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Laparoscopic sigmoidectomy for sigmoid diverticulitis in a female patient: primary splenic flexure mobilization

This is a live operative demonstration of an unusual approach to perform sigmoidectomy using only 3 trocars. A detailed anatomical approach is presented together with a lively discussion of technical points in laparoscopy. This technique is suitable for advanced laparoscopic surgeons.

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Laparoscopic sigmoidectomy for sigmoid diverticulitis in a female patient: primary splenic flexure mobilization

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摘要

This is a live operative demonstration of an unusual approach to perform sigmoidectomy using only 3 trocars. A detailed anatomical approach is presented together with a lively discussion of technical points in laparoscopy. This technique is suitable for advanced laparoscopic surgeons.

媒體類型

手術影片

期間

25'00''

刊物

2007-04

普通的

最愛

Favorites Media

音訊

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數位出版

WeBSurg.com, Apr 2007;7(04).
URL: http://www.websurg.com/doi-vd01en2121.htm

Laparoscopic sigmoidectomy for sigmoid diverticulitis in a female patient: primary splenic flexure mobilization

1. Trocar placement 00'12''

We are looking forward to a rich tapestry of anatomical exploration. This is a very simple technique, the scope is in the upper port between the umbilicus and the xiphoid. This port is the second one between my assistants. These are the anatomical details that we can get through the positioning of the scope. This is the anterior aspect of the stomach, you can recognize the nerve of Latarget, the crow’s foot, the greater curvature. This is the Winslow arcade made up of the left and right gastroepiploic vessels. This is the point where the left gastroepiploic artery joins the right one. You can see the short vessels changing direction; from the left it’s going down and from the right it’s going up.

2. Division of gastrocolic ligament 01'52''

My procedure starts by lifting up the stomach, grasping the anterior aspect and opening the gastrocolic ligament; the second forceps is cutting and coagulating the gastrocolic ligament. I am using the 5mm Ligasure. You have 10mm trocars right? Yes, because I have to change the port position of the scope, I can use the other one again. I have a 30 degree camera, I can’t do anything with a 0 degree except a transhiatal total esophagectomy. The Ligasure device has really revolutionized the performance of these procedures. It is bipolar electricity that does this; in essence, the heat coagulates or boils the tissue and then holds and crushes it together in such a way that it adheres. My only concern is that the blade is not good enough, sometimes we have very good coagulation but cutting is not so easy. That is more true of the smaller Ligasures than the previous bigger ones. We open the lesser sac and we can see the pancreas very nicely, this is very safe. You can see the mesogastric fascia covering the pancreas and some congenital adhesion of this fascia that we can cut very easily with the Ligasure.

3. Mobilization of splenic flexure 04'50''

At this moment, we need to change our instruments. I now change to have the Ligasure in my left hand and the forceps in the right one so I can pull down the colon and the splenocolic ligament can be exposed and divided. I am using only two instruments without any problems. I think this is a very favorable case because the spleen is extremely far, the colon is already very down. I think one of the difficult steps is when you are near the spleen in this type of dissection, this is a good case where the colon is very far away. The problem is to cut the fold step by step exposing very nicely the colon because we have to avoid any thermal injury of the colon. Is taking down the splenic flexure easier in laparoscopic or open surgery? I think Cristiano makes this method using any three trocars placed low down on the right, it really seems to me as an open surgeon that that is optimizing the advantage that you get by using long laparoscopic instruments and the camera. We try to expose again the field, I get my swab to protect the spleen. This is the colon falling down. As you can see, the ligament is open. This is the beginning of the Monk’s line, in the lateral part of the abdominal cavity where three fascias join each other. The first one is the posterior one that we call the Zuckerkandl’s fascia, covering the posterior aspect of the kidney. The anterior one is the Gerota’s fascia and then we can find the Toldt’s fascia. The Zuckerkandl’s fascia is very important for a radical nephrectomy. Do you always begin by the splenic flexure? In very old patients where I suggest to do only a very short sigmoidectomy, in cases where I have a very long sigmoid loop, I try to avoid this step but usually I do this operation every time. What would be the intraoperative difficulty in this procedure as compared to the other ones? I think to do a three-port technique or such a dissection of the splenic flexure, you have to use both hands, I am very happy when I see videos done by other surgeons because I see that they move both hands at the same time so this way you can expose every detail nicely and you can get the 3D vision that you lose with laparoscopic surgery. We have to move our forceps in every direction, and it is the most difficult part of the operation.

4. Division of IMV 10'30''

Now the first step is over, and we have to push up the transverse colon. I push it in this position just to expose the left mesentery. This is the Treitz ligament, the aorta and very rapidly the IMV. The Treitz arcade, left colic artery and the left colic vein come in into the inferior mesenteric vein. You see the aorta, the inferior mesenteric vein, the Treitz arcade, left colic vein coming into the IMV and the IMV and the left colic artery. In the small one, it’s very delicate to open a window, the big one is not so good for this. We can coagulate these vessels very easily like this. See the gonadal vessels, we are in the right plane, the gonadal covered by the Gerota’s fascia and the nerve covering the gonadal vessels. This is the white line of the fusion and the window coming out on the other side.

5. Medial mobilization of left mesocolon 12'35''

Let’s go down now. The second step is over, we change the camera position and the port goes in the middle port. I would like to show you according to the technique by Umberto Parini that the small bowel falls down by itself if you have a good Trendelenburg position. The aorta, the Treitz jejunal loop, IMV, IMA, bifurcation of the aorta, and usually the small bowel can fall down by itself; in this case I have to help it fall. Again the right iliac artery, ureter crossing, gonadal vessels, promontory, the Gruber’s ligament very nicely exposed. We lift up the Gruber’s ligament and we open a window between the IMA and the aorta. In Italy, we often do emergency procedures for perforation and in this case, we wash the abdominal cavity and 3 days later, we do an emergency resection for stage 3. Now the window is open, we are very close to the artery. We can cut the artery very distally so we can spare the nerve in a safe way even in difficult cases. We now go in the ureter, behind the Gerota’s, you see the fascia covering the ureter. See the nerve on the other side of the artery, the branches coming all around this IMA, you can see all the branches coming from the right and left nerves and becoming a plexus all around the IMA. If you don’t cut the plexus, all the nerves come up.

6. Division of IMA 16'20''

The artery can be cut at this stage; I think it’s a safe technique. You see the colon is now completely dissected free. The colon is dissected, mesentery too. I get the impression that you don’t often use the knife. I use the knife all the time but in my opinion, it’s not as good as I’d like. I think this device is very nice because you can coagulate for some time, but you can use it in many other ways, reducing the coagulation time. We can see how easy it is to go down.

7. Division of colorectal junction 18'30''

Now this is the sigmoid junction, the left aspect, I think that we have to see where the tenia stops, usually in front of the promontory it ends. In this part, we have to rotate the mesentery like this and again, this finger is very useful to do a blunt dissection. Now I enter the mesentery; in this part, we have to be very close to the colon, opening first the posterior of the mesorectum. We are in front of the Mondor’s hilum, it is where the superior rectal artery splits to right and left. As you can see, the tenia stops and so we have to remove the high pressure zone. Have you had the problem of bringing the staple line from the anus? Sometimes, yes. What do you do then? I reduce the diameter of the anvil, and use a smaller one. This is the boundary and I transect it.

8. Exteriorization of sigmoid colon and anvil placement 21'15''

See the coagulated IMA. I put a 28 anvil. The color is quite good.

9. Anastomosis 23'25''

Now we check the tenia. We needed to dissect the splenic flexure free. Without the splenic flexure dissection, I think that we cannot do things properly. See the anastomosis.