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Laparoscopic ileal resection for stenosing neuroma

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Laparoscopic ileal resection for stenosing neuroma

作者群

J Leroy, J Marescaux

關鍵字

sténose iléale,entérectomie,névrome plexiforme

媒體類型

手術影片

期間

07'00''

刊物

2004-12

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1623.htm

Laparoscopic ileal resection for stenosing neuroma

1. Case presentation 00'09''

This video will demonstrate laparoscopic small bowel resection. The case is that of a 48-year-old male patient with no significant past medical history. The patient presented with acute abdominal pain and episodes of subacute small bowel obstruction. Blood tests revealed the high amylase level. MRI examination of the abdomen was normal. Contrast study of the small bowel showed a short tight stenosis with regular margins at the level of the ileum.

2. Trocar placement 00'35''

Following insertion of the optical trocar in the umbilical position, a 5mm trocar is inserted in the suprapubic site. This trocar site will later be extended for bowel extraction. A further trocar is inserted in the left iliac fossa and the exploration of the abdominal cavity is commenced. The stomach seems dilated with air but otherwise seems normal. Now towards the bowel. There seems to be a focus of encystment resulting from edema in this area. Two atraumatic forceps are now inserted to continue with the exploration.

3. Exploration and exposure 01'20''

Back to the laparoscopic view. We can see the greater omentum here, which is retracted cephalad in order to create the right exposure. We now come to the area of the caecum, which will help us identify the terminal ileum. The appendix is visible now. The small bowel is now gently manipulated to expose the terminal ileum and the ileocecal junction. A thorough examination of the small bowel is performed by passing from one grasper to another. The pathological part of the bowel is visible here. The bowel seems slightly dilated although still soft. The bowel is comprehensibly examined to exclude any obvious pathology. As you can see, this is done by passing the bowel between the graspers while the camera holds still. This allows us to stack the loops of small bowel in layers in order to achieve a good exposure of the pelvis. There are some subserosal fat deposits, which are visible here. We now move proximally until we feel the traction of the Treitz ligament at the duodenojejunal flexure. We now have a good view of the pelvis. There seems to be no pus or nodules on the rectouterine pouch of Douglas. We continue with the exposure of the terminal ileum. In this case, it is ideal to divide the ileum at about 40cm from the ileocecal valve as there is a suspicion of pathology in this area.

4. Small bowel division 03'54''

Two further trocars are inserted in preparation for bowel division and anastomosis. The linear stapler is now introduced and the ileum is divided proximally. We then move distally to divide the bowel again for a segmental resection of the ileum. The bowel is now divided.

5. Mesenteric division 04'42''

The Ligasure Atlas sealing device is now used to join the 2 divisions by dividing the mesentery. As evident, a rapid division can be performed with secure hemostasis of vessels.

6. Anastomosis 05'06''

The anastomosis will now be performed. A seromuscular anchor stitch is first placed to keep the 2 bowel loops in the right orientation. A knot is slid down using the knot pushing device. A second anchoring stitch is placed to avoid twisting of the bowel during anastomosis. This is also secured with a knot. The enterotomies can now be performed using the monopolar scissors. The hole should be just large enough to accommodate the linear stapler. The stapler is now introduced and the lateral lateral mechanical anastomosis is formed. The remaining hole is also closed using a 2nd load of the linear stapler. The resection specimens are now placed in a bag ready for retrieval.

7. Mesenteric defect closure 06'24''

The remaining mesenteric defect needs to be closed by continuous suture in order to avoid risk of internal herniation.

8. Extraction 06'51''

Now to the retrieval of the specimen. The suprapubic trocar site is extended and the wound protector is applied. The small bowel is then gently pulled through. A final check for hemostasis is made, and there seems to be no bleeding. This is the end of the operation.

9. Anatomopathological examination of the specimen 07'27''

We can see here the pathological portion of the small bowel with mucosal ulceration. Pathological examination revealed the benign plexiform schwannoma.