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Laparoscopic sigmoidectomy for diverticulitis: difficult case

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Laparoscopic sigmoidectomy for diverticulitis: difficult case

作者群

J Leroy, J Marescaux

關鍵字

sigmoïdite diverticulaire

媒體類型

手術影片

期間

16'00''

刊物

2004-12

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1593.htm

Laparoscopic sigmoidectomy for diverticulitis: difficult case

1. Trocar placement 00'12''

This is the case of a 55-year-old woman with a history of sigmoid diverticulitis. Here we show the position of the ports. Five ports are used with the One-step system. The first, the optical port of 10mm in size is placed superior to the umbilicus. One retracting port is placed along the left mid-clavicular line, and 2 operative ports along the right mid-clavicular line at 5 and 10mm. Only one 5mm suprapubic port is placed.

2. Exposure 00'43''

We put the patient in Trendelenburg position of approximately 15 degrees and left lateral tilt of approximately 10 degrees. We begin by adhesiolysis with the adhesions noted adjacent between the omentum and the small bowel. Upon completion of this, we begin to put the small bowel in the upper side of the abdomen to provide a good exposure of the sigmoid colon. We do find some difficulty in completing this task; therefore, an additional 6th port is placed in the right upper quadrant again along the mid-clavicular line. A grasper is then advanced through this port to provide a framework for which the small bowel mesentery can be looped over effectively retracting the small bowel for the duration of the procedure.

3. Sigmoid colon dissection 01'40''

We begin the dissection of the sigmoid using the 10mm Ligasure device. The dissection begins with opening the peritoneum of the mesosigmoid to provide direct access to the sigmoid vessels that are sectioned directly with the Ligasure. Upon continued dissection, we notice strong adhesions between the sigmoid and left adnexa. These are taken down with a 10mm Ligasure device. However, we have found some difficulty in completing this task and the lateral attachments of Toldt’s fascia are taken down to aid in this process of dissection.

4. Colon division and end of dissection 03'40''

An Endo-GIA device is then used to ligate the proximal sigmoid. This enables more exposure of the troubled area adjacent to the left adnexa. Blunt dissection is continued with the 10mm Ligasure device. In this area, the ureter will be located and its identification is crucial to avoid complication. Electrocautery is not used to aid in the dissection of the dense adhesions caused by the recurrent diverticulitis in this area. Completion of the adnexa from the sigmoid colon is then realized with the use of both electrocautery and the Ligasure device. Completion of the dissection of the sigmoid is done with the Ligasure and circumferential as well to free the rectosigmoid junction below the diverticular disease to aid with the eventual anastomosis.

5. Rectal division 06'27''

The Endo-GIA is used once again to section this junction. We identify the left ureter once again as well as the left iliac vessels prior to further dissection in this area.

6. Adnexectomy 06'53''

As we suspect a left hydrosalpynx and therefore requirement of completion of the resection of the left adnexa. As you can see, this case was complicated by the left adnexal structures and their dissection thereof. With a proper exposure and technique, dissection of this area can be maintained while continuing the laparoscopic technique. The left adnexa and sigmoid are placed in the pelvis. Once these specimens are out of the way, exposure is once again obtained retracting the small bowel out of the way to aid in dissection of the splenic ligament. Exposure is once again obtained retracting the small bowel out of the way.

7. Mobilization of splenic flexure 09'13''

We mobilize the splenic flexure of the colon with a medial approach. The inferior mesenteric vein is identified in the lower portion of the screen and dissection is continued lateral to it. As you can see, the Ligasure device is used not only for dissection with the cautery device but also as a blunt dissector. Further dissection now anterior to the pancreas is completed, and entrance into the lesser sac is then realized. The left colic artery is then identified and ligated with the Ligasure device. This allows for further dissection to the posterior attachments of the proximal left colon. Here the left colic artery is identified. Speed of the procedure is enhanced with the use of a device such as the Ligasure as vessels up to 7mm have been shown to have equal hemostasis with suture or this device. Now with the left colic artery ligated, continued dissection in a posterior lateral approach is then done, and the tail of the pancreas is now maintained out of the dissection plane with this technique. The lateral attachments of the proximal left colon are completed and a tension-free anastomosis can then be achieved. Good mobilization of the colon is seen.

8. Extraction 11'08''

And with this, the suprapubic port is now enlarged to approximately 4cm, and a wound protector and Endocatch bag are then used to obtain the specimen. The sigmoid colon as well as the left adnexa are placed within the bag and removed from the patient.

9. Anastomosis 11'46''

The left colon is then retracted out of this port for placement of a 28mm anvil for the end-to-end anastomosis. The purse-string device aids in this process. The colon is then retracted back into the abdomen and we re-use the purse-string device again for temporary closure of the enlarged suprapubic incision. The end-to-end anastomosis is then completed with the aid of an assistant advancing the device trans-anally and firing upon confirming appropriate orientation and lack of tension on the anastomosis. The intra-abdominal portion of the procedure is now completed and the approximation of the fascia to 4mm port site as well as a 10mm port site will then be done.