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Laparoscopic colorectal resection for anastomotic stricture following reversal of Hartmann's procedure

Reversal of Hartmann's procedure is a major undertaking and due to its associated morbidity and mortality, many patients are left with permanent colostomy and many others elect not to have the reversal. The advances in laparoscopy and stapler anastomosis have made the reversal simpler and easier. The objective of this film is to show how to carry out a laparoscopic re-intervention of a stenosis of a colorectal anastomosis performed some months before for the restoration of the colorectal continuity after a laparoscopic reversal of Hartmann’s procedure that was performed to manage a perforated sigmoid diverticulitis.

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Laparoscopic colorectal resection for anastomotic stricture following reversal of Hartmann's procedure

作者群

J Leroy, J Marescaux

摘要

Reversal of Hartmann's procedure is a major undertaking and due to its associated morbidity and mortality, many patients are left with permanent colostomy and many others elect not to have the reversal. The advances in laparoscopy and stapler anastomosis have made the reversal simpler and easier. The objective of this film is to show how to carry out a laparoscopic re-intervention of a stenosis of a colorectal anastomosis performed some months before for the restoration of the colorectal continuity after a laparoscopic reversal of Hartmann’s procedure that was performed to manage a perforated sigmoid diverticulitis.

關鍵字

Laparoscopy, colorectal resection, anastomotic stricture, reversal of Hartmann's procedure, colorectal continuity, perforated sigmoid diverticulitis, stenosis of colorectal anastomosis

媒體類型

手術影片

期間

10'00''

刊物

2010-12

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Dec 2010;10(12).
URL: http://www.websurg.com/doi-vd01en3117.htm

Laparoscopic colorectal resection for anastomotic stricture following reversal of Hartmann's procedure

1. Case presentation 00'11''

The objective of this film is to show how to carry out a laparoscopic re-intervention of a stenosis of a colorectal anastomosis performed some months before for the restoration of the colorectal continuity after a laparoscopic reversal of Hartmann’s procedure that was performed to manage a perforated sigmoid diverticulitis. The previous procedure had been performed laparoscopically in good conditions. However, a postoperative stenosis occurred. It was probably related to a fistula or an anastomotic leakage, which caused a fibrotic envelopment and compression. A protective lateral ileostomy was performed to prevent a proximal bowel dilatation. After attempting to carry out a dilatation using an endoluminal approach and trying to place a stent, the stenosis reformed. Consequently, a new intervention is decided upon using a laparoscopic approach. It is obviously necessary to free numerous adhesions, which originate from sequels of previous surgical interventions, and especially from the peritonitis that justified the first surgical intervention.

2. Dissection of adhesions 01'54''

The adhesions are taken down by means of the scissors in a stepwise fashion. The patient should be well relaxed. Good traction and a correct identification of the lowered colon are necessary to free the anastomotic area, the descending colon, and the left transverse colon in order to rule out the presence of ischemia of the lowered colon. To do so, the descending colon should be followed. Attention must be paid to the dissected areas, and especially to those in contact to the iliac vessels and the left ureter. The best option is to stay in contact to the small bowel wall by using just the scissors.

3. Freeing of small bowel from pelvis 03'19''

Once the small bowel has been freed from the deep pelvis, the pelvis is approached in order to find the anastomotic area. On the external aspect of the lowered colon, attention must be paid to the ureter. Dissection using the 5mm Ligasure Blunt Tip® vessel-sealing device can be seen here. This is performed by detaching the planes by means of the blunt tip of the instrument, which is used like a finger in order to open the space, thus avoiding any major risk for the ureter and the nerve structures.

4. Identification of anastomotic area 04'14''

The surgical maneuver is carried on caudally towards the pelvis on the posterior aspect of the bladder, which will be followed to slide progressively towards Douglas’ pouch. A fibrous area is found. It corresponds to the anastomotic area.

5. Rectal stump identification and dissection 04'37''

A bougie is introduced in the rectal stump in order to better identify the stump. Dissection is pursued, remaining in contact to the rectal wall thanks to the 5mm Ligasure Blunt Tip® vessel-sealing device. Dissection is carried out on all aspects of the rectal stump, and notably on its posterior aspect while staying in contact to the wall; this helps to better preserve the vascularization in the mesorectum. The progressive dissection of the rectal stump by means of the 5mm Ligasure® device can be seen here.

6. Colon mobilization 05'32''

Once the stump has been well identified thanks to the dissection and to the introduction of the bougie in the rectal stump, the mobilization of the descending colon is completed, trying to find the previous dissection plane. Here the defect area that had been closed with staples can be observed. These staples initially allowed to close the mesocolic defect. It is essential to avoid dissecting in contact to the colon in order to preserve the entire network of marginal arteries and the mesocolon’s vascular network. It is important to mobilize the colon as cranially and as much to the right as possible. Here the duodenojejunal junction is visible. It is freed on its lateral portion.

7. Rectal stump division 06'46''

The rectal stump that has been prepared is divided by means of an Endo-GIA linear stapler, blue cartridge.

8. Suprapubic incision and anvil introduction 07'00''

As soon as the possibilities of lowering the descending colon are verified, and once recuts have been performed on the descending colon, the anvil of a circular stapler is introduced through a small suprapubic incision.

9. End-to-end colorectal anastomosis 07'14''

An end-to-end transutural mechanical colorectal anastomosis is then performed. The donuts are controlled. The anastomosis is also checked using an air test to rule out the presence of bubbles as can be seen in these pictures. Lavage of the abdominal cavity is carried out. The presence of mesenteric defect and small bowel incarceration underneath the defect is ruled out. In order to secure the anastomotic area and reduce tension at the level of the stapling line, the procedure is completed with seromuscular stitches on the anterior aspect of the rectum and of the lowered colon. As a result, tension at the anastomotic area is reduced. Extracorporeal knots are tied using absorbable threads. PDS material is used here. Several stitches are applied to reduce tension at the level of the stapling area. Attention must be paid to avoid any ischemic suturing. Only the seromuscular plane should be re-approximated.