Laparoscopic ileo-caecal resection

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Laparoscopic   ileo-caecal   resection

Authors
J Leroy
Keywords
colon,operation,laparoscopy,ileum,caecum,cecum,resection
Media type
Duration
18'00''
Publication
2003-10
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Oct 2003;3(10).
URL: http://www.websurg.com/doi-vd01en1511e.htm

Laparoscopic   ileo-caecal   resection

1. Case presentation 00'06''
I will begin the procedure using 3 trocars. It’s as appendectomy. It’s not necessary to have more trocars. The ileocecal junction is visible here. You see perhaps the ascending colon. We have few adhesions between the ascending colon and the omentum. The transverse colon is here. We will soon free the adhesions and we have explored the small bowel. As you see, we don’t move the camera, we only move the bowel in the field of the camera. As you do when you incise your abdomen, with a small incision, we can completely explore this bowel. This is a good technique to explore the abdominal cavity. There’s no dilatation probably due to the diet before. I will probably resect at this level 20-30cm at a distance from the ileocecal junction. So we will resect this part of the small bowel and the cecum too but before I want to free the adhesions. I use the Ligasure Atlas device. Do you want to excise only the diverticulum? The problem is that it is not a diverticulum, it’s a pseudo one, it’s a functional disease of the terminal ileum. Not only the diverticulum. It’s difficult here. First, I will divide the ileum using a 60mm stapler. The Ligasure is a bipolar high-frequency system. This is a vessel-sealing or tissue-sealing device. The sealing is possible for vessels about 7mm in size. I apply the system and wait for the alarm, which indicates that the sealing is done as you can see here. It’s not a cancer so it’s not necessary to have a vascular approach at the origin of the superior mesenteric vessels. So it’s a division of the mesentery close to the small bowel. It’s a completely different approach compared with cancer. Here it’s an inflammatory disease. It’s a medial approach. So we continue laterally to free the ascending colon. So we have resected this piece and I want to free this now because I will continue the excision outside. I divide the colo-omental ligament. I know some people say the tool is too big but believe me, for colonic surgery, it’s better to use 10mm instruments. It exists in 5mm but it’s not well adapted for this kind of surgery. It’s not a problem of trocar because it is a 12mm trocar. The exposure is very good here. This is the hepatic flexure. The sweeping movements help so much here as you divide. We have enough freed to do the excision outside. So we divide close to the bowel. It’s not a right colectomy for cancer. So we’ll finish the excision outside. Here with this Ligasure device, there’s no smoke, no fog. It’s efficient and does not depend on the experience of the surgeon. And this can’t be achieved with Harmonic scissors. This is the bowel and I put it against the instrument and there’s no risk of burns. It’s not the same with Harmonic scissors, the blade is dangerous if you touch structures. I do the anastomosis outside, except in benign disease. I have finished the freeing now. We can see the incision you’re making here. So we have a drape with a plastic ring. The size of the ring is 7cm. I have grasped the ileum, you can see it now. Here’s how the small bowel is positioned. Usually I do it outside but it’s only to show you. Now the small bowel and the colon are well positioned. The colon and the ileum are here and I’ll do the anastomosis. At this stage, one of the difficulties is to have a twist. This is a 60 Endo-GIA stapler and I use my hand since it is easier. If there is a staple, does the Ligasure cause any problem? Yes, there is a contact between the 2 jaws and there’s difficulty to seal. The anastomosis is here. We can complete the sutures with a side-to-side serosal suture. We can also use hand-made sutures only. Do you always put in a seromuscular suture? I think it’s better if you have a leak. This wound protector here is a Vi-Drape by Becton-Dickinson. We use a sterile soap. Here is a flask and we put the scope in. We now have the inside view. The duodenum is probably here and the small bowel too. Is it necessary to close the window? We don’t. You didn’t make a big hole this time. We will close it.