Laparoscopic ileocaecal resection for mucinous cystadenoma of the appendix

作者群

J Leroy, F Costantino, J Marescaux

摘要

This video demonstrates a laparoscopic limited ileocecal resection for a large mucinous cystadenoma of the appendix.

關鍵字

laparoscopy, ileocecal resection, mucinous cystadenoma, appendix, ileocecectomy

媒體類型

期間

11'00''

刊物

2008-04

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, Apr 2008;8(04).
URL: http://www.websurg.com/doi-vd01en2314.htm

Laparoscopic ileocaecal resection for mucinous cystadenoma of the appendix

1. Case presentation 00'15''

This is the case of a patient in his fifties who was diagnosed with a mucinous cystadenoma of the appendix during a routine examination. Laparoscopic surgery is decided upon.

2. Operation commencement 00'18''

Four ports are used. The first step of the procedure consists in the exploration of the abdominal cavity, which allows to identify the appendicular mucocele. The appendix is big in size, dilated but not very adherent. The exploration allows us to rule out the presence of adenopathies or carcinosis since no nodule was visualized during this exploration. The small bowel is partially fixed on its posterior surface. First it has to be freed by opening the peritoneum on the posterior lateral aspect of the ileocecum region.

3. Peritoneal incision and posterolateral dissection 01'20''

The freeing is continued while keeping proximal to the root of the mesentery and distal from retroperitoneal structures and especially from the ureter. Dissection continues on the posterior aspect of the cecum using monopolar scissors and cephalad and anterior traction on the ileocecum. Throughout this stage of the procedure, the appendix is not manipulated. Freeing is performed progressively staying anterior to Toldt’s fascia. Once the posterior surface of the cecum and the posterior aspect of the terminal bowel loop have been freed, we divide this loop with a linear stapler (Endo-GIA, white cartridge).

4. Ileal transection 02'29''

This ensures a better hemostasis. This division prepares for ileocecal resection, which is carried out first in order to separate the ileocecum from the colon.

5. Medial dissection 02'41''

The mesentery is further divided using the 10mm Ligasure Atlas® while keeping proximal to the digestive tract in order to preserve the vascular supply of the marginal arteries of the ascending colon. You can see perfectly here the beating of the ileocolic vessels and of the marginal arteries.

6. Transection of ascending colon 03'24''

We check the color of the colon to make sure that it is well vascularized. Once the mesentery and the mesocolon have been divided, the colon is divided distally from the ileocecum while still using a linear stapler (Endo-GIA, white cartridge) that allows for a better hemostasis. The ileocecum is then placed into the pelvis. The procedure continues with the preparation of ileal and colic stumps, paving the way for a side-to-side isoperistaltic ileocolic anastomosis performed laparoscopically.

7. Preparation for ileocolic anastomosis 04'25''

The terminal portion of the small bowel is prepared by division of the bands, which prevent the small bowel from expanding. The ascending colon is freed of its posterior adhesions and attachments until the hepatic flexure of the colon is reached. The right flexure is also mobilized by dividing the superior adhesions and attachments towards the liver. This is carried out in order to obtain better motility of the colon and position it in an ideal way to perform an ileocecal anastomosis under excellent laparoscopic visual control. This anastomosis is prepared by fixing the 2 intestinal segments (ie, small bowel and ascending colon) with 2 absorbable or non-absorbable sutures. These sutures are placed on the colon, then on the small bowel, while making sure to stay anterior and in front of the anterior band in order to perform a suspension and introduce the linear stapler (Endo-GIA) posterior to the suspension zone. Here we can see the 2nd suspension stitch.

8. Intracorporeal re-anastomosis 06'20''

The assistant is given one of the suture wires and the surgeon places traction on the other suture in order to obtain a straight line between the 2 traction stitches. The small bowel, then the colon is opened with electrocautery scissors. The opening is only large enough to introduce the linear stapler. We begin by introducing the thicker portion of the Endo-GIA, then the thinner portion and with the help of the wire left in place, we can place a better traction to perform the straightest possible anastomosis. The stapling is done endoluminally with blue cartridges. Once the stapling is done, the opening should be stitched up after having verified the absence of bleeding at the level of the stapling zone. To perform an ideal anastomosis, we put an absorbable suture at each angle, the first stitch is carried out using PDS at one of the extremities, the 2nd stitch is placed at the other extremity while checking that we have visual control on both extremities. Thanks to the traction placed on these 2 landmarks, we can see perfectly the limits of the suture zones. The closure of the incision is made with a running suture, this one being made in 3 extramucosal stitches. Several stitches will be placed before pulling on the running suture, which will allow for the re-approximation of the 2 edges of the incision. The monofilament facilitates this and especially allows to gain time as these sutures are placed quickly before closing the incision. The last stitch is placed by keeping in mind the inferior angle guide wire in order to have complete closure and avoid in that way a hole that would lead to a fistula. Once the anastomosis is being performed, the different guide wires are shortened or removed, control of the anastomosis and especially of the mesocolic defect are done.

9. Extraction of specimen 10'23''

The next stage is the extraction of the specimen. This extraction is done through a suprapubic incision where the 12mm port was placed. The specimen is put into a plastic bag, which itself is introduced in a plastic drape, which allows to protect the abdominal wall. The specimen is verified, measured before being sent to pathological examination.

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