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Laparoscopic colpo and rectopexy with sigmoid colon resection

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Laparoscopic   colpo   and   rectopexy   with   sigmoid   colon   resection

作者群
J Leroy
關鍵字
laparoscopy,colpopexy,rectopexy,sigmoid colon,resection
媒體類型
期間
07'00''
刊物
2003-07
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Jul 2003;3(07).
URL: http://www.websurg.com/doi-vd01en1459e.htm

Laparoscopic   colpo   and   rectopexy   with   sigmoid   colon   resection

1. Case presentation 00'06''
We will begin now treatment of rectal prolapse. We use routinely 6 trocars, 3 on the right, one at the umbilicus for the camera, one in a suprapubic position, one in the left iliac fossa. You can see the pelvis is well exposed here; with the anterior traction of the uterus, we can see the pouch of Douglas. We place cephalad traction on the rectosigmoid region in order to begin our dissection. The 1st step is to open the retroperitoneum at the level of the sacral promontory and continue to open the peritoneum deep into the pelvis to get control of the rectosigmoid mesentery. You can see the right iliac vessel now on the right side of the screen. We have anterior traction on the rectosigmoid mesentery here and we will attempt to get vascular control. As we enter the pelvis, you see the endopelvic fascia and the fascia propria of the rectum. In women who are not in child-bearing age, which is typically true for these patients, we can use a transuteral stitch in order to suspend the uterus anteriorly, thereby allowing for more dissection space. Once this has been accomplished, we continue our dissection of the peritoneum, traction on Douglas’s pouch to reflect this entire region and you can see here we intend to perform both the resection and the mesh placement. In order to place the mesh, we need to have a channel between the rectum and the sacrum. Here we also need to maintain our vascular supply to the region. You can see that our mesh has got 2 legs and is configured to wrap around attaching both to the sacral promontory as well as the rectum. It is positioned posteriorly at first and a tacking device is used to anchor it posteriorly under the sacral promontory. We then take each of the individual legs and suture them to the anterior surface of the rectum being careful not to violate the rectal wall. And this is our 2nd leg. So a 2nd stitch on the 1st leg of the mesh. This is an extracorporeal knot-tying device; it facilitates the placement on the posterior vaginal wall. And now we can completely divide our peritoneal lining. Distally, we use fibrin glue in this area to aid adhesion. Once this has been accomplished, the area is reperitonealized with a combination of clips and sutures. This is absolutely essential in order to prevent mesh infection and subsequent adhesions and fistula formation. There is of course a danger that the small bowel when it descends into the pelvis could form a fistula with the mesh. Reperitonealizing the mesh decreases this chance significantly. Next we will plan to perform a sigmoid colon resection. As we have already opened the retroperitoneum, our subsequent step is to divide the sigmoid mesentery. This is accomplished with a high frequency device, the Ligasure Atlas®. We will divide the mesentery directly with its vessels with this device. You can see we have taken some sigmoid branches already, which extend up from the inferior mesenteric artery. This device is able to take the vessels along with the soft tissue surrounding them, in the mesentery obviating the need for staplers or clip applying devices and you can see we have a bloodless division here. Because this operation is not for cancer, we will not need to necessarily respect the intactness of the vasculature or the lymphatic drainage. It is similar to resection for diverticulitis and distal division of the vessels feeding the colon is perfectly acceptable. As we approach the colon itself, we will have division of the mesentery up to the anticipated proximal division. We perform the distal division using an Endo-GIA stapler here. Then we place our wound protector. The colon grasped by its distal division point is then exteriorized so that we can perform the resection and proximal division extracorporeally. We find a place of adequate vascularization and we complete the last couples of centimetres of mesenteric division. A purse-string device is then placed. The bowel is divided and an anvil is placed and an end-to-end stapling device introduced through the rectum is used to complete the anastomosis. And now we used a dual modality for the treatment of rectal prolapse.