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Laparoscopic treatment for sigmoid diverticulitis

This video demonstrates a routine sigmoid colectomy for diverticular disease. The surgeon uses ultrasonic scissors to carry out a medial mobilization of mesenteric vessels and an endo-GIA stapler to divide the vessels. The pelvic nerves are spared and a local sigmoid resection is carried out and an EEA end-to-end anastomosis is made. The specimen is removed through a small transverse midline incision.

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Laparoscopic   treatment   for   sigmoid   diverticulitis

作者群
T Rockall
摘要
This video demonstrates a routine sigmoid colectomy for diverticular disease. The surgeon uses ultrasonic scissors to carry out a medial mobilization of mesenteric vessels and an endo-GIA stapler to divide the vessels. The pelvic nerves are spared and a local sigmoid resection is carried out and an EEA end-to-end anastomosis is made. The specimen is removed through a small transverse midline incision.
分類
routine cases
關鍵字
diverticular disease,sigmoid,left colectomy,laparoscopic approach
媒體類型
期間
21'00''
刊物
2005-11
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Nov 2005;5(11).
URL: http://www.websurg.com/doi-vd01en1878.htm

Laparoscopic   treatment   for   sigmoid   diverticulitis

2. Medial approach 00'56''
You can see the right ureter crossing the right iliac. Here’s a segment of diverticular disease and we’re going to do a medial to lateral dissection underneath. The sacral promontory is here. I don’t think you have seen this instrument used so far today. But you can see the steam that it generates; actually it forms the plane for you just to some extent. You can see where the gas has gone there. I’m making quite a broad incision to start with. What I want to happen is for the aorta basically to be my horizontal line. So we’re twisting the camera slightly to the left. So the aorta now is running along the bottom of my screen and as we start to operate down in the pelvis we then unrotate the camera; the lower edge of the view is the sacrum. That’s how we operate. The assistant is down between the legs. I’m going to lift, insinuate my instrument underneath the IMA and lift up. It’s worth doing very carefully to keep it as bloodless as possible. We’re trying to get in to that plane, in front of the nerves, in front of the ureter, and in front of the gonadal vessels. We can just see a glimpse of the left common iliac vein in the distance. You have to be careful here not to get in the wrong plane but tension is crucial. I’m just lifting up with my left hand. I’ve just got the inferior mesenterics in my left hand pushing up and I think we can probably see the ureter, well haven’t got the ureter yet. I haven’t taken the sigmoid out of the pelvis yet, it’s probably stuck down there at the present time. I’m just going to broaden this incision there, a little bit of pushing down. We’re all set. But what you don’t want to do is end up underneath the gonadals either. This is the IMA here. I’m pushing everything down. I’m travelling northwards towards the IMA and we’re developing this plane going from medial to lateral under here. All I want to see here if I look underneath is the ureter there. You’ve got the nerves and in fact, that little bit of fascia there it should be intact really over the surface of the ureter. So I’ve made a mistake there. Nevertheless it’s out of the way here. This is the vascular pedicle which at this level is going to include the vein just on the other side and what my plan of action is actually to take the artery and the vein together with a stapler. I’m just going to take the peritoneum over the top. There’s the vein. And obviously if you’re doing a cancer operation and you wish to take the vein separately higher up then you’d be taking the artery at its origin, which is separate from the vein and you can chase the vein up as high as you wish. The reason for taking the vein higher up usually is a knock-on from rectal cancer but it’s done for mobility not for oncological purposes. I agree absolutely. This lady’s left colon actually looks remarkably healthy, so I’m hoping just to do truly a sigmoid colectomy. We shall see. Here we are. We got this medial to lateral dissection underneath, it should become much easier the moment I’ve stapled these vessels, but the nerves we’ve seen overlying the bifurcation of the aorta. Here’s the ureter, the gonadals are going to be a little bit further lateral and I’m not going to be fussed about those at the moment. I’m stapling this now. So we’re right into the jaw there. I’m closing. So now I’m lifting up with my left hand, all this is done just by me, there’s no real assistance going on at all at the moment. And this is a nice plane of dissection. You can see the ureter moving away. The trick here I think is really to use your left hand, I think that most novices in laparoscopic surgery fail to use their left or their non-dominant hand to lift up the tissues, and that’s we’re doing here. And you can see just by pushing gently down the correct plane appears. It’s quite subtle, it’s about lying there. And if I were to push underneath it, I’d end up underneath the gonadal vessels. I’m now heading off directly towards the lateral abdominal wall at this stage. And we’ve probably done enough there. We’ll get the rest of that from the other side. I’m now picking up the pedicle with my left hand. This is a view you’ve seen several times already I think. There’s your areolar plane found to stick on the back of the mesorectum there because the sigmoid is still all down in the pelvis at the present time. A little bit of blunt dissection, a little bit of sharp. The ureter is going to be coming here underneath so you’ve to be a little bit careful. Again lifting up and I’m just pushing the fascia down like that.
3. Lateral mobilization 09'30''
I’m now going to pop over the top here and release it laterally, and once you’ve done that, the whole sigmoid comes out of the pelvis and we are, with any luck, almost done. We make a little hole here with the tip and you can see the gas going in again. Insinuate the active blade underneath. There was some discussion about the use of Ultracision earlier on and whether it’s any better. But I’d fail to see that if you’ve done enough medial to lateral dissection, the moment you’ve opened the peritoneum you’ll see this bruised effect because you’re entering the same space than you’ve operated on already. But I fail to see that this should cause any more damage than the diathermy. This retraction to the right side of the patient is being done by me. In fact this one does not seem to work quite so well and we’re using this method. So I go back to using the jaws of the instrument. Now take your instrument out of the way. If you’re getting lost when you’re going through there laterally the very good thing is to go and check where you are from underneath. That is a nice intact fascial layer apart from that little hole which I mentioned before. There’s the stapled pedicle from the other side. So if you do get lost at this stage, we’re not because we’ve done it completely now. What you can do is move it over to that side and lift up again and you can find yourself where you are from this side and you should be able to get completely to the other side of your dissection just there. Obviously the best way to mobilize the splenic flexure is how I’ve just demonstrated to you in the last case. But if you’re doing this dissection and you find that you need to mobilize the splenic flexure so secondarily if you like because you don’t have enough space, you can head up medial to lateral from here towards the spleen. I’m just pushing gently down all the tissues away. It should be a proper plane, shouldn’t be anything in here. Let’s go down now. I’m now going to use my assistant really to lift the sigmoid out of the pelvis. Here’s this sort of phlegmon of diverticular disease, which is clearly giving us trouble. So rather than lift up the bowel I’m just putting it on appendix epiploicky and then just very gently lift it out of the pelvis so that I can then go down to the rectum.
4. Rectal dissection and division 13'30''
This is the same view that you would opt to have in open surgery I think. Absolutely. Some of us would say that if you were sure of diverticular disease, which you probably are at this time, there’s something to be said maybe for leaving the superior rectal artery. Yes I agree. And I know several people who do that. I have to say it prolongs the operation a bit. I think the blood supply as we discussed earlier to the rectum is always excellent, isn’t it? It is. Whether you divide it or not. I’m probably going to end up going across the rectum just sort of distal to this lump of fat here. Can you come in with the camera since we’ve not a good view at the moment? We probably are going to have to come across the rectum down, which is down here somewhere. Good camera work here! We’re going to start taking this mesorectum here. I know you’d like me to go further down but I’m not going to. I’m in just down into the plane rather than across the rectum. That’s just a temptation, and a sort of habit. We know what to do, just develop a bit more. That’s the vessel I have in my grasper. We’re trying to get in through on this. There’s the rectal wall coming up now. If you leave a little bit of fat, I don’t think it matters but if you don’t do the vessels properly, it will bleed when you divide it with the stapler. There’s lots of different ways to doing the mesorectum, I’ve seen people actually staple the mesorectum, make a tunnel between the mesorectum and the rectum, and then staple the two separately, I suppose it’s not something I do. I’ve done it once, but I think that Ultracision, Ultrasonics, Ligasure and everything have made all that sort of activity obsolete. There’s a little bit more to do here so that when I come across there’s no peritoneum left. If you don’t do this bit when you staple it, you sort of get a little bit lost. So I’ve got to do this a little bit here. That’s all the rectum there, which communicates on the other side. We’re now going to go back up there and do it all from the right side. We managed to do that in one firing, which is just about most unusual thing you ever see. It’s very unusual to do it in less than two and actually I think we’re nearly finished because that’s very nice with the left colon, it’s going to come down to that without a problem. It’s amazing how far it disappears down but I’ll show you the main landmarks: sacral promontory there, the left ureter there, the nerves are all intact underneath this, you can tell it’s an intact fascial plane just by doing that sort of thing. Right ureter there, so it’s disappeared quite a long way down but no doubt it will stretch out once it has a gun inside as well. Now I’m going to grasp the end of the bowel so I know where it is, and put a lock on that like this.