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Laparoscopic sigmoidectomy for sigmoid diverticulitis in an obese (BMI=30) male patient

This is a didactic video demonstrating laparoscopic sigmoidectomy for diverticular disease. A combined medial and lateral approach is employed in the dissection of the sigmoid vessels, preserving the IMA. The use of the LigaSure device greatly facilitates the dissection. This approach is suitable for general and digestive surgeons. The authors use a medial approach to divide the branches of the sigmoid vessels. In performing the medial resection for cancer, the authors caution to avoid contact with the colon. The approach may involve a combination of medial and lateral techniques. Monopolar shears help carry out the dissection using traction. Freeing the vessels laterally enables visualization of the mesocolon.

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Laparoscopic sigmoidectomy for sigmoid diverticulitis in an obese (BMI=30) male patient

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摘要

This is a didactic video demonstrating laparoscopic sigmoidectomy for diverticular disease. A combined medial and lateral approach is employed in the dissection of the sigmoid vessels, preserving the IMA. The use of the LigaSure device greatly facilitates the dissection. This approach is suitable for general and digestive surgeons.

The authors use a medial approach to divide the branches of the sigmoid vessels. In performing the medial resection for cancer, the authors caution to avoid contact with the colon. The approach may involve a combination of medial and lateral techniques. Monopolar shears help carry out the dissection using traction. Freeing the vessels laterally enables visualization of the mesocolon.

關鍵字

sigmoid colon, sigmoidectomy, diverticulitis, obese patient

媒體類型

手術影片

期間

17'10''

刊物

2007-05

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, May 2007;7(05).
URL: http://www.websurg.com/doi-vd01en2103.htm

Laparoscopic sigmoidectomy for sigmoid diverticulitis in an obese (BMI=30) male patient

1. Trocar placement 00'19''

This is a male patient with a BMI of 30. The landmarks are as follows: the pubis, ribs, right and left anterior superior iliac spine, vertical midline, right and left mid-clavicular line, right and left anterior axillary line. I have put the umbilical trocar just above the umbilicus, 20cm above the pubis, I have also introduced two working trocars B and C positioned on the mid-clavicular line, and another one, trocar E. He had had an adenomectomy for which they used a preperitoneal approach, so no adhesions as you will see. The patient has his right arm along the body.

2. Retraction of omentum and small bowel 01'30''

The 1st step is a panoramic exploration that was performed immediately after the first trocar (optical trocar) was introduced to check that there are no adhesions, which is the case here. I want to occupy a maximum of the space that is not useful for the operation so I retract the omentum by pushing it above the transverse mesocolon, putting it underneath the diaphragm. This is the duodenum, the aorta, the duodenojejunal junction. I am sliding behind the mesentery and on the back of the abdominal cavity and I will put not on the duodenum but lateral behind. Nobody is touching it, it’s just the angulation applied by the forceps and the posterior wall that maintains it in this position. Good muscle relaxation, as you see we have no bowel movement. We put the small bowel in position like this, and finally we have exposure, it is fixed. This is part of the sigmoid and we have adhesions and it is very hard. The small bowel is retracted on the right side, this is the aorta so I don’t have to retract more. The 3rd duodenum, the duodenojejunal junction is not far. This is the root of the mesentery, and we push the bowel to the right side of the root of the mesentery.

3. Medial approach to sigmoid mesocolon 03'45''

The difference between benign disease and cancer is the vascular approach. We want to keep a maximum of the vascularisation of the rectum for several reasons: because there is the nerve, the ureter, we keep the vascularization in order to have less risk of fistula. I am dividing the meso, and the branches of the sigmoid vessels. I am doing a medial approach but I don’t hesitate particularly in this case to complete laterally with monopolar cautery to have a lateral freeing.

4. Lateral mobilization 04'37''

Going medial for cancer is more important because we don’t touch the colon. We have to remember that there is a lateral way, medial way and we have to mix them because we have to do both. I only use 20 Watts for monopolar cautery. I am using monopolar scissors with traction and counter-traction. I love this kind of instrument because it increases the possibility of working.

5. Division of sigmoid vascular branches 05'40''

I have freed laterally, it will now be easier for me to see the meso. I’m using the Ligasure. I have the window, I have the branches of the vessels visible. This is the ureter on the right; on the left, due to my approach I am far from it, I will show you why soon. I am dividing the peritoneum, you see the vessels beating here, I am keeping the superior rectal vessels and I’m dividing anteriorly to the superior rectal vessels and I’m behind the colon and rectum. Slowly I am dissecting conically to reach the colon and rectum. I am reaching the area I want to dissect more before dividing the colon and the rectum. I’m sliding. My instrument is not warming anteriorly and posteriorly but laterally. Let’s clean now. This is the anterior tenia, I am at the limit with the anterior tenia, and I will complete this. I am doing that because I don’t want to cut the small vessels when I will do the division. We have nearly finished because we have a long flexible loop.

6. Division of colo-rectal junction 08'30''

We have diverticulum only on the sigmoid where you have seen the inflammatory adhesion. If we have a good compliant colon above and if we resect the colorectal junction, we have solved the problem. We are using an Endo-GIA 45mm lens, I introduce the stapler in the right trocar. I am keeping a part of colon or rectum because we will have a reflection, to be sure that I will do the anastomosis. After retraction, it seems that I am very close. To sum up, the vascular approach is different in cancer and in inflammatory benign disease. I estimate where I will do the anastomosis, this is a good compliant colon so I will probably do the anastomosis at this level. I must evaluate the possibilities of moving down the colon. I will probably resect 30cm where we have the diverticulum; on the X-ray you will see that there is no diverticulum above.

7. Mobilization of splenic flexure 10'45''

I will do the anastomosis at this level and do lateral freeing only but not a complete mobilisation of the splenic flexure; you have less morbidity when you do that. When I speak of complete mobilisation of the splenic flexure, you have less morbidity when you do that, I mean division of the lateral attachments, division of the colo-omental or gastro-omental attachment, division of the root of the transverse mesocolon and division of the vessels. I am now dividing the mesocolon, I will probably do the anastomosis at this level. I am dividing the meso to keep the vascularisation of the marginal vessels like this. I am dividing a maximum at a distance. We will complete this outside. I am dividing inside because if I have to pull, I risk breaking the meso; I complete the dissection outside once I have done the exteriorisation. A study compared resections with or without mobilisation, the length of the resection. There was no difference in the length of resection with mobilisation or without it. So only mobilise only when it is necessary.

8. Exteriorization of sigmoid colon 13'12''

This is a drape. I introduce inside by pushing around the instrument. And I do a retraction. I push the ring between my finger and the instrument. Then pull at the segment of colon. We stop the insufflation. We have difference in colours: purple, pink above, and very compliant bowel. I put the atraumatic Babcock on. I have removed at least 30cm. This is a 28. We reintroduce it into the abdomen, pull this, we twist.

9. Colo-anal anastomosis 15'16''

Then put the clamp or forceps perpendicular to the scar and re-insufflate. Spontaneously without traction, the segment of colon and the anvil stick close to the rectal stump. This is important because it proves that we have a tension-free anastomosis. Before closing, we control that there is no twists or tension. It’s not a mobilisation, it’s lateral freeing. We verify the ring and we do an air test. No bubbles . This does not prove that there will not be a leak later. Now we have a gap; is it necessary to close it. No drain in this case, it is exceptional to put drains in, well eventually for rectum or if you have an abscess or oozing. But there is none.