Laparoscopic oncologic sigmoidectomy with transanal specimen removal: a step to NOTES or single port procedure

The combination of standard laparoscopy and specimen extraction through a natural orifice has the potential to decrease wound-related complications, the number of the trocars and the size of the incisions in order to avoid traumatic specimen extractions at the level of the abdominal wall. This video shows the technical approach to laparoscopic oncologic sigmoidectomy in which the specimen is extracted transanally. This procedure may be considered an alternative approach to conventional minimally invasive sigmoidectomy in patients with disease of the sigmoid or left colon.

Create account

Browse the WORLD

Virtual University

Google translate

Summary
Chapters
Your comments
Ask the Experts

You need to log in to watch this media!

Click here to log in.

Laparoscopic oncologic sigmoidectomy with transanal specimen removal: a step to NOTES or single port procedure

Authors

J Leroy, F Costantino, P Allemann, J Marescaux

Abstract

The combination of standard laparoscopy and specimen extraction through a natural orifice has the potential to decrease wound-related complications, the number of the trocars and the size of the incisions in order to avoid traumatic specimen extractions at the level of the abdominal wall. This video shows the technical approach to laparoscopic oncologic sigmoidectomy in which the specimen is extracted transanally. This procedure may be considered an alternative approach to conventional minimally invasive sigmoidectomy in patients with disease of the sigmoid or left colon.

Classification

new techniques, single port

Keywords

Laparoscopic oncologic sigmoidectomy, transanal specimen removal, NOTES, single port procedure

Media type

Surgical video

Duration

07'00''

Publication

2009-05

Popular

Favorites

Favorites Media

Audio

Subtitles

E-publication

WeBSurg.com, May 2009;9(05).
URL: http://www.websurg.com/doi-vd01en2560.htm

Laparoscopic oncologic sigmoidectomy with transanal specimen removal: a step to NOTES or single port procedure

1. Introduction 00'11''

The aim of this video is to show how it is possible to reduce the number of trocars, but also the size of the incisions in order to avoid traumatic specimen extractions at the level of the abdominal wall. This 58-year-old female patient is going to undergo a sigmoidectomy in keeping with oncological principles: we will begin by a vascular approach of the inferior mesenteric artery, which will be skeletonized and ligated about 1 to 2cm from the aorta.

2. Inferior mesenteric artery and vein division 00'59''

The ligature is performed with a Ligasure Atlas device and reinforced with a Vicryl loop to avoid bleeding: this is particularly recommended in elder patients with arteriosclerosis. Following its identification, the inferior mesenteric vein is ligated and divided with the Ligasure Atlas. The distal segment external to the duodenojejunal flexure is ligated. The posterior freeing is performed via a medial approach and is continued with the freeing of the descending colon up to the splenic flexure, which will be sufficient to lower the descending colon without applying any traction on the anastomosed area. The meso’s resection is performed with removal of the vascular package in keeping with oncological principles.

3. Proximal colon ligation 02'10''

We then ligate the proximal sigmoid colon and divide the mesorectum at its highest segment, just above the colorectal junction that is perfectly dissected in order to free the lower sigmoid at a safe distance to the tumor. We ligate and exclude the sigmoid colon using a 2/0 Ethibond loop. We rinse the rectal stump transanally with Betadine solution.

4. Rectal opening 02'54''

We then open the rectum with an incision performed just above the colorectal junction.

5. Anvil introduction and descending colon division 03'09''

The DST-EEA circular stapler’s anvil is connected to a guide-wire and is introduced via the anus, pushed into the proximal colon just above the ligature that had been previously performed. The anvil is pushed into the descending colon, which is then divided under the anvil using a blue cartridge Endo-GIA linear stapler. We identify the stapling of the ligated area and close the proximal extremity of the colon that has just been opened while keeping a long guide-wire that will serve for the extraction at the end of the operation.

6. Distal division 04'40''

The distal segment will be divided but only after having introduced an Endo-catch II through the anus that has an introducer easing its setting up in the rectum. The bag deploys itself automatically and we push the specimen while keeping the guide-wire previously placed onto the sigmoid colon’s proximal portion.

7. Transanal specimen extraction 05'12''

The bag is then brought through the anus by pulling on the bag and the specimen, which allows for an easy extraction. We further divide the colorectal junction with a 60mm blue cartridge Endo-GIA linear stapler. The segment that has been further divided is placed in a small extraction bag and extracted through the trocar situated on the right iliac fossa. In order to perform the anastomosis, the tip of the anvil is extracted through an incision done near the stapling area. This task is facilitated by a guide-wire that had been previously fixed to the anvil. A purse-string suture is performed in order to make an airtight ligature around the anvil’s shaft. The plastic tip is extracted via the right iliac fossa’s trocar. We then perform the colorectal end-to-end anastomosis with the DST-EEA circular stapler.