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Laparoscopic left colectomy with transmesenteric colorectal anastomosis on the mid-transverse colon

The objective of this film is to show the totalization of a left partial colectomy performed one year ago and the possibility of doing a transmesenteric laparoscopic colorectal anastomosis. This patient had undergone a sigmoidectomy for sigmoid diverticulitis with a colorectal anastomosis one year ago. During the postoperative period, the patient had several subocclusive episodes and suffered from pain related to an ischemic stenosis of the lowered colon with no necrosis. The stenosis has become increasingly incapacitating, not only at the level of the anastomosis but especially at the level of the left colon, which has been getting narrower.

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Laparoscopic left colectomy with transmesenteric colorectal anastomosis on the mid-transverse colon

作者群

J Leroy, J Marescaux

摘要

The objective of this film is to show the totalization of a left partial colectomy performed one year ago and the possibility of doing a transmesenteric laparoscopic colorectal anastomosis. This patient had undergone a sigmoidectomy for sigmoid diverticulitis with a colorectal anastomosis one year ago. During the postoperative period, the patient had several subocclusive episodes and suffered from pain related to an ischemic stenosis of the lowered colon with no necrosis. The stenosis has become increasingly incapacitating, not only at the level of the anastomosis but especially at the level of the left colon, which has been getting narrower.

關鍵字

Laparoscopy, left colectomy, transmesenteric colorectal anastomosis, mid-transverse colon, partial colectomy

媒體類型

手術影片

期間

11'30''

刊物

2010-10

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Oct 2010;10(10).
URL: http://www.websurg.com/doi-vd01en3029.htm

Laparoscopic left colectomy with transmesenteric colorectal anastomosis on the mid-transverse colon

1. Introduction 00'18''

The objective of this film is to show the totalization of a left partial colectomy performed one year ago and the possibility of doing a transmesenteric laparoscopic colorectal anastomosis. This patient had undergone a sigmoidectomy for sigmoid diverticulitis with a colorectal anastomosis one year ago. During the postoperative period, the patient had several subocclusive episodes and suffered from pain related to an ischemic stenosis of the lowered colon with no necrosis. The stenosis has become increasingly incapacitating, not only at the level of the anastomosis but especially at the level of the left colon, which has been getting narrower.

2. Colon and splenic flexure freeing 01'08''

The freeing of the lowered colon and of the splenic flexure can be seen here. This is performed by dividing the mesocolon using both a lateral and medial approach in contact to attached/adjoining loops, which are a result of the previous surgical intervention. Adhesions are few in number, since the surgical procedure was performed laparoscopically. The previous division area can be seen here. It is completed by means of the 5mm Ligasure Blunt Tip® vessel-sealing device, a mini Ligasure Atlas® instrument. The attachment plane resulting from the previous surgical procedure is easily freed. This proves that there were probably no postoperative peritonitis, which could have accounted for the ischemic stenosis.

3. Anastomosis resection 02'26''

However, the mesocolon is in good condition. It seems to be very thick and rigid. The dissection is pursued until reaching the junction between the left colon and the rectum, where the anastomosis had been performed. The anastomotic area is found. It will be resected. The mesorectum is divided using the 5mm Blunt Tip Ligasure ®. A non-inflamed, perfectly compliant area is found on the upper rectum. The anastomosis will be performed there with the remaining colon. There will be no risk of causing a new stenosis. The colorectal anastomotic area can be clearly seen here. It is very narrow. The upper part of the rectum can also be seen here. It looks well-vascularized and compliant. After performing a posterior, anterior, and lateral freeing, always using the 5mm Ligasure® vessel-sealing device, a compliant, well-vascularized portion of the rectum is selected for division. The division will be performed by means of a 60mm long Endo-GIA linear stapler. As this portion of the rectum is relatively large, the stapler is introduced in the trocar placed at the right iliac fossa. The stapler is then angulated. The upper rectum is divided by means of this linear stapler, whose extremity is controlled in order to check that no significant structure, such as the ureter, nerve rami or vascular elements, is trapped by the stapler.

4. Completion of colonic mobilization 05'37''

Once the upper rectum has been divided, the mobilization of the colon is completed. Here can be seen the transverse colon and the division of its lateral attachments, that is, the colo-omental ligament, as well as the division of the mesocolon using a medial approach. One can see here the attachment areas generated when lowering the left colon and the splenic flexure, the latter being divided by means of the 5mm Ligasure® vessel-sealing device until reaching the plane situated anterior to the pancreas. This will allow for a perfect freeing of the posterior attachments of the lowered colon. This procedure should be carried out cautiously, since adhesion areas could be found in contact to noble structures, especially vascular ones. If these were divided, additional ischemia could be caused, especially at the level of the small bowel and of the pancreas. The splenic flexure can be seen here. Attempts to lower the compliant area of the colon, which is situated on the transverse colon, are made, but this looks almost impossible. Consequently, the mobilization of the colon is completed.

5. Transverse mesocolon dissection and middle colic vessels division 07'28''

To do so, the root of the transverse mesocolon is divided. This will lead to the division of the middle colic vessels. This allows to lower the mobile, compliant, well-vascularized portion of the transverse colon. However, there is a major drawback: the colon has to be placed above the entire small bowel, this being accompanied by a significant tightening of the mesenteric gap. The mobilization is completed, as can be seen here, by the division of the middle colic vessels. This will allow to obtain a significant mobility. But, as previously said, this can only be made possible by grasping the entire small bowel along with its mesentery.

6. Passage of transverse colon through mesentery 08'33''

Decision is made to pass the transverse colon through the mesentery, close to the terminal small bowel, by performing a mesenteric defect. The 5mm Ligasure® vessel-sealing device makes this defect easy to create. A rather wide orifice is made. The colon is then prepared. It will be exteriorized in order to resect the left colon and to introduce the anvil of a circular stapler in the transverse colon. The good condition of the colon is controlled —it should be compliant. This demonstrates that the colon is well-vascularized. The lowered portion is rather fibrous and, as can be seen here, rather stenotic and thick, the mucosa being utterly smooth; this is evocative, indeed, of an ischemic stenosis.

7. Preparation for anastomosis 09'53''

As can be seen here, the left transverse colon is now prepared for the introduction of the anvil of a PCEEA 31mm circular stapler. It will be placed at the transverse colon and secured by means of a purse-string so as to maintain it without any colonic slippage. The anvil and the colon are reintroduced in the abdominal cavity and a whole passage is carried out through the mesentery of the last bowel loop, just where the orifice had been made. Once the colon has been passed through the mesentery, one can realize that there is less traction to perform a colorectal anastomosis. The rectal stump is then transfixed after having controlled the absence of leaks in the stapling area by performing a betadine test.

8. Anastomosis 11'17''

Later on, the anastomosis is carried out between the transverse colon and the rectal stump.

9. Colonic defect closure 11'28''

The colonic defect having passed through the mesentery remains to be closed. To do so, sutures or Endo-Hernia staples may be used. The latter will be used in the present case.