Laparoscopic sigmoidectomy with initial splenic flexure mobilization for diverticular disease

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摘要

This live video from a recent course at IRCAD demonstrates clearly the performance of a laparoscopic approach for sigmoid colectomy that commences with mobilisation of the splenic flexure.

關鍵字

sigmoid colectomy, laparoscopy, splenic flexure mobilization, diverticular disease

媒體類型

期間

17'00''

刊物

2008-01

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, Jan 2008;8(01).
URL: http://www.websurg.com/doi-vd01en2259.htm

Laparoscopic sigmoidectomy with initial splenic flexure mobilization for diverticular disease

1. Initial discussion 00'17''

We have a typical middle European patient here. She is a little fatter than other patients have been, as you heard the BMI is 35. This is a female patient so that really means that the fat is on the outside of the abdominal cavity and I hope it is the same in this case.

2. Trocar positions 00'40''

The suprapubic trocar is 5mm in an incision she had before because she had ovarian resection I think. We have a second trocar on this side, subumbilical, the umbilicus is here, I think you may see that. The incision is 3-4cm below that and 2cm lateral. This incision is a few centimetres above the umbilicus and not in the midline because from my point of view it is easier to introduce the trocar if you have two layers: the anterior and posterior sheet of the rectal muscle and therefore I prefer to do this incision here. So this is the beginning of the operation. We have a fourth trocar in the same line as that first one, lateral and close to the ribs. So we have a 5mm trocar 10cm lateral to the first one. The optical trocar is subumbilical and the fourth trocar is only for retraction, we will put in some instrument to retract the tissues. We usually do that kind of surgery with three people.

3. Operation commences 02'17''

Now we would like to put the small bowel on the other side. Here is Treitz ligament, a little further away than on the other view and the camera is somewhere else.

4. Identification of ligament of Treitz 02'31''

The first step is to try and find the inferior mesenteric vein. We can now see the vein.

5. Identification and dissection of inferior mesenteric vein 02'47''

This is the vein we were looking for. You can also do this with the scissors. My recommendation is to go behind the vein. You see the nerves immediately posterior to the inferior mesenteric vein. Does anyone know what they are? Good question, we almost cut them but we don’t know what they do. I think that they are the sympathetics part that come down from the coeliac ganglia, that behind the inferior mesenteric artery becomes hypogastric plexus. The danger at this point is to go too far deep, to rupture the vein. I will go here. Now if you cut it you can lift it and you get into the plane. This is our usual beginning, we try to get into the lesser sac. This is always a bit difficult. My opinion is that you should take down the peritoneum not more than that, lift up something and now you can tell that the pancreas is here.

6. Entry into the lesser sac over the pancreas 04'56''

We can see it very nicely. Now I continue lifting up the mesentery of the transverse colon. I think it’s important to point out to the audience here that this is a potentially dangerous area because if you do not see the inferior border of the pancreas it is possible to take your plane posterior to the pancreas and then hopefully before you really get into trouble you have a surprise. We see the pancreas very well and if you go there it is not a risk, you must realize that posteriorly. We just go down, now you can see that this fat belongs to the pancreas. We see the stomach very well. You see the layer, it will be here. My problem in the beginning was that the lateral approach for the left flexure in overweight patients, I did not feel comfortable, I always had the feeling that I would go inside the hilum, or the spleen or the pancreas or somewhere because often you don’t see where you are going. In this case, we saw right from the beginning what we were doing. The rule is all the small vessels should be on the back side, downwards. And then we retract the transverse colon downwards.

7. Dissection of supracolic omentum 07'00''

Never grasp the wall of the colon, that is also a rule. Then open the lesser sac by resecting or dissecting the omentum from the transverse colon. We see the swab on the other side so we are on the right side, so we go on here. For the audience, you can use the Ligasure, you can use the harmonic scalpel or you can use scissors for that matter, but the Ligasure is going to be more hemostatic, the benefit of the harmonic scalpel has been traditionally that it is quicker, with the new generator if you have it from Valleylab, that has pretty much equalised those two, which in my opinion has favored the use of the Ligasure. You must always be very careful, the colon is often closer than you expect. This is excellent because you have just shown us the difficulty to localize the colon at this point, you lift it with your fatty tissue and you just cut inside of it. We have some part of the omentum just here, the colon is going down just here, so I feel safe to go here. Probably this flexure is not as nasty as you were afraid. Now we have to control you see, there is the colon. Now a little more retraction and now we are on the Gerota’s or Toldt’s fascia here.

8. Mobilisation of splenic flexure 08'45''

I think we can see the tip of the spleen, the fantastic thing is very often you don’t see the spleen, you don’t need too if you are in the right plane. I will do some retraction with my left hand to come to the final corner here. You can see the left angle very well, it is coming down slowly here. If there is a little fat, the layers open more easily I think. Now we position the left flexure and the transverse colon, we haven’t looked for the pathology up to now. One thing is I would like to have the small bowel a little more in the upper abdomen. Therefore we increase the level of the Trendelenburg.

9. Identification and dissection of inferior mesenteric artery 10'15''

I think you have to be very flexible, the anatomy is very different from one person to the other, the tissues are very different. Usually if you follow the inferior mesenteric vein, you follow the posterior part of it, you continue and you will be on the anterior part of the anterior mesenteric artery arriving to the sigmoid pedicles. This is the only possibility we have now, you see the artery is there, as I said I try to spare the artery, you should be anterior to it. I expected a little bit that the artery would be coming from here, and the first branch is coming along the vein, usually it’s like that, it comes from here. I’ll just cut that vein now that we have completely mobilized. So now we start lateral I think.

10. Lateral mobilisation of left colon 11'35''

You changed for the scissors? The Ligasure is too much. My feeling is that since we have HD, the scissors get a new chance and for this kind of surgery, the single use scissors are also good.

11. Further medial dissection and vascular division 12'08''

When you free the sigmoid and hold it up and put it on tension, that is the best and easiest way to find the IMA, your sigmoidals as they go down to become your superior hemorrhoidal vessels and is a most important landmark in a left colectomy in my opinion. We always want to see the best layers we can find. That is a good point, you are sure there is no ureter, no nerves and now you can divide it because we saw the ureter just before. This is a nice demonstration, the patient has a previous operation, there are some adhesions, it is pretty fatty, he has inflammations from the diverticulitis of last year. It’s a challenging operation. You see the adhesions to the ureter are still there.

12. Distal colonic resection margin 13'29''

This gives me an answer as to where we are, 10 or 12cm here from the anus. We can put the circular stapler in and try to measure. Cut it this way, the idea is you only need one step because you have the best angle from above.

13. Delivery of specimen extracorporeally and preparation for re-anastomosis 15'23''

The idea is to be able to put that easier inside. This is a trick I learned at the last course here.

14. Intracorporeal re-anastomosis 15'53''

So now we need two graspers, we check the rotation and I think it is fine. Usually don’t put in a drainage.

15. Final steps before operation finish 17'00''

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