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Laparoscopic sigmoidectomy for colovesical fistula

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Laparoscopic   sigmoidectomy   for   colovesical   fistula

作者群
J Leroy, J Marescaux
關鍵字
laparoscopy,sigmoid colon resection,colovesical fistula
媒體類型
期間
19'00''
刊物
2004-04
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Apr 2004;4(04).
URL: http://www.websurg.com/doi-vd01en1441e.htm

Laparoscopic   sigmoidectomy   for   colovesical   fistula

1. Case presentation 00'12''
I have insufflated the abdominal cavity and using open laparoscopy and I am freeing the adhesions of the omentum. It is a male patient who has been receiving treatment for acute leukemia for one year and he is on chemotherapy. He has developed signs for colovesical fistula since one month. He has gas in his urine. There is a fixation of the sigmoid with a lot of diverticula and there is a big inflammatory mass at this level. It is not an easy case but interesting anyway. We can use laparoscopy here. This is not a contraindication. The 1st step is to expose. I have to free adhesions after appendectomy because there was scar in the right iliac fossa. I have to free sufficiently to have a good exposure throughout the whole procedure. We use a right lateral tilt. I’m exposing the operative working space progressively. I retract the proximal jejunum cephalad. We have the head of the patient here. The whole team is on the right side and between the legs, the right arm alongside the body, the left arm at a right angle or alongside the body. We have nobody on the left side, only the equipment with video monitor, insufflator and light source for the camera, also electric devices such as electrocautery, Harmonic scissors, monopolar cautery Ligasure and one nurse on the surgeon’s right. We have the pubis here, the left and right anterior superior iliac spine. I have introduced 6 ports as a maximum number. The 1st port is the optical port, just above the umbilicus, 1, 2 or 3cm above depending on the patient and the site of the umbilicus, at a minimum of 20cm above the pubis after insufflation. I have introduced a 12mm port using a mini-open technique: port B at the crossing between the horizontal line through the umbilicus and the right mid-clavicular line; it is a working 5mm port; 8-10cm underneath, I have port C, where I have introduced the 5mm one or a 10-12mm port because I will introduce the stapler or electrocautery device like the Ligasure through it. Then port D at the crossing between the horizontal line through the umbilicus and the left mid-clavicular line. In this 5mm trocar, I’ll introduce a forceps to retract, expose, or to dissect when I mobilize the splenic flexure. Port E is located at 4-5cm above the pubis on the midline. This is where I’ll perform a small incision to then extract the specimen. We have a fixation between the sigmoid and the urinary bladder. We have a barium enema but we have no fistula visible. We have only bubbles in the urinary bladder. As you have seen, we have maintained the proximal bowel retracted in the left hypochondrium after we have pushed the greater omentum free in the left hypochondrium too. We maintain the small bowel using the grasper introduced in port D to the left. The ileocaecum is fixed by adhesions so we don’t have to free all the adhesions completely and using a forceps that maintains the last loop in this position, we have exposure of the mesosigmoid. Because it’s benign here, I’ll try to keep the vascularization of the lower rectum. I will cut the meso at mid-distance between the sigmoid and the vessels. I can dissect the origin of the artery but it’s not my goal at the beginning. It’s unusual in our practice for benign disease; usually we try to keep the vascularization of the rectum because it’s a benign disease. We see the sigmoid vessels very well here. I’m opening the peritoneum. This is the sigmoid trunk. And I’ll divide the vessels anteriorly to the superior rectal vessels. I don’t open the vascular sheet but it’s not necessary to dissect completely. I have just opened the meso on the left. Here you have the left side of the rectum. I want to show you where I’m dissecting: here is the ureter. So I’m opening the meso laterally to the inferior mesenteric vein. You have the ureter here. I have opened too much. Usually we have to stay anteriorly to the Toldt’s fascia. This is a good plane that is completely avascular and which protects the structures and paves the way for mobilizing the descending colon. Now I want to free laterally because I have completely mobilized this. As you see, we open the space that we have just dissected previously using a medial posterior approach. I think that it’s easier to find the ureter by a medial approach. It is a safe approach. I’m not sure that particularly when there is diverticulitis it’s easy to dissect laterally. We will soon finish the posterior dissection. Now I change my retraction. I use the trocar introduced in the left port to expose better. You see the fistula is here. I have some fixation. The sigmoid is here. I want to continue my posterior dissection. We have big vessels here. I think this is an anastomosis between the last branch of the inferior mesenteric artery or between the left branch. It’s the anastomotic branch between the Drummond’s vessels namely the sigmoid vessels and the superior rectal vessels of the last branch of the inferior mesenteric artery. I’m dividing the mesorectum as you see just anteriorly to the vessels. We have the fistula here. I don’t cut; I use only this 10mm instrument as 2 fingers to separate. I have freed the sigmoid as you have seen without electricity coming around the rectum. I’m freeing posteriorly. I dissect until I reach approximately the high rectum, the colorectal junction so it’s around the Douglas’s pouch. Slowly we reach this area. There is a lot of oil here. You see now I’m against the rectum, completely compliant bowel. I’m dividing around the meso. You see I have kept the vessels for the rectum. I have a bulky meso. It’s interesting to protect the ureter. We have seen it before, but also the nerves, particularly important in male patients but not only. I think I’ll do the anastomosis at this level. I divide now using a stapler. I ask my assistant to move cephalad because I have a straight instrument as you see and I’m in the right direction to see what I have to do. If I have to complete the extraction, I’ll do the section outside. I want to complete the mobilization now. I have my finger in. I introduce the drape and I push the drape around the forceps and I pull on the specimen and I have the fistula. We have the limit between the colon with good vascularization. A length of 45mm for the stapler is fine. You have to maintain your pressure on the rectal stump. If you have divided the rectum at a good level, it’s not difficult to introduce a stapler. It’s fixed now. I’ll control that there is no twist. You see when you have a wide circular line of sutures, there is less risk of fistula, because the risk is essentially due to the ears laterally not because of the circular line and if we include the whole of the circular and linear line in the same sutures, it’s good. Air test first, but remember that we use a Trendelenburg, we put fluid in the pelvis. We clamp the bowel and we insufflate the rectum. No bubbles. Now we are filling the bladder with blue dye. We may see a leak. I will dissect with the bladder filled. See the blue coming out. We have the fistula inside. We suck in. We have gas in the bag. We will do a cystoscopy. I can put it in a bag. It’s not so big, I can remove it. I use monofilament absorbable material. I perform an extracorporeal knot. We can put several knots, several sutures in the same trocar. I push inside the knot and come back outside to tie another knot.