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Laparoscopic sigmoidectomy for diverticulitis
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摘要
The description of the laparoscopic sigmoidectomy for diverticulitis covers all aspects of the surgical procedure used for the management of sigmoid diverticulitis.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, vascular approach, vascular division, posterior medial dissection, resection of mesorectum, lateral mobilization, division of sigmoid colon, mobilization principles, lateral mobilization, medial mobilization, extraction, preparation of anastomosis, anastomosis.
Consequently, this operating technique is well standardized for the management of this condition.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, vascular approach, vascular division, posterior medial dissection, resection of mesorectum, lateral mobilization, division of sigmoid colon, mobilization principles, lateral mobilization, medial mobilization, extraction, preparation of anastomosis, anastomosis.
Consequently, this operating technique is well standardized for the management of this condition.
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媒體類型
 刊物
2001-06
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普通的
最愛
 音訊
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數位出版
WeBSurg.com, Jun 2001;1(06).
URL: http://www.websurg.com/doi-ot02en165.htm
URL: http://www.websurg.com/doi-ot02en165.htm
Laparoscopic sigmoidectomy for diverticulitis
1. Introduction
Symptomatic and complicated diverticular disease represents the most common indication for sigmoid colectomy in Western countries. As these resections are performed for benign disease, care must be taken to minimize any untoward sexual or urinary postoperative sequelae.A laparoscopic approach may be used to perform sigmoid resection in a manner equivalent to the open technique. Indeed, most laparoscopists consider laparoscopic sigmoid colectomy relatively straightforward. However, the difficulty of the procedure increases significantly with complicated diverticular disease.
2. Anatomy
• Colon
The sigmoid colon is the mobile terminal portion of the left colon. Its mobility depends on the length of the sigmoid loop.The vascular supply of the sigmoid colon is based entirely on the inferior mesenteric artery and its branches. Thorough knowledge of the vascular anatomy and its variations is essential for a safe resection.
The close proximity of the vessels to the left sympathetic trunk and the left ureter represent potential risks in sigmoid colon resection.
• Arteries
• Overview
The arteries are all branches of the inferior mesenteric artery (IMA).1. Inferior mesenteric artery (IMA)
2. Left colic artery (LCA)
3. Trunk of sigmoid arteries
4. Superior rectal artery (SRA)
5. Marginal arteries
• Inferior mesenteric artery
The inferior mesenteric artery (IMA) originates from the anterior surface of the abdominal aorta, 1 to 3 cm below the third portion of the duodenum, to form the main blood supply of the left colon. It gives off branches for the left colon, the sigmoid colon, and the rectum.• Left colic artery
The left colic artery (LCA) is the first branch of the IMA and supplies the vasculature of the left colon. After crossing over the inferior mesenteric vein (IMV), the LCA courses along the IMV's left border for a variable distance. It then approaches the marginal arteries, which it generally joins somewhere between the splenic flexure and the transverse colon. Its preservation is possible during mobilization of the left colon.• Sigmoid arteries
There are at least 3 sigmoid arteries (SA), often originating from a common trunk distal to the LCA. Variations are common. These sigmoid branches can originate separately from the IMA up to the promontory or from the LCA. They are always situated medial to the sigmoid veins and posterior to the superior rectal vein.• Superior rectal artery
The superior rectal artery (SRA) is the terminal branch of the IMA. It is located just anterior to the fascia propria of the rectum at the rectosigmoid junction. It gets progressively closer to the rectal wall as it divides into a right and a left branch, or into even more branches in 17% of cases (Ayoub, 1978). These branches supply the upper two thirds of the rectum. The larger right branch often extends from the IMA (Ayoub, 1978). These 2 branches divide 2 or 3 more times without anastomosing and end on the pelvic floor. All these arterial branches remain in the mesorectum along with the rectal veins, which drain into the superior rectal vein (SRV) and then into the IMV.• Veins
• Overview
Rectal, sigmoid, and left colic veins join to form the inferior mesenteric vein (IMV).1. Inferior mesenteric vein (IMV)
2. Left colic vein (LCV)
3. Trunk of sigmoid veins
4. Superior rectal vein (SRV)
5. Marginal veins
• Inferior mesenteric vein
The sigmoid and left colic veins join to form the inferior mesenteric vein (IMV).1. Portal vein
2. Splenomesenteric trunk
3. Splenic vein
4. Inferior mesenteric vein (IMV)
5. Superior mesenteric vein (SMV)
• Sigmoid veins
There are several sigmoid veins (SV). They run separately or as a common trunk into the SRV to form the IMV.• Left colic veins
The left colic veins (LCV) often join into a main trunk. There are often 2 LCVs for 1 LCA. Accessory venous branches, originating from the descending colon, run directly into the IMV. They must be divided to allow mobilization of the left colon.3. Operating room set-up
• Patient
It is essential that the patient be appropriately positioned to avoid complications (nerve and vein compression, injuries to the brachial plexus) and to facilitate the procedure and anesthetic monitoring.- Trendelenburg position with a 15° to 25° tilt and a 5° to 10° right tilt;
- lithotomy position;
- buttocks placed at the distal edge of the table;
- thighs and legs stretched apart with a slight flexure;
- right arm alongside the body;
- left arm at a right angle or alongside the body (surgeon's preference);
- gastric tube and urinary catheter;
- heating device.
• Team
1. Surgeon2. First assistant
3. Second assistant
4. Scrub nurse
5. Anesthesiologist
Although the procedure can be performed with a single assistant, it is preferable to have 2 assistants and a scrub nurse, especially when experience in performing the procedure is limited.
The team can remain in the same position throughout the entire procedure.
• Equipment
- The table must allow for both abdominal and perineal access. It is advisable to use a table that can be easily tilted laterally and placed into steep Trendelenburg and reverse Trendelenburg position, facilitating perineal exposure.- The laparoscopic unit is located to the left of the patient along with the main monitor. It may be useful to use a second monitor placed above the patient's head.
- To perform the procedure in excellent conditions, a 3CCD camera is mandatory.
- A high output (>= 9L/min) insufflator should be used to electronically monitor pressures. Its inertia should be low to make up for losses in carbon dioxide (induced or not).
- Voice-controlled robotic arm
1. Laparoscopic unit
2. Electrocautery
3. Operating table
4. Monitor
5. 3CCD camera
6. Instrument table
4. Trocar placement
• Number of trocars
Although a sigmoid colectomy can be performed using only 3 trocars, for complicated presentations and especially when the surgeon's experience in performing the technique is limited, the use of more trocars is preferable. This helps to ensure the safety of the procedure by allowing improved exposure of the operative field and the mesentery, and by facilitating mobilization of the splenic flexure.We readily use 6 trocars, with a trend toward reducing trocar size. The patient's body habitus, previous surgical history and the initial laparoscopic exploration via the supraumbilical trocar should be used as guides for introducing the various operating trocars.
• Principles
Firm trocar fixation in the wall is important. This is achieved by adapting the size of the incision to the trocar and, if needed, fixing the trocar to the abdomen with a suture. We no longer use screw-like devices, as they increase parietal trauma.• Optical
Trocar A: 10/12 mm, 0° opticalThe trocar is positioned on the median line 3 to 4 cm above the umbilicus or 20 cm above the pubis in patients with a small stature.
0° optical
• Operating
• Trocar B
This is a 5 mm operating trocar, used for retraction during mobilization of the splenic flexure (caudal retraction of the left colon), during which time trocar D is used for operating instruments. At the end of the procedure, Trocar B may be replaced by a 12 or 15 mm trocar for introduction of a linear stapler.It is situated on the right midclavicular line, at the level of the umbilicus.
Atraumatic grasper
• Trocar C
This is a 5 mm operating trocar, used for retraction during mobilization of the splenic flexure (caudal retraction of the left colon). At the end of the procedure, it may be replaced by a 12 or 15 mm trocar for introduction of a linear stapler.It is situated on the right midclavicular line, 8 to 10 cm below trocar B.
Scissors (monopolar, high-frequency hemostasis device, clip, staplers), bipolar hook, surgical loop, suction-irrigation device
Atraumatic grasper
• Retractors
• Trocar D
This is a 5 mm retractor, except during mobilization of the splenic flexure, when it is used as an operating trocar. It is situated on the left midclavicular line, at the level of the umbilicus.
Atraumatic grasper
Scissors (monopolar, high-frequency hemostasis device, clip, staplers), bipolar hook, surgical loop, suction-irrigation device
• Trocar E
This is a 5 mm retractor, except during mobilization of the splenic flexure when it is used as an operating trocar. It accommodates a grasper used to expose the mesosigmoid and left mesocolon.It is situated 8 to 10 cm above the pubis on the median line.
Grasper, suction-irrigation device
• Trocar F
This is a 5 mm retractor that accommodates an atraumatic grasper used to laterally retract the terminal portion of the small intestine and to better expose the attachments of the omentum to the transverse colon during mobilization of the splenic flexure.It is situated on the right midclavicular line in the subcostal position.
Atraumatic grasper
5. Instruments
• Optical devices
Most authors use laparoscopes with 0° and 30° visual axes and with a 70° visual field.Some authors use a laparoscope with a 45° visual axis.
• Operating devices
1. Grasper2. Bipolar
3. Ultrasonic dissectors
4. Linear stapler
5. Scissors
6. Clip applier
7. Circular stapler
8. Plastic-coated drape to protect the incision after freeing the colostomy
• Retracting devices
1. Flexible retractor2. Peanut swab
• Others
Efficient suction-irrigation device for lavage and dissection (lysis of adhesions)6. Exploration
The first step of the procedure is an exploration of the abdominal cavity. Visceral organs may be manipulated with blunt instruments to complete the exploration and to evaluate the colon.The length, degree of inflammation, and presence of pelvic adhesions of the sigmoid loop are evaluated. Similarly, the quality and mobility of the left colon are assessed.
7. Exposure
• Exposure
Improved exposure greatly facilitates the surgical procedure.Proper exposure is a function of a host of factors. These include the working space in the abdominal cavity, the quality of the preoperative gastrointestinal (GI) preparation, the positioning of the patient as well as a perfect understanding of the organization of the operating field.
• Working space
• Principles
This depends on the quality of the preoperative GI preparation, the positioning of the patient and complete relaxation allowing the abdominal wall to distend correctly under the pressure of the pneumoperitoneum.• Intestinal preparation
An empty digestive tract facilitates the layering of intestinal loops. It is achieved by a strict, fiber-free diet 8 days prior to surgery.As most experts do, polyethylene glycol is no longer used before surgery to complete the intestinal preparation.
The day before, or even on the day of the operation, the patient is placed on a fibre-free diet and undergoes enemas.
• Patient positioning
To prevent the patient from sliding, shoulder supports or straps around the thorax may be used.In our current practice, we rarely use such measures, despite a 20° to 30° Trendelenburg position and a right tilt.
• Muscle relaxation
In addition to the pressure of the pneumoperitoneum (12 mm Hg), complete relaxation of the muscular wall is essential to create the working space.• Layering the intestinal loops
• Gravity
Layering the intestinal loops requires gravity and retraction of organs.• Transverse colon
The greater omentum and the transverse colon are placed in the left subphrenic region and maintained in this position by the Trendelenburg tilt. An atraumatic retractor, introduced through trocar D, may also be used.• Proximal portion of jejunum
The jejunum is retracted toward the right hypochondrium, below the right transverse colon. The right tilt and Trendelenburg position, along with an atraumatic retractor if needed, maintain the small intestine in this position.• Distal portion of jejunum
The distal portion of the small intestine is placed in the right iliac fossa along with the cecum. If the small intestine is too bulky, this operative maneuver can be difficult, notably in obese patients.• Specific cases
• Obese patient
Obesity characterized by a flaccid muscular wall (female patients) is not a major handicap as ample working space remains. In the setting of a tonic muscular wall (male patients) and short, fatty mesenteries, the surgeon must progressively layer the intestinal loops to expose the dissection areas.• Adhesions
By freeing the digestive tract, layering can be performed for better exposure of the operating field. It is sometimes useful to preserve adhesions, especially at the level of the cecum or the splenic flexure.• Uterus
The uterus may be an obstacle to adequate exposure in the pelvis. In postmenopausal female patients, the uterus can be suspended to the abdominal wall by a suture. This suture is introduced halfway between the umbilicus and the pubis to suspend the vagina and make it horizontal, thereby opening the rectovaginal space.8. Vascular approach
• Preservation of supply
The vascular approach is the first step of the dissection. A medial approach from right to left is used.When a segmental resection of the sigmoid colon is planned, it is advisable to preserve the vascular supply of the left colon and rectum to improve short and long-term results (Adachi, 2000).
Except in simple cases where vessels are visible due to transparency, the vessels are gradually exposed once the peritoneum of the mesosigmoid has been widely opened.
• Peritoneal incision
The peritoneum is opened along the right anterior border of the aorta, starting the incision from the promontory and extending it to just below the third portion of the duodenum.Anterior traction of the mesosigmoid, using a grasper introduced through trocar E, exposes the base of the mesosigmoid. The pneumodissection (entry of CO2 into the retroperitoneal space), which results from the pneumoperitoneum, facilitates the dissection.
• Identification of IMA
After division of the perivascular fibrous elements, the IMA trunk is identified near the aorta.This identification is mandatory in obese patients or in cases of severe mesenteric inflammation, in order to identify the arterial branches that must be preserved.
• Dissection of IMA
The dissection of the IMA near its origin is pursued caudally along its anterior aspect, opening the vascular sheath.The left colic branch on the left aspect of the IMA is rapidly identified, followed successively by the trunk of the sigmoid arteries and the SRA.
The dissection of these vessels must be meticulously pursued to identify any vascular anomalies. Indeed, sigmoid branches (SB) can also originate from the LCA and the SRA.
9. Vascular division
• Principles
Some authors consider division under laparoscopic guidance of the IMA near its origin easier than preservation of the left colic and superior rectal vessels (Domergue, 2000; Leroy, 2000). However, this is not recommended in benign pathologies, as anatomical and functional studies have shown that preservation of the LCA and SRA leads to improved short-term and long-term results (Adachi, 2000).• Division of IMA
• Principles
1. Toldt's fascia2. Sympathetic trunk
3. Ureter
4. IMV
5. LCA
6. Peritoneum
Division of the IMA is performed either after applying clips, or after sealing the vessels with a hemostasis device. The distal end of the SRA at the level of the mesorectum must also be controlled during the procedure. Preservation of the LCA is possible, in which case care must be taken to avoid injuring the left sympathetic trunk situated on the left border of the IMA.
• Division proximal to LCA
Performed 1 cm from the aorta, this technique is used when the inflamed mesentery is difficult to dissect.• Division distal to LCA
This allows preservation of the vascular supply of the left colon, but it can limit the mobility of the left colon.• Division of sigmoid arteries
• Selective division
We recommend selective division of the sigmoid branches, thus preserving the left colic and superior rectal arteries.The risk of injury to the hypogastric nerve plexus and to the left ureter is relatively low at this level. Nevertheless, the left ureter must be identified before any ligature, cauterization or division.
• Sigmoid trunk
The sigmoid trunk must be divided at its origin, either after applying clips or after sealing the vessels with a hemostasis device. This trunk is always situated anterior to the SRV, which must be preserved.• Branches of the trunk
These branches may be divided separately (after applying clips or using a vessel-sealing device) or together after creating windows in the mesentery to divide the various branches with a linear stapler.• Other branches
Dissection of the anterior surface of the superior rectal vessels exposes the sigmoid branches that must be divided. These vessels may be encountered up to the level of the promontory.Dissection of the first few centimeters of the LCA is performed to check for the presence of sigmoid branches arising directly from it. Such branches, if present, are divided separately.
• Division of veins
• Preservation of IMV
As a rule, the veins, situated lateral to the arteries, are easily identified after division of the sigmoid artery trunk. In case of difficulty, the vein trunk is identified further down on the left margin of the SRA.In our opinion, preservation of the IMV is important and does not prevent the lowering of the left colon.
• IMV
In our early experience with laparoscopic sigmoid colectomies, we systematically divided the IMV below the LCV or below the inferior border of the pancreas, after division of the IMA (Leroy, 2000). In our current practice, however, we try to preserve it. In the presence of severe inflammation preservation of the IMV can be difficult and in such cases it is sacrificed. • Sigmoid veins
The sigmoid veins are often paired with the sigmoid arteries, although there may be more than one venous branch for each arterial one. This is particularly true on the anterior surface of the SRV.• Left colic veins
This step is almost always required in order to lower the splenic flexure with or without preservation of the LCA.10. Post medial dissection
• Principles
Mobilization of the colon follows vascular division. It may be performed medially or laterally. We prefer a medial approach, which is well adapted for laparoscopy, as it preserves the working space and demands the least handling of the sigmoid colon. If a fixed colon is encountered, the surgeon must know how to alternate between medial and lateral approaches according to the difficulties encountered.• Posterior freeing
The objective of this step is to expose the anterior surface of Toldt's fascia. This fascia protects the retroperitoneal structures.• Exposure
After division of the vessels, the mesosigmoid is retracted anteriorly (trocar E) to open the posterior space.• Dissection
1. Ureter2. Genital vessels
3. Posterior surface of mesosigmoid
4. Lateral layer of mesosigmoid
5. Mesorectum
The dissection plane is situated between Toldt's fascia and the mesosigmoid. This plane is avascular and easily dissected. It is exposed in the course of the dissection along the posterior surface of the mesosigmoid.
Once Toldt's fascia has been exposed, the detachment of the mesosigmoid is pursued posteriorly and laterally to the white line of Toldt.
The left sympathetic nerve trunk, the ureter, and genital vessels, covered by Toldt's fascia, are viewed during the dissection.
11. Resection/mesorectum
• Anatomy
We recommend a partial resection to preserve the superior rectal vessels.• Partial resection
We recommend partial resection of the mesorectum, anterior to the superior rectal vessels, to preserve the vascular supply to the rectum. This is performed above the origin of the first superior rectal branch, which is divided. This branch is an excellent landmark for the posterior surface of the colorectal junction. The division of the mesorectum is thereafter avascular.12. Lateral mobilization
• Exposure
The sigmoid loop is pulled toward the right hypochondrium (grasper in trocar F) to exert traction on the left layer of the mesosigmoid.• Dissection
The white line of Toldt is opened cephalad and caudally.Laterally, care must be taken to avoid the genital vessels and the left ureter. Identification of the ureter with a ureteral catheter is usually not necessary. When difficulty is encountered in identifying the ureters, it is preferable to pursue its dissection higher up in a non-inflamed area, using a medial approach, and to follow it caudally into the operative field.
After incision of the left layer of the mesosigmoid, the lateral dissection joins the plane of the previously performed posterior dissection along Toldt's fascia.
• Danger
1. Sigmoid colon2. Mesosigmoid
3. Adhesions
In the case of inflammatory adhesions of the sigmoid colon to the abdominal wall, lateral mobilization can be difficult. In this case, it is advisable to perform a medial posterior approach to identify the ureter in a healthy, non-inflamed area.
13. Division/sigmoid
• Anatomy
Once it is freed, the sigmoid colon is resected. Total resection of the sigmoid colon, including the rectosigmoid junction, is performed. Cephalad, the proximal division is performed on a portion of the colon that is supple and without any diverticula.• Distal division
After division of the mesorectum, the distal division of the sigmoid colon is performed below the rectosigmoid junction. The junction is identified on the anterior surface of the rectum by the coalescence of the anterior tenia, and posteriorly by the first collateral branch of the superior rectal vessels.Division of the rectum is performed using a mechanical linear stapling device, which can divide and staple without opening the digestive tract. The stapler is introduced through trocar C into the right iliac fossa. We prefer using staples for thick tissues (green cartridges, 4.8 mm), applied perpendicular to the digestive tract. The use of reticulating staplers may be useful.
• Proximal division
• Principles
The proximal division should be performed in a non-inflamed area on a perfectly healthy and supple portion of the colon. It includes division of the mesocolon, followed by division of the colon. The division of the mesocolon is always performed in the abdominal cavity. The colon may be divided outside of the abdominal cavity, after it is exteriorized.• Division of mesocolon
Division is performed with a high-frequency hemostasis device, ultrasonic dissectors, monopolar scissors or linear staplers. The marginal arteries are preserved up to the area of transection.Whether the colon is divided intracorporeally or extracorporeally, it is important to perform this mesocolic division first because it prevents the mesentery from tearing (during the extraction of the sigmoid colon).
• Intracorporeal division
Intracorporeal division is used in surgery for cancer of the sigmoid colon. It is usually performed with a mechanical stapler (blue cartridges) introduced through trocar C into the right iliac fossa. The sigmoid colon is then completely freed.• Extracorporeal division
In sigmoid colectomy for diverticulis, the colon is usually exteriorized before it is divided. The exteriorization is pursued until a healthy portion of colon is reached. The preceding division of the mesocolon facilitates this.14. Principles/mobilization
In the event that a long segment of sigmoid colon is resected, mobilization of the left colon is necessary to allow for a tension-free colorectal anastomosis.The left colon is freed by division of its posterior and lateral attachments. Occasionally, division of the left colic vessels is required for full mobilization of the left colon.
The vascular supply of the mobilized left colon should be preserved. This is often difficult to assess in laparoscopic surgery.
Mobilization of the splenic flexure is frequently required. This can be achieved in a number of different ways. It is important for the surgeon to be familiar with all these approaches in order to select the approach most suitable for each case.
15. Lateral mobilization
• Freeing the attachments
1. Attachments of omentum to colon2. Phrenicocolic ligament
3. Toldt's line
4. Toldt's fascia
This approach is conventional in open surgery. It is used in simple cases with an easily mobilized splenic flexure. It includes freeing of the lateral and posterior attachments.
• Toldt's line
An ascending incision is made along the white line of Toldt using scissors introduced via trocar D.• Phrenocolic ligament
The phrenocolic ligament is then divided using scissors introduced through trocar D. Retracting the colon and the splenic flexure toward the right iliac fossa using graspers introduced through trocars C and E helps in this exposure.• Dividing the attachments
Attachments are incised close to the colon until the omental bursa (lesser sac) is opened. Division of these attachments is pursued as needed toward the right, to facilitate lowering of the left transverse colon.16. Medial mobilization
• Principles
Medial mobilization is perfectly suited to the laparoscopic approach as the surgeon, situated to the patient's right, has an excellent view of the anterior surface of the pancreas and the base of the left transverse mesocolon.It follows the medial posterior freeing of the mesosigmoid, which then continues upward, anterior to Toldt's fascia.
• Peritoneal incision
The splenic flexure is freed on its posterior surface while remaining close to the left mesocolon. This avoids the risk of a dissection posterior to the pancreas with an attendant injury of the splenic vein. Division of the IMV just below the inferior border of the pancreas facilitates this operative step.• Posterior freeing
On the anterior inferior border of the pancreas, the base of the transverse mesocolon is identified. This is divided caudad to cephalad and from right to left, opening the omental bursa (lesser sac). Anterior to the pancreatic tail, care must be taken not to injure the pancreas and small mesocolic vessels, which course through the left transverse mesocolon.17. Extraction
• Principles
Extraction is performed through a mini-incision while protecting the abdominal wall.• Incision
• Principles
The size of the specimen, its location, and the extraction technique take into account the volume of the specimen, the patient’s body habitus, and cosmetic concerns.• Size
The incision should be adapted to the size of tissues to be extracted. Care must be taken not to crush the specimen during extraction.• Location
The incision is generally performed in the suprapubic region (1), more rarely in the right iliac fossa (2), but never in the left iliac fossa (3). The lowering of the colon in (1) or (2) allows evaluation of the possibilities of mobilization of the colon in the pelvis. If the mobilized colon reaches the extraction area in a tension-free manner, it may be safely assumed the anastomosis will be tension free as well. • Protection
The wall should be protected to avoid bacterial and cellular contamination (risk of wound implantation of cancer cells). This protection is made up of a waterproof plastic-coated drape with a ring (7 or 11 mm in diameter).The same plastic-coated protection is used during intracorporeal anastomosis. The bag is twisted on itself to reseal the peritoneal cavity in a reversible fashion.
• Extraction
• Principles
The extraction of the specimen is performed either using an airtight plastic bag or through a plastic-coated drape with a ring that allows reestablishment of the pneumoperitoneum following the extraction of the specimen. In our current practice, we frequently combine the techniques.
• Simple
The resected sigmoid colon is extracted through the plastic drape introduced into the abdominal incision. The intra-abdominal division of the mesocolon prevents it from tearing during extraction, especially in obese patients.
• In a plastic-coated bag
After placing the sigmoid colon in a plastic bag, the extraction is done directly through the abdominal incision. For improved abdominal wall protection, the use of both the plastic drape and waterproof bag provides ultimate coverage. 18. Preparation/anastomosis
• Preparation
The colorectal anastomosis is a delicate step. We always use a mechanical circular stapling device to transfix the rectal stump.Performing the anastomosis includes an extra-abdominal preparatory step and an intra-abdominal step performed laparoscopically
The extra-abdominal step takes place after exteriorization of the left colon through the incision protected by the plastic-coated drape.
• Placement of anvil
If necessary, the colon is cut again in a healthy, supple and well-vascularized zone. The anvil (at least 28 mm in diameter) is then introduced into the colonic lumen and closed with a purse string. The left colon with the anvil is then reintroduced into the abdominal cavity.• Closure of abdominal incision
The closure ensures the airtightness of the abdominal cavity required to perform the anastomosis under laparoscopic guidance. The closure is achieved either by primary closure of the abdominal wall or by introducing a plastic-coated drape with an airtight ring. The second option is more attractive because it leaves the surgeon the possibility of exteriorizing the colon if necessary.19. Anastomosis
• Principles
The intra-abdominal step is performed entirely under laparoscopic guidance after reinflation of the abdominal cavity. It includes transfixing the rectal stump and performing the colorectal anastomosis with a circular mechanical stapler.• Transfixing the rectal stump
After ensuring that the abdominal cavity is airtight, the pneumoperitoneum is reestablished. The circular stapler is introduced into the rectum through the atraumatically dilated anus. The rectal stump is then transfixed with the tip of the head of the circular stapler.To avoid ischemic risks, the stapler can be introduced in the middle or at one of the ends of the rectal stump staple line while avoiding leaving lateral ear-shaped flaps.
In women, the posterior vaginal wall should be retracted anteriorly.
• Anastomosis
Once the anvil has been clicked onto the proximal part of the circular stapler, it is mandatory to ensure that the proximal part of the colon is not twisted. The stapler is then closed; the surgeon should check that no neighboring organs are incarcerated before stapling in accordance with the manufacturer's recommendations.The stapler is then loosened and withdrawn through the anus.
• Testing the anastomosis
Verification of the anastomosis is mandatory. This includes checking for the circular aspect of the amputated rectal and colon rings, optional air test and for some authors, endoscopic transanal evaluation of the anastomosis.20. Conclusions
Sigmoidectomy for diverticulitis is often difficult to perform due to the inflammation of the tissues and the obesity which is often associated with the patient’s condition.Although the medial approach is rarely used in conventional open sigmoid resection for inflammatory disease, it is used in laparoscopy, as it permits the surgeon to safely perform the procedure while avoiding manipulation of the colon and mesenteries.
Laparoscopic sigmoid resection for diverticulitis is currently considered to be an excellent technique which is beneficial for patients.
Even though it is not yet a “gold standard”, it seems quite evident that this minimally invasive approach will play an increasingly important role in the surgical management of diverticulitis.
The smooth performance of this technique depends on:
- the quality of the equipment;
- perfect knowledge of the operative steps;
- exposure of the operative field;
- the experience of the surgical team.
21. Reference
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Bashankaev B, Wexner SD. New indications for laparoscopic sigmoidectomy. Nature 2009;6:388-90.
Domergue J, et al. La chirurgie laparoscopique : aspects techniques. In : Benchimol D, Domergue J, editors. Chirurgie de la maladie diverticulaire sigmoïdienne. Rueil-Malmaison : Arnette; 2000. p. 119-34.
Forgione A, Leroy J, Cahill RA, Bailey C, Simone M, Mutter D, Marescaux J. Prospective evaluation of functional outcome after laparoscopic sigmoid colectomy. Ann Surg 2009;249:218-24.
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