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Laparoscopic sigmoidectomy for diverticulitis: a standard case

This video demonstrates principles of laparoscopic sigmoidectomy for benign disease with preservation of superior rectal artery. In this case, the patient had several episodes of diverticulitis and the surgeon only resected the affected sigmoid colon after mobilization of the splenic flexure. The preservation of the superior rectal artery will ensure nerve preservation and is believed to reduce the possibility of anastomotic ischemia causing leaks or stenosis.

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Laparoscopic sigmoidectomy for diverticulitis: a standard case

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摘要

This video demonstrates principles of laparoscopic sigmoidectomy for benign disease with preservation of superior rectal artery. In this case, the patient had several episodes of diverticulitis and the surgeon only resected the affected sigmoid colon after mobilization of the splenic flexure. The preservation of the superior rectal artery will ensure nerve preservation and is believed to reduce the possibility of anastomotic ischemia causing leaks or stenosis.

分類

basic techniques

關鍵字

operation,sigmoidectomy,diverticulitis, superior rectal artery

媒體類型

手術影片

期間

12'00''

刊物

2004-11

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Nov 2004;4(11).
URL: http://www.websurg.com/doi-vd01en1376e.htm

Laparoscopic sigmoidectomy for diverticulitis: a standard case

1. Case presentation 00'16''

This is the case of a 53-year-old male patient with 2 previous episodes of acute sigmoid diverticulitis.

2. Patient position and trocar placement 00'28''

In position A is the optic trocar, B and C for the operative trocars, and D, E and F for retracting trocars. These are the 2 operative ports, this one is the retractor, this one as well, but D is sometimes used during mobilization of the splenic flexure as an operative trocar. Trocar F is a retracting port as well.

3. Exposure 01'05''

To achieve exposure, the omentum is pushed along with the transverse colon cephalad in the subphrenic area. This grasper maintains the proximal small bowel in an orthostatic position. The rest of the small bowel is located at the right lower quadrant.

4. Vascular approach 01'53''

The 1st step is the opening of the peritoneum from the sacral promontory to the angle of Treitz. While retracting the sigmoid anteriorly, the peritoneal layer at the base of the sigmoid colon mesentery is opened with the use of scissors and monopolar coagulation. While maintaining the same anterior retraction, the spleen is dissected progressively. We are now localized medial to the superior rectal artery and vein. We are now opening the vascular sheath of the superior rectal vessels. This is the superior rectal artery. The superior rectal vein is located laterally to the superior rectal artery. While preserving these vessels, we will divide the sigmoid vessels using the Ligasure device. We can see now the superior rectal vein. The dissection is continued anteriorly to Toldt’s fascia. The mesocolon is divided and the dissection proceeds anterior to Toldt’s fascia, and the nerves, the gonadal vessels are protected by this fascia. Now to continue the dissection, we need to mobilize the colon laterally.

5. Lateral mobilization 05'07''

We are now dividing the lateral attachments of the sigmoid colon. The area of dissection that has been performed anteriorly is met by this lateral dissection. This dissection is continued cephalad and now caudad.

6. Distal dissection 05'50''

The sigmoid is now changed and the retraction is now performed on it cephalad. This retraction is held by the instrument in trocar D. The dissection of the distal part of the sigmoid colon and the rectosigmoid junction is performed anteriorly to the superior rectal vessels. This dissection will be performed down to the rectosigmoid junction. This will be the line of distal resection and we now finish the preparation of the distal line of resection; keeping the sigmoid junction at this position, we will perform the distal division using an endoscopic linear stapler.

7. Rectal and colonic division 07'11''

8. Mobilization of splenic flexure 07'41''

We will now change the exposure and proceed with the mobilization of the splenic flexure. The left colon is retracted medially and kept in this position by the grasper in trocar E. The operative field is now opened and mobilization of the splenic flexure can begin. The posterior attachments of the left colon as well as the lateral attachments are divided sharply. This is the kidney. We have now reached the splenic flexure. The lateral attachments are completely divided now and the posterior attachments as well. We will now divide the mesocolon as the assistant with his grasper is showing the site of proximal resection. The sigmoid colon is now completely resected and we make a suprapubic incision to perform the extraction. The sigmoid colon is placed in a retrieval bag. The incision is dilated with the fingers and we then introduce the ring of the plastic drape. The sac is then exteriorized.

9. Anastomosis 10'34''

The anastomosis will then be performed with a circular stapler. After performing a purse-string suture, the anvil is placed in the proximal part of the bowel and is pushed back in. The circular stapler is fired to complete the anastomosis after making sure that there is no twist of the colon. There is no twist. The anastomosis is complete and shows no leak. This concludes the operation.