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Laparoscopic coloproctectomy for ulcerative colitis

Laparoscopic coloproctectomy for ulcerative colitis is a safe procedure and is associated with short-term benefits such as faster recovery and less pain. In this live video shot during the IRCAD Advanced Course in Laparoscopic Colorectal Surgery in November 2009, Prof. Cristiano Huscher shows a laparoscopic coloproctectomy for ulcerative colitis in a female patient.

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Laparoscopic   coloproctectomy   for   ulcerative   colitis

作者群
C Huscher, J Marescaux
摘要
Laparoscopic coloproctectomy for ulcerative colitis is a safe procedure and is associated with short-term benefits such as faster recovery and less pain. In this live video shot during the IRCAD Advanced Course in Laparoscopic Colorectal Surgery in November 2009, Prof. Cristiano Huscher shows a laparoscopic coloproctectomy for ulcerative colitis in a female patient.
分類
basic techniques
關鍵字
Laparoscopic coloproctectomy, ulcerative colitis
媒體類型
期間
27'40''
刊物
2009-12
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Dec 2009;9(12).
URL: http://www.websurg.com/doi-vd01en2822.htm

Laparoscopic   coloproctectomy   for   ulcerative   colitis

3. Last small bowel loop division 02'28''
As you can see, I am on the other side. And so I’m ready to staple it. I use a white cartridge to avoid any oozing and any bleeding from the bowel. Very often, if you use a blue one, which could be a good idea, you can have some bleeding. See the fatty tissue all around, the small bowel loop and now we are ready to staple very nicely. I’d like to show you these adhesion and we have to dissect and to cut them in order to lift up the right colon and the caecum in order to spare the mesentery and all vessels; so I have to change a trocar now. Can I have another trocar please? I am now behind the caecum trying to spare every vascular supply of the last small bowel loop. I don’t know if it’s important or not but we try to spare everything, especially in benign disease and now we try to show you some more details behind and we go step by step avoiding any oozing and bleeding. So you can have a good landscape. These are the ileocaecal vessels and the last part of these vessels has to be clipped. See the vessels. I’m very comfortable with this instrument; recently I’ve been using it for many procedures. In other cases where the neoplasia is not suspected, and we go very close to the bowel. And in this particular case, what you have chosen is to go very narrow from the colon. In this case, cancer is not suggested. See now you have in front of us the Monk’s line and we can spare time using diathermy and the field sometimes is very clean. As you can see, even when you grasp the tissue, we can use diathermy. Then we go back and try to expose again the mesentery now in front of the duodenum. So if I understand well, you go in front of the duodenum and then you come back to the caecum, is that correct? Yes, sparing the ileocaecal vessels. I’d like to see the last small bowel loop. So I’m very far away. Now we have to change our exposure. We push the right colon in the right iliac fossa like this and my assistant exposes for me the Morrison’s pouch in front of us, see this is the Morrison’s pouch and we can coagulate. And even when I have to go fast, instead of radiofrequency, I can use diathermy. My aim is to have a very clean field. You can avoid any oozing and any bleeding. Here’s the duodenum as you can see, in front of us. Now we go expose in another way.
5. Middle colic artery dissection 07'35''
We are in front of the pancreas, see. This is the middle colic artery bifurcation, and left and right vessels. I’m sure we can coagulate; these are vessels that we can avoid any clipping. This is the right branch and now if you twist just a little, I can surround. And now I’d like to show the Treitz’ arcade, left colic vessels well prepared from below and now I expose it. I can coagulate this one. And now we are ready to change the scope’s position if we have a camera outside, we put the camera in front of the transverse colon. Now we put the patient in reverse Trendelenburg position. And now we open the gastrocolic ligament again. This is one of the major vessels of the greater omentum: we call them Barkoff’s vessels or Barkoff’s arcade. Why don’t you leave the entire omentum inside of the patient? Because as you know, I like to dissect the splenic flexure dividing the gastrocolic ligament to be in front of the pancreatic tail and to avoid any lesion of the pancreatic tail. Now we are changing the camera’s position again. As you can see, the specimen is big enough. This is the transverse colon mesentery in front of you and the Treitz’. And now I finish the mesentery’s dissection. Jejunal loop. I go on the patient’s right side. Now the camera is in the upper port in front of the anterior aspect of the stomach. Here’s the gastrocolic ligament in front of us, and a forceps in my hands. See with this technique how easy it is to go close to the spleen.
6. Splenic flexure mobilization 11'08''
Well you can see the splenic, you can see the splenic flexure of the colon and this is the mobilization of the splenic flexure of the colon. The main idea is that very quickly if you cut the gastrocolic ligament, you are into the lesser sac. And then if you are at this level, you can see the pancreas first. So it’s easier for him but it is not a conventional strategy. He’s probably the only surgeon doing that and he uses this strategy because he’s working only with 2 instruments, only with 2 hands because for his strategy, he’s working conventionally with 3 ports. And now we are in front of the attachments. So now we can push the small bowel in the right position, see. We have to push the small bowel in the upper quadrant. If we are able to see nicely the left colic artery and vein, we can spare the inferior mesenteric artery and we stay far away from its origin. See the bowel and the mesentery. That is probably the distal part of the left colonic artery. Yes, indeed. So how many instruments do you use during one procedure? Only one because I like it a lot, I can do a lot of things. Is that the left colic artery? yes. What is the grasper you are using here on the left side? It is a dissector with diathermy to prepare the vessel and perform precise diathermy. You don’t think it could be traumatic for the colon and the bowel, never had problems with it? It could be, but I think that for a total colectomy, we need to coagulate sometimes and so I try to avoid any grasping on the bowel and I try to grasp only the mesentery. Now we are free to prepare the vessels. I try to do a window and to prepare my vessels. There is no study comparing dissection close to the bowel wall. We preserve the mesorectum for different reasons, the first is that there is zero risk of nerve injury because we know that even if we identify and preserve the nerve, you have some functional problems because you can induce some trauma to the nerve during the dissection, to the anastomosis because there is no posterior residual space because the mesorectum is still there. The problem is that they are very young patients, and this is a benign disease. So even if you are a good surgeon, even if you can do a TME with preservation of the nerves, you cannot accept any risk of a genital dysfunction. Eric, do you see the vessels, IMA in front of us? Yes. I think it would be a good idea to stay far away. You are in the mesentery, there is no risk even for the hypogastric nerve. I think that all we said was that if you stay close, it has been made easier by Ligasure. It used to be easier to stay outside the mesorectum. There is a third advantage to preserve the mesorectum: it is to preserve the woman’s fertility. I am not conscious of any of them with any trouble having babies if they wanted to. We are not speaking of TME for rectal cancer, we are talking about total coloproctectomy with ileal pouch for very young patients, between 20 and 30 years old. We believed 10 years ago that the pouch was the best way, and we know now that preserving the rectum is important for women, but also because the quality of life is better. Theoretically, it could an option, but it is not very often that we have this opportunity.
7. Rectal dissection 18'30''
Cristiano, what are you doing with this big needle? It is to expose the pelvis. You understand why it is difficult for a woman to become pregnant after that. This patient is 50 years old. That’s nearing her sexual peak. Cristiano, do you always do that to lift up the uterus? Yes. Are you working with your right or with your left hand? Both, in my right hand, I have a Ligasure Advance®, and in the left I have coagulating forceps. We now have all the mesorectum in front of us, we are inside, and we have dissected the Mander hilum, the bifurcation of the superior rectal artery. Now it all becomes easier as you can see. Now we have to expose the anterior aspect, or the lateral aspect. It is complex for the surgeon to stop before the end, it is easier to go very low at the end of the mesorectum, and it is not so easy to cut the mesorectum. That is why the rectoscopy can help you. We recognize the right plane, we go very close to the bowel, and then we are ready to go down. How far do you think you are from the dentate line at this point? 10cm now. The anastomosis will be done very close, I think 1cm. We also try to tract the rectum with an instrument. I am dissecting the middle part of the rectal stump and the instrument is too short probably as you can see, I have to push a lot. We now change the camera’s position to have a very good view of the last part of the dissection which can be clean. We are very low and very close to the bowel. How many centimetres do you think you are now from the anal canal itself? Probably 5cm, now we go and check. There is still some mesorectum there. We see this very interesting final dissection on the rectum. The first stapling was done, and now we do the second one. The problem is that we can go too low. Now we have to retrieve the specimen. Now we do a rectal finger exploration. Yes we will make a pouch. I would like to show you something, in ulcerative colitis, very often we have such a greater omentum: very short and very thick. It is not very useful, we do not use it very often as it is short, thick and not very good quality. This is the reason why we can remove it. Some authors suggest that this greater omentum with a lesion that occurred during the procedure can create adhesions and small bowel occlusion.