Stenotic anastomosis after sigmoidectomy: laparoscopic redo

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摘要

This recording of a live case reveals all the key technical steps in laparoscopic revision of an anastomotic stenosis following a prior sigmoidectomy.

關鍵字

stenosis, anastomosis, sigmoidectomy, laparoscopy, redo, laparoscopic revision

媒體類型

期間

18'40''

刊物

2008-02

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, Feb 2008;8(02).
URL: http://www.websurg.com/doi-vd01en2250.htm

Stenotic anastomosis after sigmoidectomy: laparoscopic redo

1. Case presentation 00'15''

2. Trocar position 00'40''

3. Operation commences 00'45''

So first, we do the panoramic exploration. We have a few adhesions of the small bowel to the colon, colon that is well vascularized so there are a lot of vessels.

4. Adhesiolysis of small bowel 01'08''

We free the adhesion of the small bowel with scissors without electrocautery. We have to free the last attachment of the small bowel to better understand where the limit is. There was probably a fistula at the beginning. I am now finding the plane, it will be coming up soon enough. The attachments are freed.

5. Mobilisation of sigmoid colon and rectum 02'18''

I have to get the posterior mobilization now. This stenosis is approximately there, I have to free laterally the sigmoid, then medially first to evaluate the quality of the colon. We can see that this colon is mobile, it can move down very easily. Soon we will put a bougie in the rectal stump but the problem is that first in this case to free the colon in the right plane, we use a lateral approach. I will free the pelvis more. The problem is to know where the limit of the mesosigmoid is. The problem is to find the ureter in this case. I want to expose more like this later. I don’t know what it is, I think it was for the vein. The aim is to find the plane posteriorly, but not too posterior, we need to stay anterior to the Toldt’s fascia to be sure that I’m not dissecting too posteriorly. I think this is the right plane that I am finding now, it is anterior to the kidney. Normally the ureter is more medial, due to the previous surgery, it is not sure that I have the right plane, for that it is necessary to have a lateral view. There is an edema, this explains why it is not easy, perhaps we will do on the other side. I think the rectal stump is there, we have to confirm that with a bougie. It is dangerous to have an injury of the ureter, vessels, nerves. The plane is probably there, I will use hydro-dissection. I am now using a 10mm Ligasure device. I think I have found a way anterior to the presacral fascia, I don’t know if it is in the rectum or in the presacral space. Push your bougie. This is the rectum, so I have found the posterior rectal stump, I need to find it anteriorly. I think I am in the right plane of the rectum there, I must find laterally now. I think that in order to continue the dissection it is better to get more access - there is fibrotic tissue, I am not far from the rectal stump – and be sure that we are far from the nerve and from the ureter too even if we know there is sometimes a modification of the anatomy during this kind of fibrotic tissue, abscess, fistula. We are now in softer tissue, I will put stitches on this. We are preparing the rectal stump, it is important that there is no fibrotic tissues. I think that if there is ischemia, it is not on the rectal stump but on the descending colon or there was a fistula with local ischemia, because it is a very limited stenosis.

6. Excision of stenotic segment 15'00''

I use a short cartridge, and another 30mm one.

7. Set-up for re-anastomosis 15'19''

We will now control the stump, can you rinse with Betadine. There seems to be no leak. This is not ischemic, we can do the anastomosis there; we will have the possibility to do the anastomosis with this segment. I am sure that we can do the anastomosis approximately there, but I will divide at this level to complete outside.

8. Extracorporeal anvil insertion 16'44''

We reintroduce this, we have to pull like this. We will now see if enough comes into the pelvis, I think so. The mesentery was like this before, it is necessary to have the possibility to turn and have the mesentery underneath like this.

9. Re-anastomosis 17'45''

We check the ring, proximally and with the staples and distally, that seems very good. We will do the air test. It’s fine.

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