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Standardized laparoscopic sigmoidectomy for diverticulitis in an obese male patient using the triple stapling technique

Obesity is a modern-day phenomenon that is increasing throughout the world. Laparoscopic colorectal surgery is clearly more technically demanding in the obese patient. Apart from this, however, it is not associated with any increased risk of postoperative complications. This is the case of a 52-year-old man with a BMI of 30 who was admitted several times to the hospital because of diverticulitis. The video demonstrates the technical details in performing the laparoscopic sigmoidectomy using the triple stapling technique.

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Standardized laparoscopic sigmoidectomy for diverticulitis in an obese male patient using the triple stapling technique

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J Leroy, J Marescaux

摘要

Obesity is a modern-day phenomenon that is increasing throughout the world. Laparoscopic colorectal surgery is clearly more technically demanding in the obese patient. Apart from this, however, it is not associated with any increased risk of postoperative complications. This is the case of a 52-year-old man with a BMI of 30 who was admitted several times to the hospital because of diverticulitis. The video demonstrates the technical details in performing the laparoscopic sigmoidectomy using the triple stapling technique.

關鍵字

Standardized laparoscopic sigmoidectomy, diverticulitis, obese male patient, triple stapling technique

媒體類型

手術影片

期間

21'19''

刊物

2009-05

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, May 2009;9(05).
URL: http://www.websurg.com/doi-vd01en2637.htm

Standardized laparoscopic sigmoidectomy for diverticulitis in an obese male patient using the triple stapling technique

1. Clinical case presentation 00'12''

This is the case of 52-year-old man with a BMI of 30 who was admitted several times to the hospital because of sigmoiditis requiring IV fluids and antibiotic treatment and it resolved with medical treatment. The colonoscopy showed a stenosis of the sigmoid colon, which was easily overcome by the scope, and this is the CT-scan showing what I’ve just said. We can get started with Joel. This is a male patient presenting with diverticular sigmoiditis. He has a BMI of 30. It’s mainly a subcutaneous obesity and a little visceral but the interest with this kind of obesity is that the abdominal wall can be distended easily so the abdominal cavity is very large and we have an easy manipulation of the bowel and the mesentery is long. I have done first a suprapubic mini-open approach in this patient and introduced a first 12mm optical trocar for the zero degree scope. I’m standing on the right side of the patient with all the team. I’m using a 5mm trocar and a 12mm in the right iliac fossa, right flank. I have a 5mm suprapubic trocar in order to expose the root of the sigmoid mesocolon and we can have another trocar there. If I do the procedure with 3 trocars, I use only 3 trocars like this and one trocar inside the umbilicus. I have freed the omental adhesions laterally and left to the abdominal cavity to push it above the transverse colon we can see. This is the abdominal cavity we can distend due to the good muscle relaxation and pressure of the pneumoperitoneum (at about 12 mm Hg). We have a few adhesions due to inflammatory problems. We’ll see better later.

2. Operative field exposure 02'42''

The first step is to expose the small bowel and it’s interesting to take a look at the length of the mesentery, which is very long. This proves that it’ll be easy to expose. My first step is to push the small bowel cephalad before we put the patient in a Trendelenburg position. See the duodenojejunal junction; I am sliding the instrument under the loop to maintain the small bowel retracted. Nobody is touching this forceps outside, it is free but it maintains the small bowel retracted. I will push the small bowel laterally to better expose and we use a right lateral tilt to free. See the rigidity of the mesentery at this level. So I guess it’s a good indication. In cases of sigmoiditis in benign diseases, I carry out the division of the mesentery keeping the vascularization of the rectum.

3. Peritoneum incision and medial to lateral dissection 04'10''

The first step is to incise the peritoneum approximately at mid-distance from the root of the sigmoid mesocolon, between the root and the mesenteric side of the colon. The electrical setting is 2 bars. It looks quite gentle at the moment. At this moment, I’m dividing the peritoneum mainly to understand the meso and find the vessels, the branch of the sigmoid mesocolon. See I have reached Toldt’s and Gerota’s fascia and I’m finding the right plane lateral to the sigmoid mesocolon. We have difficulty to grasp because it’s an inflammatory meso. We use the Ligasure device. This is the medial posterior approach. Tell us about the options on Ligasure 5 and 10mm and so on. I think in big mesos, in obese patients, the 10mm device particularly for dividing is faster, larger and safer because we have a long and large dissection. Mainly for dividing meso, it’s not fine dissection; it’s also used for the dissection of planes as a finger. The danger is for the ureter, that’s why we have to continue the dissection perhaps laterally in order to free the lateral attachments or to see the ureter before beginning. But we are more lateral normally. This is the lateral attachment, the root of the meso but we have inflammatory attachments. We see the genital vessels there. We will free laterally like this. This is a healthy colon, no diverticulum there. And I use the principles of dissection (as used during rectal resection): traction, counter-traction, and the main dissecting instrument is not the scissors but the surgeon’s left hand at this moment. In many videos, we can see that diathermy produces a lot of smoke but in this case, there is very little smoke. Why so? I use low power (20 to 25 Watts) and with the Ligasure Advance I will use 5 Watts. The timing after an episode is sometimes something that is open to exploration, but the few works that have been done in the literature and there is one prospective work showing that you should not go, as some people propose, too fast after the episode, especially if this episode was severe. We will change the traction because you have seen that there is fixation and a problem of abscess so I’m coming back medially using the 2 forceps and monopolar cautery. Is there always an indication to put a ureteric stent in a patient? It could be a good indication. The ureter is an essential structure. It’s very difficult here to find it. In some cases, it’s good to have the urologist before because on the CT-scan or on the pelvic digital examination, you can see that there is inflammation and you can put the only one ureter, usually the left one. It’s much more difficult to go like Joel directly here on the main site of the inflammation. You should go away from it and then go down and follow the ureter to see, and here it’s a typical example where you see the ureter coming totally medially and it’s extremely easy, especially if it’s bloody. Now we have to be careful because you have instrument where you can cut the aorta without any blood. So it’s very dangerous because you can go anywhere with this instrument and you can even cut the ureter without knowing it. Because you make a sealing of the ureter and you don’t have urine coming out so it’s a real problem. People who are more beginners should go away from the inflammation and go down to the inflammation following the ureter. That’s my advice. And as for the artery, theirs is no doubt that common sense would be to keep the artery, but there are cases when the meso is so inflamed like here that then if you go under the inferior mesenteric artery, you are in a better plane but you are at a greater risk for the nerves. I think I have divided the inflammatory meso where there was probably an abscess. I am now in a better plane to do the dissection. I am closer to the bowel. We can sometimes have difficulty in dividing, but the problem is: is it necessary to approach the vessels at their origin? I’d say that in 95% of cases or even more, it’s not necessary, even if you divide the superior rectal vessels and not the IMA, we try to respect. It’s not a real problem but we are far from the nerves and further from the ureter, so there is less risk of injury of the anatomical structures. It’s also one of the reason of choosing this approach. So now we have to choose the limits of the division.

4. Distal division 12'54''

Normally it’s at the colorectal junction, that means on the rectum. See, you divide not too close there, but keeping at least half a centimetre because you’ll have a retraction or 1cm is even better. And we’ll do a new resection with the circular stapler. So now you’re doing the lateral mobilization but you don’t attempt to take down the splenic flexure. The descending colon, yes. Will you free the splenic flexure? Perhaps laterally and posteriorly perhaps to turn the colon. In our experience, we don’t do large mobilizations. It’s not necessary as we notice regularly and we do the same resection but with limited morbidity as compared to large mobilizations. I think there is a confusion between large mobilizations (for the surgeon the possibility to demonstrate his varied skills and the necessity to do that for the patient’s case). Why do we do mobilization? In order to have a tension-free anastomosis. It’s not for oncologic purposes nor for the disease. If I have to do a larger resection, I’ll do more. Do you use change in patient position to help? No I’m not changing. I have only modified it because the Trendelenburg was too steep. The main problem is that we have adhesions also there and I want to check if we can do a tension-free anastomosis. I want to perform the anastomosis approximately there. Remember the patient is a male with a BMI of 30. We have to free the posterior attachment there. This is the lesser sac.

5. Colon exteriorization 17'43''

So now we do the suprapubic incision to exteriorize the colon. Now to the anvil. I did a small suprapubic incision and put a plastic wound protector. I pulled more than 20cm of colon outside. Due to obesity, I have difficulty to exteriorize the proximal colon. The problem is to mobilize more. Here’s a trick: you do a small incision in the colon, and I have the anvil inside the colon; I won’t exteriorize the colon with a risk of injuring the vessels.

6. Proximal division and anastomosis 18'50''

I will further mobilize the colon when necessary. I’m dividing so that we can remove it. I’m so lucky to have the sutures. Pull more. That’s an excellent way to test the force of the stapler. I have finished this now. I will try to check. I may have to free a little more but not too much if I do the complete exteriorization. I won’t have any problem to do the anastomosis. I have to free medially a little more perhaps. There is no twist.