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Laparoscopic total colectomy with the new 5mm Ligasure Blunt Tip® device

The objective of this film is to demonstrate how to perform a total colectomy by means of the new Ligasure Atlas Blunt Tip® vessel-sealing device, which allows for a perfect hemostasis and can be used for dissection like the finger of one’s hand.

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Laparoscopic total colectomy with the new 5mm Ligasure Blunt Tip® device

作者群

J Leroy, J Marescaux

摘要

The objective of this film is to demonstrate how to perform a total colectomy by means of the new Ligasure Atlas Blunt Tip® vessel-sealing device, which allows for a perfect hemostasis and can be used for dissection like the finger of one’s hand.

關鍵字

Total colectomy, laparoscopy, Ligasure Blunt Tip®

媒體類型

手術影片

期間

14'26''

刊物

2010-12

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Dec 2010;10(12).
URL: http://www.websurg.com/doi-vd01en3013.htm

Laparoscopic total colectomy with the new 5mm Ligasure Blunt Tip® device

1. Introduction 00'22''

The objective of this film is to demonstrate how to perform a total colectomy by means of the new Ligasure Atlas Blunt Tip® vessel-sealing device, which allows for a perfect hemostasis and can be used for dissection like the finger of one’s hand. The patient is placed in a Loyd-Davis position. The surgeon stands between the patient’s legs. The procedure is started at the level of the right colon.

2. Identification and division of ileocolic vessels 00'55''

The identification of the ileocolic vessels can be seen here. They will be divided using the new generation 5mm Ligasure Blunt Tip®, close to the superior mesenteric axis. The dissection of the vascular structures can be seen here. They will be divided after sealing.

3. Dissection of pancreas and duodenum 01'29''

The pancreas and the duodenum are detached by using traction and counter-traction maneuvers. This allows to reach up to the first duodenum above the pancreatic head.

4. Mesocolon dissection 01'52''

Dissection is continued at the level of the transverse mesocolon’s root, which can be perfectly seen here. The right gastric and omental vessels are divided.

5. Division of middle colic vessels 02'09''

The middle colic vessels are divided at the level of the root. The best way to find them is to reach just above the duodenojejunal flexure and to open the lesser sac, as can be seen here. The procedure is now carried out on the posterior aspect of the stomach. The first duodenum can be seen here. An adipose cellular vascular package can be found between the lesser sac and the first duodenum. It contains the middle colic vessels, which will be divided by means of the new 5 mm Ligasure Blunt Tip® by progressing towards the posterior aspect of the stomach. The posterior aspect of the gastric antrum can be very well seen here to the right. The trunk of the middle colic artery can also be seen here. Once sealed, it will be divided by means of the 5mm Ligasure® device. Dissection is pursued more deeply in contact to the posterior aspect of the stomach. Once this vascular axis has been divided, dissection is pursued on the external border of the stomach in order to detach the greater omentum from the stomach. The procedure is continued slightly to the right in order to detach the omentum from the duodenum.

6. Dissection of ascending mesocolon 04'00''

Mobilization of the ascending mesocolon is continued using a medial approach. The ascending mesocolon is freed on its posterior aspect from Gerota’s fascia, which covers the kidney and the renal fossa. The freeing of the posterior aspect of the ascending mesocolon can be seen here, as well as the division of the superior attachments just posterior to the hepatic flexure. The division of the mesocolon and its detachment on the duodenum is continued from the superior aspect of the first duodenum until the phrenicocolic region, as can be seen here. Once the posterior attachments have been freed, the decision is made to free the ascending colon from its lateral attachments. To do so, the caecum is retracted towards the left hypochondrium. Medial traction is exerted on the ileocaecum, while the surgeon divides the lateral attachments from caudad to cephalad by means of the 5mm Ligasure Blunt Tip®.

7. Division of terminal ileum 06'03''

Once the right colon has been completely freed, the mesenteric bridge of the ileum can be divided close to the terminal ileum before dividing the ileum. This division is performed using the Endo-GIA linear stapler, white cartridge, allowing for a better hemostasis.

8. Left transverse colon and left colon medial dissection 06'33''

The left transverse colon and the left colon still need to be freed. A new exposure is obtained. To do so, the surgeon stands to the right of the patient. This technique allows to approach the sigmoid mesocolon medially by dividing the sigmoid vessels, respecting the inferior mesenteric vessels and the superior rectal vessels. The division of the sigmoid vessels allows to open the space posterior to the mesocolon. Dissection must be carried out anterior to Gerota’s fascia in order to preserve the retroperitoneal structures. The descending mesocolon is divided progressively, as can be seen here. This dissection will be carried on until the root of the transverse mesocolon anterior to the pancreas and close to the inferior border. The two division areas are joined, remaining outside of the inferior mesenteric vessels and dividing the mesos by means of the 5mm Ligasure® device, which allows for an appropriate sealing of the vessels and for a reduced risk of hemorrhage. The quality of this sealing is excellent. When approaching the pancreas, attention must be paid not to cause any pancreatic wound. To do so, the root of the transverse mesocolon must be detached.

9. Lateral sigmoid dissection 08'58''

Once the medial approach has been completed, the lateral attachments and the sigmoid adhesions are freed. This division may be carried out by means of the 5mm Ligasure® device. However, the use of monopolar scissors is preferred here, as these allow for a quicker freeing. To do so, one must absolutely remain in the plane of adhesions, that is, inside the parietal peritoneum and outside the sigmoid mesocolon. Thanks to the monopolar scissors —here roticulator Mini-Shears—, this maneuver can be performed quickly. This will be an easy maneuver, as the medial approach allowed for a complete freeing of the posterior attachments.

10. Greater omentum dissection 09'57''

The left transverse colon remains to be freed from its lateral attachments at the level of the stomach. To do so, the greater omentum is divided. This division had been initiated using an inferior right transmesocolic approach. It is then continued to the left by means of the 5mm Ligasure Atlas®, long shaft (37cm). This allows for a relatively easy access by introducing the instrument in the right iliac fossa. The division of the greater omentum is pursued until laterally in order to remove the greater omentum along with the splenic flexure. To do so, division is carried out using a superior medial approach, and also a lateral approach. The division of the attachments must be very accurate. It is rendered easier thanks to the Ligasure Atlas® device.

11. Upper rectum division 11'20''

Once the rectosigmoid junction has been dissected, the upper rectum is divided by means of a 60mm Endo-GIA linear stapler, blue cartridge. The division is completed by one stapler’s firing.

12. Colon and small bowel exteriorization 11'39''

The colon is then exteriorized though a suprapubic incision, which is protected by a plastic drape. The exteriorization will be continued until the caecum. The ileum had been previously divided by applying a first row of staples. The whole exteriorized specimen can be seen here. It is placed on a plastic drape.

13. Anvil introduction 12'25''

The procedure is carried on by exteriorizing the terminal small bowel. The anvil of a circular stapler will be introduced though a mini-incision in the terminal small bowel. It will be pushed proximally in order to allow for a side-to-end anastomosis. The introduction site is resected by applying an Endo-GIA linear stapler, white cartridge. A purse-string is placed around the anvil’s shaft. The whole system is then re-introduced in the abdominal cavity.

14. Ileorectal anastomosis 13'15''

The anvil is then pushed towards the pelvis. The absence of bowel’s malrotation is controlled. The rectum stump is transfixed by means of a 28mm PCEEA DST circular stapler. The anvil and the circular stapler’s shaft are connected. Staples are applied. The donuts are controlled. An air test is performed. The rectum is insufflated so that the presence of any air leakage is ruled out at the level of the anastomosis.

15. Mesenteric defect closure 14'09''

The mesenteric defect is then closed in order to avoid any potential internal hernia that could occur in the future. No drainage is placed. The anastomosis is controlled for the last time. The peritoneum is cleaned before closing the incisions.