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Laparoscopic sigmoidectomy for sigmoid diverticulitis with transanal specimen extraction

Laparoscopic colectomy is performed widely all around the world, and some institutions perform more laparoscopic operations than conventional open operations. Skin incision is required to remove the resected colon. This video shows a laparoscopic sigmoidectomy, which involves transanal specimen extraction.

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Laparoscopic sigmoidectomy for sigmoid diverticulitis with transanal specimen extraction

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J Leroy, J Marescaux

摘要

Laparoscopic colectomy is performed widely all around the world, and some institutions perform more laparoscopic operations than conventional open operations. Skin incision is required to remove the resected colon. This video shows a laparoscopic sigmoidectomy, which involves transanal specimen extraction.

關鍵字

Laparoscopic sigmoidectomy, sigmoid diverticulitis, transanal specimen extraction

媒體類型

手術影片

期間

19'03''

刊物

2012-01

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Jan 2012;12(01).
URL: http://www.websurg.com/doi-vd01en3554.htm

Laparoscopic sigmoidectomy for sigmoid diverticulitis with transanal specimen extraction

1. Introduction 00'18''

I will show you a sigmoidectomy in a female patient, not too obese, as her BMI is around 22. She had several attacks and it was decided to do a sigmoidectomy because the enema and the endoscopy found some diverticulum on the sigmoid. I will use a three-trocar technique, and we have introduced a trocar just at the level of the umbilicus, it’s a 12mm trocar, to have a better view for you, but we can put a 5mm trocar, we have a 5mm trocar in the right flank, and a 12mm trocar in the right iliac fossa. We can do the procedure with three 5mm trocars.

2. Patient position 01'09''

The patient is in a Lloyd-Davis position, two arms alongside the body. One assistant, the first one lateral to the right shoulder holding the camera, and I sit on the right side of the patient, and the second assistant is between the patient’s legs and the scrub nurse on my right side, lateral to the right leg. First step was to put the patient in a Trendelenburg position, we can use a small right lateral tilt; in this case, we don’t; we only put a small cushion on the left side.

3. Shelving the omentum 01'48''

We have exposed pushing the omentum after dividing some adhesion on the right iliac fossa probably due to an appendectomy and the omentum is shelved in the left hyponchondrium just under the rib. You see this is a small necrosis of omental loop, perhaps this explains the pain. I’m removing this using as you see the 5mm Ligasure® Blunt Tip® device, a very nice tool to do this approach easily. Now it’s not necessary to do a suspension of the uterus because it is well fixed, and we have the sigmoid loop and the part with the diverticulum and some dense tissue, and probably this is explained by the inflammatory attacks of the patient. What is the strategy?

4. Mesosigmoid division 02'50''

We will keep the vascularization of the rectum, this is the promontory, iliac vessels, and I’m doing a division of the meso, not far from the sigmoid, using the Ligasure® device and dividing first the peritoneum to open the meso and to divide only the sigmoid vessels as we will see soon. I’ve decided to do the resection just above this diverticulum, I will divide probably at this level. I’m using a medial approach, and I’m continuing to do this division not too deep, step by step, going from up to down, and dividing the vessels as you see. If I have a small doubt, it is better to free the lateral attachment, as you see now, this is a rigid segment. The danger, particularly in women, is to injure the genital vessels at this level, particularly when there is adhesion, and more medial to injure the ureter. This is working with two hands, only working, dissecting, having a good traction, counter-traction, opening the anatomical embryological plane, I’m freeing the lateral attachment of the descending colon, prepare the tension-free anastomosis; as you see, in this kind of patient we can do even if we have diverticulum very high on the descending colon, if there are no inflammatory diverticula, we will not remove all the colon, we will remove only the colorectal junction that is the main purpose we have to do, to have a low risk of recurrence.

5. Lateral dissection 05'22''

See I’m reaching the lateral attachment of the splenic flexure; the danger with this lateral approach is to be too posterior and it is the case, because I will be, if I am too posterior behind the kidney, with the danger to do too posterior a dissection and to injure the retroperitoneal structures. It will not be necessary to do too large a mobilization. We come back, we will see how to free. You remember I have begun the division at this level. I will continue to dissect the colon more distally. What is fantastic as you see, it is the Ligasure® device that facilitates the standardization of these procedures, it is dividing without traction after sealing, and we seal slowly all the vessels, we limit the traction on the meso to avoid breaking the meso more; we see the sigmoid vessels beating. I’m continuing the division, step by step, not too far, keeping the superior rectal vessels, because it is a benign disease; superior rectal vessels represent 80 percent of the vascularization of the rectum, and we have to keep the rectum. It is not necessary to divide the vessels at their origin in benign diseases, first advantage: faster, since we have the Ligasure®. Second advantage: the dissection is done further away from the plexus trunk, so less risk of injury of the plexus, or no risk, same for the ureter. Probably the last one that is called the sigmoida ima, last sigmoid branch, after you have the rectal branch, but over 5cm normally we will have no branch between the sigmoida ima and the first rectal branch. I can do an elective dissection of all the vessels, but I think it is not the goal.

6. Dissection of colorectal junction 07'50''

I’m now going closer and closer to the rectal and sigmoid wall, as I said, I have to remove the colorectal junction, I’m doing the division of the meso, closer and closer, until I recognize the colorectal junction, this is normally larger, but it’s not enough. Advantage of the device: even if I am in contact with the bowel, it’s not warming, so less risk of thermal injury, so this is the anterior taenia, you have it at this level, and the end is approximately at this level, just above the Douglas’ pouch.

7. Identification of ureter 08'45''

I want to see proximal, you see, we will see the ureter. These are the genital vessels. The ureter is medial to the genital vessels, between the aorta and the genital vessels. I want to show you, you will see soon. I think it is at this level. The ureter is moving when the camera is coming. I think it’s enough to have tension-free. I’m calculating now where I’ll do the anastomosis without problems.

8. Distal sigmoid ligation and rectal washing 09'34''

What I have to do now is to ligate the distal sigmoid. I’m putting a ligation to do a loop to do the exclusion of the colon and we’re ligating, doing a ligation like this, washing the distal rectum. We’ll do a transanal extraction of the specimen.

9. Colonic wall opening 10'10''

Now that we’ve washed, we’ll open this using the Ligasure® device and dividing. We’ll verify the aspiration. We’ll fix. We continue the division so we close better to have a longer suture, pushing this inside. It is what I want and now introduce your forceps. First I want to open.

10. Colonic exteriorization 11'28''

You can pull this and we’ll pull the segment of bowel. I’ve now pulled the colon through the anus.

11. Anvil introduction 11'45''

Now we’ll introduce the anvil so I’m preparing the anvil of the circular stapler, putting a big decimal 2 Polysorb suture or a big suture—it’s not Polysorb that is important but a big suture. I have a tube when I’m introducing the anvil as you see, and I’m grasping this inside. I’m opening the colon; we have a lot of diverticula in this segment, and the rigid part under. I introduce the anvil inside the colon and push the anvil. I have a small resistance at the level of the sphincter so I’m pushing globally and I can pull and introduce the anvil in the proximal colon as you see by this inside view. And I’m removing the system so we clean locally. So as you see, we have a small diverticulum at this level. So what we’ll do, you remember, I decide to do the division just above this diverticulum. It’s what I’ll do. I’m dividing the colon at this level using the stapler. You see the suture is not completely cut. How did the blade not cut the suture? It is due to the fact that when the suture is trapped by the staples, the knife will cut the sutures. If the suture is not trapped by the staples, you will push the sutures because it’s too hard for the knife to cut; if there’s no suture, maintain on up and down.

12. Anvil exteriorization 14'40''

So what I’ll do now is to exteriorize the anvil. I can put a swab to protect inside with Betadine on the antimesenteric side close to the corner of the stapling line, I’ll do a small hole and pull the anvil using what I’ve called the fishing technique. So it is very close here. I’m doing a hole to perforate like this. We pull. We do a partial exteriorization of the anvil pulling this slowly now. We will try to secure the hole, we have exteriorized the anvil’s shaft. I’m perhaps removing this fat. I’m removing this.

13. Rectal stump closure 16'19''

Now we have to close the rectal stump and I’m putting this stapler using the sutures as forceps. Watch. I’m stapling and this stapler is not pushing the tissue; that’s why we use less cartridge to do the anastomosis, and we can remove. I’m pushing this.

14. Anastomosis 17'21''

You can introduce the circular stapler now slowly. You slide on the back. You push. You do the perforation, open. So we’ll remove this corner even if we have a small doubt, it’ll not be risky. This is now what we can do, pushing this and you close. It’s green. So you remove the security. You fire. Remove. Stop. You can move back now. Yes, we verify the doughnuts: so on the rectal side, thick and complete, and the same on the side of the colon.