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Laparoscopic sigmoidectomy for diverticulitis

This case is for beginners in which Professor Joel Leroy explains all steps showing patient, trocars and surgical team position.

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Laparoscopic sigmoidectomy for diverticulitis

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摘要

This case is for beginners in which Professor Joel Leroy explains all steps showing patient, trocars and surgical team position.

關鍵字

Laparoscopic sigmoidectomy for diverticulitis

媒體類型

手術影片

期間

12'00''

刊物

2005-05

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, May 2005;5(05).
URL: http://www.websurg.com/doi-vd01en1782e.htm

Laparoscopic sigmoidectomy for diverticulitis

1. Trocar placement 00'20''

This case is for beginners. We have installed the female patient in supine position with the right arms alongside the body. The team is standing on the right side of the patient, with the 1st assistant on the surgeon’s left and the 2nd assistant standing between the patient’s legs, ready for the anastomosis and for better exposure. The laparoscopic unit is located on the left side of the patient. Now to a few bearings: Right and left anterior superior iliac spine, pubic bone, supra-umbilical trocar, optical trocar, 10-12mm trocar, this one is a working trocar. I will introduce the forceps. Trocar C, 8-10cm lower on the mid-clavicular line to have a better and more ergonomic position. If necessary, I will add another trocar on the mid-clavicular line just under the rib for potential retraction, behind my trocar the ileocecum but also to do the dissection of the splenic flexure, what I will not do in this case. Trocar D to the left, mirror to trocar B used for exposure of the small bowel, not necessary probably in this case, trocar E: I put it rapidly because it’s not on this side that I’ll do the extraction of the colon. Trocar E to have a good exposure, we can retract the uterus; we can expose the sigmoid colon with the retractor and we can lift laterally and anteriorly the sigmoid mesocolon to have a good exposure of the root of the sigmoid mesocolon. We have put the patient in Trendelenburg position, with a right lateral tilt.

2. Transversal positioning 02'45''

I have introduced my instruments into the abdomen. I will push the omentum and the transverse colon. This patient has had a good bowel preparation 2 days ago using polyethylene glycol.

3. Positioning the bowel 03'11''

Yesterday he had a small enema so there is no bowel dilatation. We put all the bowel on the right side. I will show you the small bowel on the left as you see now. The kidney can be seen clearly here. This is the duodenojejunal junction and you let your instrument fall and you can put the small bowel this way on the left; in this case we can put it completely on the right and we keep some part of the small bowel up and on the left to obtain a good exposure like this one. It’s an essential part of the operation putting the small bowel well away. You see that we have a very compliant sigmoid colon, very long sigmoid loop, we have found a few diverticula but we have a small inflammatory part as you see here. We will not resect too much. It’s not a big diverticulitis. We will keep the vascularization of the rectum. You have here the aorta, IMA, IMV, left colic vessels or sigmoid vessels, inferior, middle and superior branches, superior rectal artery probably.

4. Medial approach of sigmoid colon 05'17''

We will divide into the meso. The ureter is behind. This is the lateral insertion of the sigmoid mesocolon.

5. Lateral mobilization of left colon 06'00''

We are respecting the superior rectal vessels. You can use monopolar. These are iliac vessels. I use the Ligasure device as a finger to open up the plane.

6. Left ureter 06'48''

This is the ureter behind Toldt’s fascia. This is my division. I have to divide the sigmoid branches that are here. With the Ligasure device, this surgery is easy, fast and safe. We have to do the anastomosis on the upper rectum, just under the colorectal junction and of the anterior tenia. In this case, it was mainly an inflammatory bowel segment but not diverticulosis. It is better probably for this patient to keep the sphincter to avoid the potential risk of future incontinence. We don’t have to open the presacral space. It is not the rectum. It’s warming only lateral, and not posterior or anterior. The steam exits laterally.

7. Division of rectosigmoid junction 09'12''

We are not far from the Douglas’ pouch. I exert traction and use the stapler. This is a 45 lens. We regularly push the segment of bowel so it becomes a bit longer. With the forceps, we get a better exposure. I’ll go towards the forceps, which is a landmark.

8. Section of sigmoid mesocolon 09'58''

You see the vessels beating, particularly important in case of obesity because you prepare inside the division of the meso and when you’ll do the extraction outside, there’s less danger of breaking the meso when you exert traction through the small incision.

9. Extraction and resection 10'18''

Now I introduce the drape with the ring, 31cm length. The patient will be able to eat solid food on postoperative day 2. With this system of closure, water-tightness is ensured.

10. Anastomosis 11'10''

You see that the bowel is falling and the anvil stays close to the rectal stump, which means that there is a low tension on the anastomosis. We have removed a 30cm length. We are not far from the Douglas’ pouch (1 to 2cm at the most), we’re sliding on the posterior aspect. We’ll do the transfixion removing one of the corners of the stapling line to avoid 2 ears. We maintain this more anteriorly, lock, tighten. We check that there is no twist.

11. Air test 12'10''

We will control the ring and we will do an air test and to do so, we put serum saline to be sure that no bubbles are trapped, put a clamp or we close with 2 instruments. This test aims at verifying that there is no immediate leakage.