Anastomotic stenosis and fistula after laparoscopic sigmoidectomy are a subject of interest in the literature. Most series reporting results on these complications are heterogeneous. In addition, the selection of patients for treatment vary considerably. The objective of this film is to show a complication, although exceptional, three months after a laparoscopic sigmoidectomy; this complication is a peri-anastomotic stenosis combined with potential rupture of the anastomosis, fistula and peri-anastomotic abscess.

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Laparoscopic approach for symptomatic benign stricture following laparoscopic sigmoid resection

Authors

J Leroy, F Costantino, J Marescaux

Abstract

Anastomotic stenosis and fistula after laparoscopic sigmoidectomy are a subject of interest in the literature. Most series reporting results on these complications are heterogeneous. In addition, the selection of patients for treatment vary considerably. The objective of this film is to show a complication, although exceptional, three months after a laparoscopic sigmoidectomy; this complication is a peri-anastomotic stenosis combined with potential rupture of the anastomosis, fistula and peri-anastomotic abscess.

Classification

complex cases

Keywords

Laparoscopic approach, symptomatic benign stricture following sigmoid resection

Media type

Surgical video

Duration

17'10''

Publication

2009-10

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E-publication

WeBSurg.com, Oct 2009;9(10).
URL: http://www.websurg.com/doi-vd01en2648.htm

Laparoscopic approach for symptomatic benign stricture following laparoscopic sigmoid resection

1. Introduction 00'11''

The objective of this video is to show a complication, although exceptional, following a laparoscopic sigmoidectomy; this complication is a peri-anastomotic stenosis combined with potential rupture of the anastomosis, fistula and peri-anastomotic abscess.

2. Clinical case presentation 00'27''

The patient is examined 3 months later and he shows quite an amazing tolerance when looking at the imaging which shows an important stenosis with discontinuity over a few centimetres. First of all, and considering the context, the laparoscopic approach consists in a careful port introduction through a mini-open technique at the umbilicus.

3. Dissection of inflammatory adhesions 00'50''

We are surprised to find so important inflammatory sequels with the small bowel fixed into the pelvis at the level of the sigmoid region. Some inflammatory bands are carefully divided using the 10mm Ligasure Atlas® device, which helps to mobilize the distal small bowel that was found to cover a fistulous orifice. At pelvic level, the dissection is continued and the sigmoid colon is freed by dividing fairly dense bands that are suggestive of the ongoing inflammatory process.

4. Left ureter probe introduction 02'02''

Faced with the risk of injuring the ureter, a bougie is introduced into the left ureter. The bougie is connected to an external light source. This bougie is introduced through a ureteroscopy and urethrocystoscopy. By dimming the light intensity of the laparoscope, the pathway of the ureter can be visualized thanks to this bougie. We can notice that the small bowel was fixed onto the inflammatory area with dense adhesions that may be a sign of a small bowel fistula. The dense adhesions are resected and we check the condition of the small bowel wall intra-operatively and postoperatively, screening for any opening that may have gone unnoticed during the procedure. The most difficult task is to complete the freeing of adhesions in contact to the sigmoid colon and to the stenotic region. Indeed, adhesions are in contact to the large iliac vessels and to the ureter. Here we can see the benefit of using the bougie in case of trouble, at least for the ureteral identification and in case of doubt, we do not hesitate to dim the light intensity while maintaining the instruments in contact to the dissection area. We check that there is no fistula at the level of the small bowel. A slight doubt persists here, but after a closer examination, no digestive fluid is found during the intervention. The final control through the mini-incision at the end of the procedure corroborates the absence of fistula.

5. Rectal stump identification 04'30''

The rectal stump is searched for. To do so, a bougie with a flashing or constant light, is introduced into the rectal stump until complete identification.

6. Identification of stump opening 04'56''

A colored contrast solution, here Betadine, is injected and it stands out that there is an opening at stump level. This opening is very distal from the colon and surprisingly enough, this patient has almost normal stools. Here we can see bowel debris at the colonic extremity a few centimetres distal from the rectal stump. The freeing difficulty lies in the fact that we are proximal to nerve, urinary and big vascular structures.

7. Lateral approach for colon dissection 05'51''

The colon is then freed at its descending portion using a lateral approach. Here monopolar scissors are used. These are angulated mini-shears roticulator scissors (by Autosuture™). They are sparingly used in monopolar current mode. These scissors are helpful in that they allow to cut dense and inflammatory tissues. We dim the light intensity to identify the pathway of the ureter. This helps to find the correct plane between the sigmoid mesocolon to be resected and the retroperitoneal structures. Fortunately in this patient, the inferior mesenteric vessels were not approached but only the sigmoid vessels were divided. We then decide to move forward to the origin of the inferior mesenteric artery and to use the dissection plane on its posterior aspect. Here we can see that the luminous landmark is located posterior to the vascular axis at the tip of scissors. Dissection is continued using a medial approach staying anterior to the ureter, anterior to Toldt’s fascia, which is not always obvious since the local inflammation induces adhesions between the retroperitoneal structures and the mesocolon. We can see that we are close to the nervous structures so that it is better to keep a safety margin to preserve the superior hypogastric plexus in this young male patient. It is always difficult to identify the plane that is in contact to the colon. The bougie allows us to know if the ureter is posterior to our dissection plane. We continue the dissection while keeping in contact to the posterior surface of the sigmoid mesocolon and in contact to the colon; this allows us to reach the lateral fixation of the sigmoid mesocolon and to find a sufficiently good plane in this patient with a benign pathology. Indeed, he has a perforated diverticulitis, not a cancer.

8. Mesorectum division 08'56''

The mesorectum’s division is continued with the Ligasure Atlas® device after identification of the ureter. We see this dense tissue in contact to the ureter that is divided with scissors. The aim is to remove all the colonic wall with the mucosa. This does not appear to be straightforward as the inflammatory syndrome is still important. We can see the ureteral probe’s course thanks to its luminosity and we know that we can continue the dissection ahead of the probe. Here is the colonic wall that tends to tear up. Once the lateral and posterior planes have been identified, we continue the dissection while in contact to the colonic wall. This dissection technique does not seem to be very elegant due to the bleeding, but it is efficient and especially safe as we avoid any dissection close to nervous or vascular structures. However, we should be careful because with such inflammatory syndromes, the colonic wall can be situated very close to the nervous, vascular or urinary structures.

9. Completion of rectal stump dissection 12'15''

Once the colonic stump has been freed, we complete the freeing of the rectal stump, which, like the colonic stump, often has a very fibrotic and inflammatory wall. We recall that a Betadine test had shown a fistula on a fibrotic zone in an area in which there was probably a route allowing for the discharge of faeces from the colon to the rectum.

10. Rectal stump re-cutting 13'00''

We complete the dissection to mobilize the rectal stump and especially to re-cut the rectal stump in a less inflammatory area. Using an Endo-GIA linear stapler and once we have applied staplers, we check the rectal stump’s water-tightness and get the best possible closure. The re-cut segment is placed in an extraction bag that is left in the abdominal cavity to insert elements that will be dissected at a later date. The descending colon now remains to be dissected as a re-cut is needed in a non-inflammatory and compliant zone. The mobilization had been partially performed and we can carry on this mobilization via a lateral approach and associate it to a freeing of the transverse colon.

11. Colon exteriorization and Knight-Griffen anastomosis 14'05''

Once the colon has been freed, we exteriorize it and introduce a circular stapler’s anvil following a re-cut. We also introduce a luminous bougie in the rectal stump as it allows to identify the extremity. The stapling is then performed according to Knight-Griffen technique. We check the doughnuts, the water-tightness and that the staples are well closed. We also perform an air-test, a lavage and close the mesocolic defect with staples as a more extended mobilization of the colon could induce a freeing of the duodenojejunal flexure and risk having the proximal bowel trapped in this defect as shown in an article recently published and shown at the SAGES around 2 years ago and in the Journal of Gastrointestinal Surgery this year.