Laparoscopic small bowel resection for metastasis of melanoma

This is the case of a patient who has had digestive bleeds. Lesions of the distal small bowel segments were reported about 30cm from the ileocaecal valve. The bowel segment has been identified and a complete exploration of the small bowel has been achieved laparoscopically. The objective of this video is to show a totally intra-abdominal laparoscopic segmental resection of the small bowel.

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Laparoscopic small bowel resection for metastasis of melanoma

Authors

J Leroy, J Marescaux

Abstract

This is the case of a patient who has had digestive bleeds. Lesions of the distal small bowel segments were reported about 30cm from the ileocaecal valve. The bowel segment has been identified and a complete exploration of the small bowel has been achieved laparoscopically. The objective of this video is to show a totally intra-abdominal laparoscopic segmental resection of the small bowel.

Mots-clés

Laparoscopic small bowel resection for metastasis of melanoma

Type de vidéo

Vidéo chirurgicale

Durée

06'58''

Publication

2009-11

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Nov 2009;9(11).
URL: http://www.websurg.com/doi-vd01en2718.htm

Laparoscopic small bowel resection for metastasis of melanoma

1. Introduction 00'16''

The objective of this film is to show a totally intra-abdominal laparoscopic segmental resection of the small bowel. In this patient who has had digestive bleedings, lesions of the distal small bowel segments were reported about 30cm from the ileocaecal valve. The bowel segment has been identified and a complete exploration of the small bowel has been achieved laparoscopically.

2. Isolation of the small bowel 00'54''

Once the bowel segment has been isolated, the two segments are attached using a non-absorbable stitch, which will serve as a landmark. With the help of the Ligasure Advance® device (using the monopolar electrode and the Valleylab® current), the different layers of the small bowel wall are incised distally. Once the digestive lumen has been opened, the absence of bleeding is ruled out.

3. Side-to-side anastomosis 02'15''

Then through the 2 openings kept proximally thanks to the stitch, an Endo-GIA linear stapler, white cartridge is introduced. We use a white cartridge since the hemostasis on the small bowel will be improved without any risk of ischemia. Then a side-to-side anastomosis is performed on the bowel segment that will not be resected.

4. Intra-abdominal closure of the anastomosis 02'47''

In order to avoid a manual suture, the division is completed by finalizing the side-to-side anastomosis to be achieved on the small bowel segment that is left in the abdominal cavity. The mesentery is then divided using the linear stapler with vascular cartridges in order to obtain a perfect hemostasis. Simultaneously this mesenteric division helps to achieve the closure of the mesenteric defect. This division must be complete and here the Ligasure device allows to divide the small residual bridge.

5. Running suture 03'49''

In order to complete the hemostasis, a covering suture is carried out at the level of the small bowel stapled area using a monofilament absorbable Maxon 3/0 material. A running suture is therefore achieved. The advantage of this running suture is to strengthen the stapled area and to avoid the formation of potential small bowel or omental adhesions at the level of the blood oozing. The running suture is performed under laparoscopic control. The monofilament material has the advantage of using several stitches before placing traction without any major risk of cutting the tissues. Indeed, the traction on a monofilament suture material allows for an easy sliding as can be seen on these pictures. The covering will be complete to achieve a sero-serosal suture that will bury the stapled area. The anastomotic area will be completed. The anastomosis will almost be end-to-end.

6. Specimen extraction 05'57''

Extraction of the specimen will be performed though a mini-incision. This is achieved by enlarging one of the port introduction sites protected by a plastic drape. This extraction may also be performed through a plastic bag.

7. Submucosal nodules of melanoma 06'09''

The specimen is examined and the different submucosal nodules of a melanoma can be seen. This was accountable for the hemorrhage, as confirmed later on. Port introduction sites are re-approximated carefully plane after plane for incisions larger than 5mm.