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Laparoscopic left colectomy after symptomatic constipation in a patient with previous rectopexy for rectal prolapse

The objective of this film is to demonstrate a colectomy technique after laparoscopic rectal prolapse surgery that caused increased constipation in a female patient in her fifties. Indeed, a few months earlier, an indirect rectopexy had been performed with placement of subperitoneal strips; this was combined with a partial Douglasectomy. Following the study of transit times, a laparoscopic left colectomy was decided upon.

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Laparoscopic left colectomy after symptomatic constipation in a patient with previous rectopexy for rectal prolapse

作者群

J Leroy, F Costantino, J Marescaux

摘要

The objective of this film is to demonstrate a colectomy technique after laparoscopic rectal prolapse surgery that caused increased constipation in a female patient in her fifties. Indeed, a few months earlier, an indirect rectopexy had been performed with placement of subperitoneal strips; this was combined with a partial Douglasectomy. Following the study of transit times, a laparoscopic left colectomy was decided upon.

關鍵字

Laparoscopic left colectomy after symptomatic constipation, patient with previous rectopexy for rectal prolapse

媒體類型

手術影片

期間

13'00''

刊物

2010-04

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Apr 2010;10(04).
URL: http://www.websurg.com/doi-vd01en2913.htm

Laparoscopic left colectomy after symptomatic constipation in a patient with previous rectopexy for rectal prolapse

1. Introduction 00'10''

The objective of this film is to demonstrate a colectomy technique after laparoscopic rectal prolapse surgery that caused increased constipation in a female patient in her fifties. Indeed, a few months earlier, an indirect rectopexy had been performed with placement of subperitoneal strips; this was combined with a partial Douglasectomy as can be seen here. Following the study of transit times, a laparoscopic left colectomy was decided upon. To do so, the Ligasure Atlas® device was introduced through a 12mm right iliac fossa port and a 10mm scope with a Karl Storz high definition camera was used. This surgical maneuver is fairly easy since there are no adhesions; the first intervention was carried out laparoscopically.

2. Descending colon mobilization 01'25''

Here the lateral mobilization of the descending colon until the splenic flexure can be seen. The mesocolon is then divided by preserving the inferior mesenteric vessels and the rectal vascularization in order to prevent any vascular or neurological damage. Additionally, the sympathetic innervation originating from the superior mesenteric plexuses should be preserved as much as possible.

3. Mesocolon division 01'55''

Here we can see that the division of the mesocolon is performed away from the superior mesenteric axis, and especially from the left colic vessels that are divided here, however, with preservation of the left mesenteric vein, hence achieving a perfect drainage of the mesorectum.

4. Transverse mesocolon opening 02'30''

The root of the transverse mesocolon still needs to be opened and the use of the Ligasure® Advance device is worthwhile as can be noted; it allows for a very precise cut and elicits very little smoke using either the monopolar current at the electrode level or the Ligasure® device to divide the meso.

5. Splenic flexure mobilization 02'55''

The splenic flexure will be mobilized in this case, first using a medial approach as we have just seen with the opening of the transverse mesocolon’s root and of the lesser sac, but also with the division of lateral attachments, and especially the phrenicocolic ligament as can now be observed. The left transverse mesocolon still needs to be mobilized in order to perform a high anastomosis close to the transverse colon, just after the splenic flexure. The division of colo-omental attachments will help to achieve a lowering of the splenic flexure without any excess traction on the omentum, which could entail a risk in case of adhesion with the splenic capsule and could therefore entail a decapsulation. As soon as the left colon has been completely mobilized by taking down the adhesions of the descending colon, of the splenic flexure and of the left transverse colon, possibilities for lowering the left colon are evaluated.

6. Sigmoid mesocolon division 04'13''

The sigmoid mesocolon is also divided until the superior portion of the rectum always while preserving the superior rectal vessels.

7. Rectosigmoid junction dissection 04'30''

Once the rectosigmoid junction has been identified, the dissection is completed by moving closer to the rectal wall at the upper rectum. The division is performed progressively by preserving the entire vascularization of the mesorectum. The dissection is then pursued in contact to the rectum and in this case, the lower sigmoid or even the upper rectum is ligated just underneath the colorectal junction. This ligature allows to exclude the rectum, which will be washed with a Betadine solution before being opened under laparoscopic control while coagulating the wall. Here we can see the Betadine solution that helped to perform the lavage. The rectal wall’s incision site is suspended before dividing the rectal wall completely.

8. Colon exteriorization 05'50''

As soon as a Vicryl loop has been applied on the colonic extremity in order to complete the closure, an atraumatic forceps is introduced into the rectum through the anus. This forceps is used to grab the thread’s extremity that is at the end of the colon; it will be used as a soft traction transanally until the colon is exteriorized. The exteriorized portion is variable depending on the length of the loop to be resected. This exteriorized colon will be opened. In case of stenosis, the opening is carried out above the stenotic area.

9. Anvil introduction 06'45''

The anvil of the PCEEA DST 28 circular stapler is introduced with its spike through which a thread has been placed: this helps to identify the spike. Under laparoscopic control, the procedure is continued by dividing the mesocolon using the Ligasure Advance® device.

10. Colon division 07'07''

This division is carried out before applying the Endo-GIA linear stapler, 60mm long blue cartridge, which allows for a complete division; here the thread introduced earlier is not divided. The rectal stump still needs to be closed. The closure is performed after suspension of the rectal stump with a thread to improve its manipulation. The Endo-GIA linear stapler, 45mm long blue cartridge is then applied. Two firings of the stapler are necessary. The rectal remnant is placed in a small sized plastic bag that will then be extracted through the 12mm right iliac fossa port. At the place where the thread was trapped, an opening is fashioned: it will help to exteriorize the spike along with the anvil until the anvil is pulled in contact to the stapled area. The exteriorization area is secured by a loop or a suture in order to avoid any suture slippage. This has been well explained by Morris Franklin who used a slightly similar technique by introducing the anvil and securing its introduction by a Vicryl loop.

11. Anastomosis 09'35''

The intervention is completed with an end-to-end Knight-Griffen colorectal anastomosis. The absence of twist is ruled out by controlling that the anastomosis has been performed by a complete division of the doughnuts and by closing the mesenteric defect. This is essential to close it since the risk of small bowel migration is all the more important as the colonic resection is extensive. No drainage will be associated. The abdominal cavity is simply washed. An air test of the anastomotic area is performed.