Laparoscopic sigmoidectomy for acute diverticulitis and transanal specimen extraction: tricks for removal of huge specimens

Laparoscopic surgery for colorectal cancer requires an abdominal incision to extract the resected specimen. Transanal extraction avoids the need to make any additional abdominal incisions for specimen retrieval. This video demonstrates various tricks for the removal of a huge specimen.

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Laparoscopic sigmoidectomy for acute diverticulitis and transanal specimen extraction: tricks for removal of huge specimens

Authors

J Leroy, J Marescaux

Abstract

Laparoscopic surgery for colorectal cancer requires an abdominal incision to extract the resected specimen. Transanal extraction avoids the need to make any additional abdominal incisions for specimen retrieval. This video demonstrates various tricks for the removal of a huge specimen.

Media type

Surgical video

Duration

15'00''

Publication

2011-04

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E-publication

WeBSurg.com, Apr 2011;11(04).
URL: http://www.websurg.com/doi-vd01en3076.htm

Laparoscopic sigmoidectomy for acute diverticulitis and transanal specimen extraction: tricks for removal of huge specimens

1. Introduction 00'20''

This is the case of a 60-year-old male patient with a BMI of 29 with two attacks of diverticulosis. The last one took place 3 months ago with one month of antibiotic intake. A sigmoidectomy was decided upon. We will try to show the technique we are going to do now. It is a resection technique with transanal extraction.

2. Trocar placement 00'53''

We have three trocars: this is the pubis, this is the xiphisternum, this is the umbilicus. Right side: a 5mm trocar on the mid-clavicular line at the level of the umbilicus. One 12mm port in the right iliac fossa to introduce the stapler.

3. Sigmoid colon exposure 01'19''

I have exposed the sigmoid root like this. We see that the sigmoid is fixed and we have a bulky sigmoid where there was an inflammation. When we do this surgery for benign diseases, we do not resect the inferior mesenteric artery.

4. Mesocolon division 01'37''

We divide the meso close to the bowel. First, we will keep all the innervation and vascularization of the rectum. We will be at distance of the nerves and the ureter. You see I am using the Ligasure® device, which is a fantastic tool for sealing and cutting with minimum smoke. Now I will free laterally. There is a small inguinal hernia, an indirect inguinal hernia. We will not put a mesh because the infection risk exists.

5. Lateral dissection 02'30''

I am doing lateral freeing of the descending colon as you can see. We slowly divide the low mesosigmoid. We have the sigmoid vessels beating. We are very close to the bowel. We divide this. We have a huge inflammatory segment. We have the proximal sigmoid and the descending colon.

6. Rectal stump cleaning 03'40''

We prepare the future site of the opening. I will put a ligation around, as you see. We will wash the rectal stump after the ligation is finished. Why cleaning? Because to open the colon, it will be necessary to clean as much as possible.

7. Rectal opening 04'17''

Now we will open the rectum or the low sigmoid. I remember you I will do a new resection. I am placing a stitch to maintain this outside with the forceps. This will maintain it open. We can pull on this and this. If necessary, we can clean the rectum.

8. Distal colon ligation 05'27''

Now we will put a loop around the distal colon segment, because we want to have long sutures that will be grasped by a forceps introduced transanally.

9. Colon exteriorization 06'02''

You see the forceps arriving. I tell my assistant to pull the suture transanally. It is outside now. This is where we can have difficulty, when trying to pull. If we have difficulty, we will reduce the volume. We can complete the dissection close to the bowel, if necessary, to reduce the volume of the specimen. We will try to do a new transanal extraction now. It is coming. We have now to free a little more of this. I have to free the posterior attachments. I think it’s enough because we can appreciate the mobilization and now you’ll see what I do. We have to exteriorize the inflammatory segment. I’m doing it now. I want to show you the anvil prepared.

10. Anvil introduction 07'57''

We’ll use an anvil of 28mm in diameter. We have the segment of bowel outside; the stenosis is outside. We have big sutures, this is Polysorb too. We are using the PCEEA anvil. We put the pick. And we introduce the sutures through the hole. This is not difficult to understand. Normally it is prepared before but we do it for you to show you all the tricks. We keep a long thread like this and finally we have this. Now we’ll take a forceps like this. We don’t take this part but this one with this instrument to push. But before, above the stenosis, I’m opening the colon to find the lumen. I’m introducing it in the colon. I try to push through the sphincter. I’m grasping with a forceps and watch intra-abdominally: see the anvil coming. I’m pulling back the colon like this. I’m now dividing the colon and the meso.

11. Transanal specimen extraction 10'00''

Watch what we’re doing now: we’re removing the specimen transanally. Pull completely. We have another solution and it is what we did for cancer, we’ll introduce an Endo-Catch™ to understand that we can also do it with a plastic bag. See the bag coming. Push the bag and we can put the specimen in. See the small specimen here; now you close it. It’s a small specimen. You can put a big one. We remove this and we can pull the plastic bag and outside we can remove the bag.

12. Rectal stump closure 10'58''

Now we’ll close the rectal stump. We’re lucky because we put sutures like this to expose. So you see without two staplers, we can introduce like this. This can be removed through the trocar or through a small plastic bag inside. See we’re not far from the junction, the reflection of the peritoneum. The suture is there but we will not pull the anvil at this level but on the antimesenteric side. I’m preparing the antimesenteric side to avoid the contamination risk. I’m introducing a Betadine swab. I’m doing what I call the fisherman’s technique. I try to find the sutures. So now we’ll pull this. The anvil is coming like this. And you understand why it will not be completely a triple stapling technique because we’ll have staples on a small part. This is like a tennis racket. This is the stapling line. This is the antimesenteric side. We’re not far from the side-to-end. And we keep the vascularization better this way because the meso is divided largely. See the vessels are beating very well there. I want to remove this. So we’ll soon finish.

13. Anastomosis 13'41''

We will do the anastomosis. We can use two 5mm on the right side and 12 in the umbilicus, using a 5mm scope in one of the trocars and the stapler is introduced in the umbilicus. We show you the donuts, this one and the other on the stapling line. This is a big one. We will do an air test now. Now we’ll take a sample to analyze the contamination, and it is what we do routinely. No bacteria when we do a direct examination, always positive after culture, minimum 3 bacteria. Do you use more antibiotics in this procedure? Right.