Laparoscopic sigmoidectomy for diverticulitis: three-trocar technique with transanal extraction

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摘要

This is the case of a woman who had several attacks of diverticulitis with abscess confirmed by CT-scan. A laparoscopic sigmoidectomy using three trocars and a transanal extraction is shown.

關鍵字

Laparoscopy, sigmoidectomy, diverticulitis, three-trocar technique, transanal extraction

媒體類型

期間

18'00''

刊物

2011-02

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, Feb 2011;11(02).
URL: http://www.websurg.com/doi-vd01en3060.htm

Laparoscopic sigmoidectomy for diverticulitis: three-trocar technique with transanal extraction

1. Introduction 00'19''

You will be shown a laparoscopic sigmoidectomy using three trocars and there will be a transanal extraction as you will see.

2. Clinical case presentation 00'32''

This is the case of a woman who had several attacks of diverticulitis with abscess confirmed by CT-scan and the last attack was 3 months ago and we decide to do a sigmoid resection because the check-up confirmed that there was diverticulosis.

3. Trocars position 00'59''

This patient had no past history of abdominal incision except appendectomy with a McBurney incision and I decide to do a laparoscopic approach choosing a mini-open technique introducing a 12mm trocar above the umbilicus, and on the mid-clavicular line in the right iliac fossa and right flank, on the mid-clavicular line so I put 2 trocars, one 5mm and a 12mm trocar. You will see also that this is a swab, on which we have a stitch fixed. This is a stitch - transparietal suture to suspend the uterus to open the Douglas’ pouch and to expose using a transparietal stitch fixed through the round ligament, not fixing the uterus because there are more risks of bleeding. It’s better and easy to fix through the round ligament on the right and on the left and I fix in this case only on one side. I have installed the patient in a supine position with this retracted and you see it’s a lithotomy position and we free some adhesions of the omentum fixed to the scar of the appendectomy using the Trendelenburg and right lateral tilt. The small bowel stays fixed in the upper part of the abdominal cavity and lateral part too. We have completed the exploration. It’s a little rigid at this level and we’ll see some diverticulum on this part of the sigmoid. See the diverticulum and the pelvis free from adhesions and the long sigmoid loop. So I’m beginning the procedure using the new blunt tip Ligasure® device. This is a very interesting tool, see I’m working with my 2 hands, freeing the adhesions. I think this was where there was the abscess before.

4. Start of dissection by a medial approach 03'28''

Now I will use a medial approach. I will not free the adhesions. When we do a sigmoidectomy or colectomy for a benign disease, it’s not necessary to divide the inferior mesenteric vessels. We do that only in cancer. We’re dividing not too far from the sigmoid. See the advantage of the Ligasure®: it’s the possibility to seal before dividing and this is a huge advantage if we compare with what we used in the past to do the same procedure. I will free laterally to have more mobility. We’ll come down. So we have to continue the dissection. When we know the anatomy, we see that we are very far from the ureter because the ureter is behind this, there. It’s not necessary to remove the nodes and we only remove the sigmoid.

5. Division of sigmoid branches 05'10''

We keep the superior rectal vessels and divide only the sigmoid branch. The danger of the ureter is mainly lateral because sometimes there is adhesion retraction and this is where there’s the danger, but you’ve seen it was completely free and this was useful for me but I’ll try to show removing this. I will free more laterally to show you the ureter. See the ureter is there. I see before. See I’m very close to it now. This is the low sigmoid. This is the colorectal junction. So this is not the level where we will divide. We’ll divide lower.

6. Ligation of lower sigmoid 06'57''

I’m using a loop and I’m ligating. See we ligate using extracorporeal knots. I have ligated and will do the transanal extraction of the sigmoid. So we will not do an abdominal incision. I have ligated the low sigmoid and I do a suspension, see, through the anus.

7. Bowel exteriorization 07'48''

My assistant is introducing the rectum. We put another loop at the extremity to do an easy traction in the axis. You will do the traction now, pull, pull the colon. See the stenotic part is now out. This is the colon outside. What we’ll do now, I’m coming between the legs, through the hole. We introduce the suture and we make a knot like this. So we have the anvil, suture, fenestrated grasper. Now I have the stenotic part distally, scissors, until I have the lumen largely opened, see.

8. Anvil introduction 09'50''

We introduce the anvil like this and I’m pushing. This is the sphincter. So we push the anvil inside the colon very far like this and I have the suture always out.

9. Colonic division 10'15''

Coming back, I will complete the division of the meso and divide the colon with a stapler. I’m now dividing the meso and you see, the colon is removed transanally. So we have the anvil in the proximal colon. The anvil is trapped. This is the suture in the stapling line. Watch the vessels beating. It is well-vascularized at this level.

10. Anvil exteriorization 11'37''

What we’ll do later is to exteriorize the anvil at this level on the antimesenteric side and you have seen there was also a small defect. Now stapler. Thanks to the suspension, I will now close the rectum like this. I can manipulate even if I have only one trocar as a second forceps, other cartridge. And I will remove through the trocar. So we have finished to do the hemostasis on the rectum. I will do a hole on this side. This is a fishing technique, technique of fisherman. To complete the closure of the introduction site, I want to do there. OK, it’s good. Closure is obtained like this. See I use a loop. You can put a suture line to close better. I want to verify this.

11. Completion of dissection 13'53''

So we are on the antimesenteric side, you see. I will complete the freeing of the colon to do an anastomosis. We will do by lateral. It’s enough in the majority of cases. It’s not a large mobilization. We can free only the lateral and posterior attachments, not more, and some people believe that we cannot do a large resection using this approach but we do, we do lateral. OK, it’s coming better. The omentum is maintaining anteriorly as you see. Do you think it’s a good procedure regarding contamination? Do you think there is a risk of contamination or a risk of infection? Both? We have done a bacterial analysis and there is no more risk using classical laparoscopy, that is less than open procedures. There is a recent paper from Japan comparing open with laparoscopy. There is always bacterial contamination. In all the patients, we do that till now direct examination of the lavage at the end of the procedure when we are finished and the abdominal cavity has been cleaned but the number of bacteria is very limited.

12. Colorectal anastomosis 17'00''

So we will now introduce the stapler. So we do enema only not washout. Nobody is doing the washout now and they do enema for left colon. Washouts are proposed sometimes for right colectomy and if it is done, it is done 2 days before. You tighten, pull and we will verify the donuts to check that they are complete. On the rectal side, it is, and very thick and same on the other side. No bubbles.

13. Mesenteric gap closure 18'05''

We will now close the mesenteric gap. See now we are moving down all the omentum that was exerting traction on the colon to have better low traction on the global colon.

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