SILS total colectomy with end ileostomy

Single incision laparoscopic surgery (SILS) is emerging as a method to improve morbidity and cosmetic benefits of laparoscopic surgery. This is the case of a 27-year-old woman presenting with ulcerative colitis. Because of her young age and slim body habitus, a total colectomy using a single port laparoscopic technique is performed with the SILS system manufactured by Covidien.

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SILS total colectomy with end ileostomy

Authors

R Cahill, I Lindsey, O Jones, R Guy, N Mortensen, C Cunningham

Abstract

Single incision laparoscopic surgery (SILS) is emerging as a method to improve morbidity and cosmetic benefits of laparoscopic surgery. This is the case of a 27-year-old woman presenting with ulcerative colitis. Because of her young age and slim body habitus, a total colectomy using a single port laparoscopic technique is performed with the SILS system manufactured by Covidien.

Classification

single port, contribution

Keywords

SILS total colectomy, end ileostomy

Media type

Surgical video

Duration

10'24''

Publication

2010-02

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E-publication

WeBSurg.com, Feb 2010;10(02).
URL: http://www.websurg.com/doi-vd01en2867.htm

SILS total colectomy with end ileostomy

1. Clinical case presentation 00'08''

A 27-year-old woman known to have ulcerative colitis presented urgently to our department with diffuse abdominal pain. Despite attempts at medical therapy, her condition failed to improve and so she required operative intervention on a semi-urgent basis. Plain radiology revealed no evidence of perforation or toxic megacolon. Because of her young age and slim body habitus, we elected to perform her total colectomy by a single port laparoscopic technique intending to subsequently offer her a restorative ileoanal pouch. To do this, we placed the port at the site marked preoperatively for her end ileostomy so that this would be her only site of abdominal access. Operatively, we planned to perform early rectosigmoid division followed by a close pericolic line of dissection in order to obviate bleeding risk. In addition, by minimizing specimen bulk, such an approach should allow the specimen to be removed via the port site without enlargement of this wound enabling the stoma to be fashioned securely in this space. While we have used other single port devices, in this case, we have used the SILS system.

2. SILS system introduction 01'09''

The Single Incision Laparoscopic Surgery or SILS system manufactured by Covidien comprises a cylindrical soft, molded port with three pre-bored channels that accept a cannula of 5mm internal diameter. The port can be inserted using a Robert forceps into a 2cm incision in the abdominal wall. The cannulas are then placed into the channels to maintain the air seal and their positioning at differing depths of insertion helps minimize instrument clash. A dilator to expand one of the conduits to allow 12mm instrument access is also supplied. For this case, we have placed the SILS port at the site marked preoperatively for the patient’s end ileostomy. A 5mm camera is then used to perform the laparoscopy throughout the entire operation.

3. Small bowel retraction 01'49''

The small bowel is first decanted from the pelvis by use of steep Trendelenburg positioning. In this patient, this alone is sufficient to provide an excellent exposure of the distal colon and upper rectum.

4. Mesocolon and colon dissection 01'59''

Standard rigid 5mm laparoscopic instruments including an ultrasonic shears are used then to commence mesocolic dissection at the level of the sacral promontory. Our plan is to first transect the colon distally and then proceed proximally along the pericolic plane of the entire colon before extracting the specimen via the port site in the right iliac fossa. After creating a space posterior to the distal sigmoid, the colon is flipped medially to allow access to its lateral aspect. Further mesenteric dissection at a similar level here allows a channel behind the distal sigmoid to be established. The colon is then returned to its natural position and the sufficiency of the mesocolic window is confirmed.

5. Distal colon division 02'49''

Insertion of a 12mm laparoscopic roticulating stapler to perform the distal transection requires dilatation of one of the port’s 5mm channels. Once this is performed, the colon can be divided using two blue cartridge stapler firings and the defunctioned rectal stump will be seen to fall back into the pelvis. We do not usually perform additional oversewing of the staple line in this category of patients. After division, manipulation of the proximal colon allows exposure of the mesentery for dissection along the side of the sigmoid colon. Such a line of dissection will obviate large vessels ensuring optimum hemostasis and minimize specimen bulk to facilitate intra-abdominal handling and then extraction of the specimen. The energy system utilized ensures minimal blood loss and this along with the patient’s favorable body habitus makes for excellent anatomic appreciation. Note, however, the close proximity of instruments and camera within the port means a non-independent view and often off-center visualization. Further progress then allows the left ureter to be clearly seen and preserved and thereafter the dissection continues along the junction of the sigmoid and descending colon. Despite the production of considerable vapor, the dissection proceeds efficiently cephalad using frequent repositioning of the retracting instrument to provide continuing tension on the tissues for dissection. Along the descending colon, division of the lateral attachments is required in place with the mesocolic division. Blunt dissection along posterolateral tissue planes assists the delivery of the colon while altering the patient’s positioning to left side up position is also advantageous. Further progress requires varying the angle of colonic retraction with consideration for both the intended focus point of the operator and the bulk of the distal colonic segment. With such adjustment, access to the proximal left colon is achieved and the patient’s low-lying splenic flexure is approached. Accumulating intra-abdominal vapor is seen to increasingly obscure the visual field. As the port lacks a dedicated smoke extraction channel, this meant frequent interruption of the operation to facilitate camera cleaning and even necessitated intermittent removal of the entire port to evacuate the smog and allow re-establishment of a vapor-free pneumoperitoneum.

6. Splenic flexure dissection 05'16''

Here we see the division of the lateral and omental attachments at the splenic flexure followed by further stepwise progress along the distal transverse colon aided by head-up positioning of the patient. Although this patient’s colon is somewhat foreshortened by the chronicity of her disease process, the operative flow further slowed during this part of the operation as maintaining even progress along both sides of the transverse colon required concentrated effort. The natural laxity of the tissues along with our prior dissection of the distal attachments meant frequent switching between the mesocolic and omental aspects to ensure even progress was maintained. In another patient with a heavier colon, the operation could be facilitated by the segmental division of the colon intra-abdominally to lessen the bulk of the colon then needing retraction. In this case, the operation proceeds however without requiring this maneuver. Moving each instrument and the camera singly rather than simultaneously helps reduce the tendency for clashing. Here in the background, the liver is seen indicating our proximity to the hepatic flexure. At this point, frustration with the accumulating smog encouraged us to try switching energy devices to the high-frequency diathermy. Although smoke accumulation continued to be a nuisance, there seemed somewhat less lens-smogging with this instrument. Next generation single ports will include smoke management channels that will obviate this problem while advanced energy dissectors with more rapid action and reduced vapor production are also in development.

7. Hepatic flexure dissection 07'09''

Firm caudad retraction on the colon now facilitates clean sharp dissection of the hepatic flexure. Further blunt dissection clears the posterior attachments and allows the colon to be safely lifted away from the nearby duodenum. Thereafter, sharp dissection of residual tissue between the ascending colon and both the abdominal wall and the retroperitoneum can again be performed.

8. Right colon dissection 07'53''

Returning the right colon to its natural anatomic position allows reorientation and then access to the medial aspect of the right mesocolon. The terminal aspect of the right colic artery near where it supplies the colon can then be divided followed by some final dissection of the proximal transverse mesocolon. Mesocolic dissection near the caecum is then completed including division of the segmental branches of the ileocolic artery. The caecum is then lifted cephalad to allow final dissection of the lateral and posterior aspects of the proximal colon, an action aided by tilt of the patient into a head down, right side up position. The entire colon is now examined to ensure that it is free from significant attachment and indeed it can be seen to move quite freely within the abdomen. A ratcheted grasper is then placed firmly on the distal staple line to allow extraction of the specimen via the port site.

9. Colon exteriorization and extracorporeal division 09'25''

The port is then removed and the specimen gently delivered to the exterior with only a small residual omental attachment remaining for extracorporeal division. An appropriate site for transection along the terminal ileum can then be selected and the mesentery prepared for completion of the end ileostomy. To do this safely, we returned the cross-stapled terminal ileum to the abdomen and restored the pneumoperitoneum after replacing the port. This allowed us to confirm the correct orientation of the ileum before its maturation as a stoma.