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Laparoscopic sigmoidectomy after perforated diverticulum: lateral dissection for splenic flexure mobilization

This live surgical video demonstrates in detail laparoscopic sigmoidectomy by Dr. Joel Leroy. A medial approach to the sigmoid mesocolon is used, combined with lateral dissection for a complete mobilization of the splenic flexure. This procedure is recommended to surgeons with an interest in laparoscopic colorectal surgery.

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Laparoscopic sigmoidectomy after perforated diverticulum: lateral dissection for splenic flexure mobilization

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摘要

This live surgical video demonstrates in detail laparoscopic sigmoidectomy by Dr. Joel Leroy. A medial approach to the sigmoid mesocolon is used, combined with lateral dissection for a complete mobilization of the splenic flexure. This procedure is recommended to surgeons with an interest in laparoscopic colorectal surgery.

關鍵字

laparoscopic sigmoidectomy, medial approach, sigmoid mesocolon, mobilization of the splenic flexure, laparoscopic colorectal surgery

媒體類型

手術影片

期間

15'00''

刊物

2007-09

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Sept 2007;7(09).
URL: http://www.websurg.com/doi-vd01en2174.htm

Laparoscopic sigmoidectomy after perforated diverticulum: lateral dissection for splenic flexure mobilization

1. Trocar placement 00'15''

The case is that of a female patient with a BMI of 30, who has had previous surgery for hysterectomy by laparotomy using a Pfannenstiel incision. I have introduced five trocars today to have easy exposure and a 10-15° Trendelenburg. Trocar 1 for the optic just above the umbilicus introduced first using a mini-open technique, trocar 2 and 3 on the right mid-clavicular line, my left hand is for trocar 2 (I’m a right-handed surgeon) which is introduced at the crossing of the horizontal line at the level of the umbilicus and the right mid-clavicular line after insufflation. 8-10mm lower to trocar 2 on the mid-clavicular line a 12mm trocar for my right hand to introduce the stapler, 10mm Ligasure and other 5mm instruments. A 5mm trocar on the midline suprapubically where I will do the extraction of the specimen is used to expose and retract the sigmoid.

2. Exposure 01'49''

We are the right position to see the splenic flexure, retract the small bowel eventually but also for the first assistant standing on my left lateral to the right shoulder to expose and get better visualisation. There are two parts of the colon, you see it is not a short mesentery, so we have the possibility to push the small bowel very far for a good exposure using a maximum of the space. We have to see the root of the mesentery that is between the duodenojejunal junction, here with IMV, and I am pushing the forceps located to the left underneath the bowel. My assistant now holds the mesocolon.

3. Medial approach 03'09''

If this was a cancer, where would you start your dissection? At the origin of the IMA. I am dividing the meso and I apply my both hands for this procedure. Doing a sigmoidectomy, particularly for benign disease, with the use of Ligasure is now easy, it’s good to standardise the procedure. As you see, at this moment we have to continue the division lateral to the IMV. If you do not have the Ligasure, you can use scissors, I can put clips or use the stapler. You can use monopolar to do the same dissection. This is the IMV, these are the sigmoid vessels. I am dissecting anterior to the Toldt’s fascia, when I am in this plane using the Ligasure device or peanuts to open this embryological plane, it is easy because the finger will separate the posterior aspect of the mesocolon. This is the white line, the lateral attachment of the colon, here are my instruments, we do not need to do more laterally.

4. Lateral dissection 05'58''

To dissect the lateral attachments, you have to find the right plane of adhesions. I am freeing using a lateral approach, this is anterior to the Gerota’s and Toldt’s fascia. I will now go to the pelvis, I will change the angulation of the scissors. This is with traction, counter-traction, the sigmoid loop is fixed to the peritoneum, to the scar of the hysterectomy. When we don’t understand, we go back to the other side, this is similar to open surgery. One of the tricks is to use Ligasure. We can cut without sealing. Here we cut.

5. Mesocolic division 08'00''

Retracting to the right I am now doing the division of the mesocolon. We know we have freed laterally on the left, we have to divide right and left. The patient did get bowel preparation: fibre diet one week before the operation, small enema the day before, 2 litres of enema with polyethylene glycol. I am dissecting more because it seems that I am not on the colon. Looks like I am just at the limit between the colon and the rectum from the difference in fibres. You cannot do the same with a 5mm Ligasure or a 10mm, the 10 is strong and easy to manipulate. This is nothing like a cancer operation.

6. Division of rectum 09'57''

This is a linear stapler.

7. Splenic flexure mobilization 10'35''

Here we have the stomach, the pancreas, this is the root of the transverse mesocolon, its attachment anterior to the pancreas. I will divide the attachment to have more mobility for the splenic flexure. So formal splenic mobilisation. We will try to do the anastomosis approximately at this level, I am looking to see if we have enough resected, we will probably resect 40cm.

8. Exteriorization of colon 12'07''

I grab the distal colon, this is the pathologic part of the colon. We have the anterior tenia, that proves that we were always on the colon. I am doing a small suprapubic incision, I’m incising the subcutaneous tissue. I will use a plastic wound protector. I pull on the trocar, introduce my finger in the hole around my forceps, push the ring in and pulling the segment of colon. Here we use the purse-string. We will control the rectal stump.

9. Anastomosis 13'58''

There is bit of traction so I will free more. The anvil is staying close to the stomach. I will do an air test and close the gap.