WebSurg中文版尚未完成，翻譯工作進行中！

Lessons learned after left ureteral injury during laparoscopic sigmoidectomy for acute sigmoiditis

The objective of this film is to demonstrate a laparoscopic sigmoidectomy for acute sigmoid diverticulitis in a male patient, and more specifically to highlight all the errors that led to a ureteral injury, which was identified and managed immediately intraoperatively.

建立帳號

瀏覽全世界

繁體中文 ▼

Google translate

總結
章節
您的意見
詢問專家群

欲觀看此影片請先登入！

於WEBSURG-HD購買此高畫質影片

Lessons learned after left ureteral injury during laparoscopic sigmoidectomy for acute sigmoiditis

作者群

J Leroy, C Callari, J Marescaux

摘要

The objective of this film is to demonstrate a laparoscopic sigmoidectomy for acute sigmoid diverticulitis in a male patient, and more specifically to highlight all the errors that led to a ureteral injury, which was identified and managed immediately intraoperatively.

關鍵字

left ureteral injury, laparoscopic sigmoidectomy, acute sigmoiditis

媒體類型

手術影片

期間

11'38''

刊物

2012-01

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Jan 2012;12(01).
URL: http://www.websurg.com/doi-vd01en3564.htm

Lessons learned after left ureteral injury during laparoscopic sigmoidectomy for acute sigmoiditis

1. Introduction 00'19''

The objective of this film is to demonstrate a laparoscopic sigmoidectomy for acute sigmoid diverticulitis in a male patient, and more specifically to highlight all the errors that led to a ureteral injury, which was identified and managed immediately intraoperatively. Here one can see the operator who is a beginner with some experience in laparoscopy though.

2. Start of dissection 00'50''

The intervention is started in contact with the inflammatory tumoral area in the sigmoid mesocolon. The procedure is carried on laterally by means of the 10mm Ligasure™ Atlas™ device and of monopolar scissors in a very inflammatory edematous tissue where electric currents are not very active.

3. Lateral approach 01'20''

In order to enhance the efficacy, the dissection is continued using a lateral approach – the operator may think that it is the best way of proceeding here, and progressively the parietocolic gutter is opened. Progress is made towards the pelvis in order to detach the sigmoid loop and one can see that dissection is carried out in contact with the muscle plane in an in-depth fashion, and also in contact with the retroperitoneal structures; here more particularly, the psoas muscle is clearly visible.

4. Pelvic dissection 02'13''

Dissection is then carried on in a lateral pelvic fashion by keeping distal to the sigmoid colon in a much less inflammatory, however risky area. It is likely that the ureteral injury originating from the complete vessel-sealing and division by means of the Ligasure™ Atlas™ device as one will see later on, occurred at this time of the dissection at this level or still lower down. It must be stressed that this type of maneuver should be avoided. Decision is made to pursue the dissection towards the pelvis by dividing the sigmoid mesocolon and the mesorectum medially on the posterior aspect of the rectosigmoid junction. Dissection is carried on using the Ligasure™ Atlas™ device and by keeping distal to the colonic and rectal wall. Division is made in adequate conditions in a sigmoid colon that is still attached at its upper part and that has not been completely mobilized.

5. Colonic division 03'43''

The rectosigmoid junction is skeletonized by means of the Ligasure™ Atlas™ device and one can see a healthy colon that will be divided using a mechanical stapling technique—a 60mm long Endo-GIA™ linear stapler, blue cartridge is used. Dissection is continued by drawing the sigmoid colon cranially. The ureter has not bee identified yet. Dissection has been carried out using a posterior and lateral approach. At this moment, the operator refers to his mentor who decides to perform a medial and more proximal approach and more specifically to identify the ureter in a healthy, non-inflammatory area, and that is done fairly rapidly as one can see here. At the beginning, dissection is pursued medially by means of the Ligasure™ Atlas™ device, and because of adhesions and attraction of the ureter onto the inflammatory area where most likely a peri-sigmoid abscess had progressed over the last few weeks, it is decided to carry on the procedure with monopolar scissors.

6. Identification of ureteral lesion 05'19''

Progressively, the ureter is detached from the inflammatory area as one can see here. The ureter is progressively freed and one can see that it has been divided accidentally by the Ligasure™ Atlas™ device; however, the tip of the ureter has been perfectly sealed. Here one can see the place where the ureter has been divided at the level of the inflammatory area. The intervention is carried on by mobilizing the sigmoid colon and by dividing the posterior lateral attachments as soon as the ureter and genital vessels have been identified. And here at this level, one can see that most probably these vessels have also been divided. The ureter has still to be dealt with, namely the distal end of the ureter, and its identification. The distal end should probably be divided using a vessel-sealing device. One can quickly realize that this end is part of the inflammatory tissue, which was divided by means of the Ligasure™ Atlas™ device, as pointed out at the beginning of the procedure, during the lateral approach, without any prior identification through a medial approach.

7. Laparoscopic repair of ureter 07'10''

Now what about the repair. Our urologist colleagues are contacted. They propose a laparoscopic repair, after having re-cut the two extremities that have been sealed, and by carrying out an enlargement plasty on both extremities of the ureter in order to limit the risk of stenosis. Therefore, a longitudinal incision of about 1cm is performed on both extremities. A suture is then made using a 3/0 monocryl suture, which is colored for easy identification, by taking the proximal V-shaped angle and moving it into the internal part of the distal V, and so on, to carry on the procedure and prevent any potential stenosis. Two stitches will be made prior to the introduction of a double-J catheter. Here one can see the first stitch, which has been made, the second stitch which is made under laparoscopic control as one can see, by carrying out an enlargement plasty, which will allow for a suture with no risk of stenosis. Once the first stitches have been made, the introduction of the double-J catheter has to be dealt with. The guide wire which has helped to rigidify, allows for a cranial introduction, and the distal end is then introduced caudally, which takes a fair bit longer than the videos might suggest, as they have been shortened. The procedure will be finalized by performing square knots and stitches that will allow for total airtightness of the double-J catheter.

8. Conclusion of colonic procedure 10'21''

The procedure now has to be finalized from a digestive standpoint. The procedure will be carried out using a conventional technique, which is the extraction of the bowel segment after mobilization of the left colon and of the splenic flexure; the anvil is introduced into the proximal colon, in a compliant, healthy, and non-inflammatory area, and a colorectal end-to-end anastomosis is then performed, using a 60mm long Endo-GIA™ linear stapler with a blue cartridge. The only difference here is that a pelvic drainage will be added in contact with the urinary suture and the digestive suture. A stomy is unnecessary in this case.