Three-port laparoscopic sigmoidectomy with transanal extraction for sigmoid diverticulitis

Laparoscopic resection of the sigmoid colon is currently considered a feasible option for open surgery. Many attempts have been made to reduce scars. The objective of this film is to demonstrate a transanal extraction technique for the laparoscopic management of sigmoid diverticulitis using three trocars.

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Three-port laparoscopic sigmoidectomy with transanal extraction for sigmoid diverticulitis

Authors

J Leroy, J Marescaux

Abstract

Laparoscopic resection of the sigmoid colon is currently considered a feasible option for open surgery. Many attempts have been made to reduce scars. The objective of this film is to demonstrate a transanal extraction technique for the laparoscopic management of sigmoid diverticulitis using three trocars.

Keywords

Three-port laparoscopic sigmoidectomy, transanal extraction, sigmoid diverticulitis

Media type

Surgical video

Duration

07'39''

Publication

2010-09

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E-publication

WeBSurg.com, Sept 2010;10(09).
URL: http://www.websurg.com/doi-vd01en3020.htm

Three-port laparoscopic sigmoidectomy with transanal extraction for sigmoid diverticulitis

1. Introduction 00'18''

The objective of this film is to demonstrate a transanal extraction technique for the laparoscopic management of sigmoid diverticulitis using three trocars. The optical trocar is placed at the level of the umbilicus. A 0-degree scope is introduced through a 12mm trocar. Another 12mm trocar is placed in the right iliac fossa and a 5mm trocar is placed in the right flank.

2. Abdominal cavity exploration 00'50''

First, the abdominal cavity is explored.

3. Uterus suspension 00'53''

Then, the pelvis is exposed by suspending the uterus with the use of a transparietal transfixing stitch.

4. Sigmoid lateral mobilization 01'00''

Next, the mobilization of the lateral aspect of the sigmoid colon is initiated by dividing the lateral attachments. The colonic adhesions originating from previous attacks of diverticulitis are taken down. Initially, the patient suffered from a sigmoid diverticular disease, which was fixed in the deep pelvis. The compliant non-diverticular area is identified on the lower portion of the descending colon.

5. Mesocolon division 01'41''

The division of the sigmoid mesocolon may then be initiated almost in contact to the colon in order to preserve the superior rectal vessels. The division of the meso is completed using the 5mm new generation Ligasure® vessel-sealing device, also called Ligasure® Blunt Tip. The division is pursued in contact to the colorectal junction, slightly above it. This junction will be resected at the end of the procedure.

6. Ligation of distal sigmoid 02'13''

Once the distal portion of the colon has been dissected, the distal extremity of the sigmoid colon is ligated using a thread tied with an extracorporeal knot. The dissection of the sigmoid colon is continued proximally until reaching the compliant area of the proximal portion of the sigmoid colon, or even until the descending colon. The descending colon and the splenic flexure may need to be mobilized; however, in our sigmoid diverticulitis management experience, this is very rare. The sigmoid colon has been ligated.

7. Opening of the upper rectum 02'59''

After lavage of the rectum with a Betadine solution (at least 500cc), the upper rectum is opened using monopolar scissors.

8. Colon exteriorization 03'29''

A grasper is then introduced transanally into the rectum. The extremity of the colon, which has been identified by means of a thread, is pulled in order to perform a gentle traction through the rectum until the colon is sufficiently exteriorized. In this way, the compliant part is brought to the anus.

9. Anvil introduction and sigmoid division 04'08''

The compliant part is incised lengthwise before introducing the anvil of a 28mm DST PCEEA circular stapler, which is connected to a polysorb 2 suture, allowing for an adequate identification before dividing the proximal portion of the colon. This division may be accompanied by the division of the landmark thread, which is fixed on the anvil, whether or not the thread is blocked by the staples of the stapling line.

10. Sigmoid extraction 04'59''

The sigmoid colon remains to be exteriorized. This is performed by placing traction through the rectum.

11. Rectal stump closure 05'06''

The rectal stump also needs to be closed. To do so, traction may be exerted by means of two suspension threads on the edge of the rectal stump. The linear stapler is introduced through the 12mm trocar situated in the right iliac fossa. This can also be performed by using two 5mm trocars, situated respectively in the right iliac fossa and in the right flank, and one 12mm trocar, situated in the umbilicus. In this case, a 5mm scope will be used in order to carry out the division with the stapler, which will be introduced through the 12mm umbilical trocar.

12. Anvil retrieval 05'48''

The anvil and the thread remain to be retrieved. This is made on the anti-mesenteric border using the fisherman’s technique by perforating close to the external angle of the staple area and by searching for the suture thread with a hook. Next, the anvil’s tip needs to be extracted and secured with a suture loop.

13. Colorectal anastomosis 06'20''

An end-to-end colorectal anastomosis is performed by means of a triple stapling, which is reduced to a minimum, since the triple stapling involves only a part of the colon’s anastomotic area. After tightening the suture, and once the staples have been clipped and closed, the adequacy and complete thickness of the doughnuts is controlled. An air test is performed. It is important to bear in mind that this is a three-trocar procedure and that no abdominal incision is necessary in order to perform the transanal abdominal extraction of the sigmoid colon specimen.