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Laparoscopic treatment of sigmoid diverticulitis for diverticular disease

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Laparoscopic treatment of sigmoid diverticulitis for diverticular disease

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手術影片

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30'00''

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2005-08

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WeBSurg.com, Aug 2005;5(08).
URL: http://www.websurg.com/doi-vd01en1822.htm

Laparoscopic treatment of sigmoid diverticulitis for diverticular disease

1. Trocar and patient placement 00'10''

This is a left colectomy for diverticular disease. The patient is in reverse Trendelenburg position, with a 30° tilt and 20° laterally. The first port is between xiphoid and umbilicus, easy skin incision, all the bowel is protected by the round ligament and falciform ligament so we can enter very easily and very safely. The second port is at the umbilical line and the third is in the lower right quadrant. We have a triangle and we start the procedure by looking for the abdominal cavity, as you can see we have a very severe diverticular disease, there is a mass in the sigmoid loop. We start the operation by inserting a 4 by 4 to clean and avoid any suction and we dissect the splenic flexure.

2. Splenic flexure dissection 01'38''

Here it is, this is the spleen, the phrenocolic ligament in front of us and we start from the gastrocolic ligament, in there, there is a special translucent area that we call the Boucher area, here it is already open. I lift up the ligament with my right hand and then enter the lesser sac very nicely looking for the gastroepiploic vessels, the Winslow arcade and we open the ligament very nicely. I lift up exposing the ligament, that is my lesser sac, the posterior aspect of the stomach and superior aspect of the transverse colon mesentery. We cut the ligament, I think that is a very nice way, see the colon. I have the stomach on my right side with the vessels. I twist the stomach under the liver, I have the lesser sac open and so I can change my hand position. See the splenic flexure, so I put the grasping forceps in my right hand and the Atlas in my left hand so I’m in the right position to transect the ligament safely. The ligament becomes longer because I pull down the colon. This is the colon, it is a very high splenic flexure, I have to go slowly. See the splenic flexure, now we have to divide the phrenocolic ligament just to mobilize. This is the transverse colon mesentery, the pancreatic tail.

3. Pancreatic tail 05'50''

We can see the pancreas really well in this way. We are going step by step, see the spleen. This is a 30 degree scope. Usually I do this with Ultracision, it is the first time I use Ligasure and you can see we can do it very safely without oozing or bleeding. Now we divide the ligament very nicely, here is the splenocolic ligament in front of me. By pulling down on the splenic flexure that way, how do you protect the spleen from potential tears and injuries? Usually I try to cut all the ligaments between spleen and colon. We are cutting all the folds and ligaments. We can see a band of Goravich going onto the capsule of the spleen and could very easily fall. Yes, we call it the killer ligament, we try to expose the ligament very gently, that’s the reason why I use just my hands just to expose to avoid any lesions even when the spleen is very close. Now I have all my transverse colon, when you have a part of it, such as a ligament like this, you have to open the peritoneal surface so the ligament becomes longer. My only concern is about this 5mm forceps because I usually use a 10mm one to be very atraumatic. I am now dividing the last part of the ligament. When you are teaching your residents, do you get them to use the 3 ports or do you allow them to use an extra port for the assistant? The residency program in Italy is very strange, but when I am teaching my surgeons, I stay next to them but try not to help them. I try to teach them the 3 port technique because I feel that it is safer and easier, even in this particular case. This new technology helps us to reduce the number of ports I think. I stay 1cm away from the pancreas so I can find the real plane, you see it is so easy to find even in this difficult case. I am sorry about this oozing. I am in the right plane, moving gently. This forceps can be used like a grasping forceps, this is the splenic artery. Now I try to cut this adhesion to show you the splenic artery. Here is the splenic artery. Second step, I push up the greater omentum and hold on the camera myself. The transverse colon has to be lifted up very close to the spleen exposing the mesentery. The small bowel has to push down on the right quadrant just to expose the inferior mesenteric vein. I try to immediately expose the Treitz ligament, here it is and we have to be very careful. Now the small bowel is falling down. The vein is here. I am behind the vein but I try to clean it nicely.

Now we lift up and we go in the right space, we try to identify the left colic vein; the pancreas, the transverse colon mesentery roof, and now we are ready to close the vein. Usually we go very high in cancer; in this case, we can stay a little further away. It seems that there is an accessory left colic artery, this is a good landmark to have the inferior edge of the pancreas, this is it. Now we can cut this vein immediately like this. Now I have my small bowel vein ligated very high. We now change the optic position and we put it in the middle port. The patient has to be in a very severe Trendelenburg position. I have to push all my small bowel on the right upper quadrant. This is the small bowel loop, the right iliac vessels, some adhesion between inflammatory tumor and small bowel, not very important, it is an easy case. Now I will show you how we expose the IMV. This is the mesentery of the sigmoid colon. This is the Gruber ligament; by lifting up this ligament, we can open a safe window very high in diverticular disease.

5. Sigmoid mobilization 19'00''

I try to avoid any scissors, I like it but when I open an instrument, I think that we have to be careful not to waste too much money. Why will you sacrifice the superior rectal vessels, why have you divided the IMV? Because in my experience, I don’t have a Ligasure so it was easier and safer for me to cut the artery. It is not only a problem of Ligasure because you also have Ultracision. It is not a strategy in my opinion, when I have a very severe diverticular disease, it is very difficult for me because in Italy very often the cases we have are very severe because gastroenterologists do medical treatment for many months so when the patient comes to the surgeon, they are difficult cases with a very thick mesentery. I did your operation many times but I find it more difficult. This is the most common mistake, here is the iliac artery, mesentery, this is the right plane, when you go too deep, it is very common to go to the iliac vessels. You are making a good point as long as you stay immediately inferior to the artery, you are going to spare the nerves, that is the plane to be in both in laparoscopic and open surgery. Very often when you have this adhesion between colon and abdominal wall, you cannot lift up correctly the Gruber ligament, this is the reason why you can very often go in the wrong plane. I cut this adhesion so as to lift up the loop, the sigmoid recess. This is a very nice line, this is the border line between Gerota’s fascia, Toldt’s fascia and Zuckerkandl’s fascia so when you find it, you are in the good plane. The sigmoid junction is now very well prepared, all the colon is mobilized. This is the mesentery, now I transect it. Now we go back, I’m sure I am far away from the nerve, I try to cut the mesenteric vessels. I am very far from the aorta. You see the left colic now, we are very far away from the aorta and from the nerves. See the junction, I thought the tenia disappeared completely, I can transect. We are ready to open the mini-laparotomy.

6. Specimen extraction 26'40''

We do a muscle-sparing incision. The specimen is coming out, now I understand why it was so dirty. The specimen is clearly inflammatory. Now I resect here. My indication is after two peritonites of duct, especially in very young people. We are very close to the transverse colon, and here is the IMA or the superior rectal artery, we are very far away from the origin as you can see.

7. Anastomosis 29'15''

Now we check the tenia, you see the transverse falling down. I have never done a trial comparing cleaning too much or not. We check that the Treitz jejunal loop is on the right side.