Three-trocar laparoscopic sigmoidectomy and transanal extraction of the specimen for diverticular sigmoiditis

The objective of this video is to demonstrate the laparoscopic sigmoidectomy using three ports with the transanal extraction of the sigmoid colon for the treatment of a diverticular sigmoiditis. The interest of this technique is the ability to limit the number of ports used; as a result, parietal trauma and morbidity may be reduced. In this case, two 12mm ports and one 5mm port are used.

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Three-trocar laparoscopic sigmoidectomy and transanal extraction of the specimen for diverticular sigmoiditis

Authors

J Leroy, J Marescaux

Abstract

The objective of this video is to demonstrate the laparoscopic sigmoidectomy using three ports with the transanal extraction of the sigmoid colon for the treatment of a diverticular sigmoiditis. The interest of this technique is the ability to limit the number of ports used; as a result, parietal trauma and morbidity may be reduced. In this case, two 12mm ports and one 5mm port are used.

Classification

basic techniques

Keywords

Three-trocar laparoscopic sigmoidectomy, transanal specimen extraction, diverticular sigmoiditis

Media type

Surgical video

Duration

10'00''

Publication

2009-11

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E-publication

WeBSurg.com, Nov 2009;9(11).
URL: http://www.websurg.com/doi-vd01en2774.htm

Three-trocar laparoscopic sigmoidectomy and transanal extraction of the specimen for diverticular sigmoiditis

1. Introduction 00'07''

The objective of this film is to demonstrate the laparoscopic sigmoidectomy using three ports with the transanal extraction of the sigmoid colon for the treatment of a diverticular sigmoiditis. The interest of this technique is the ability to limit the number of ports used; as a result, parietal trauma and morbidity may be reduced.

2. Trocar placement 00'27''

In this case, two 12mm ports and one 5mm port are used. However, two 5mm ports and one 12mm port placed in the umbilicus may be sufficient if the 5mm Ligasure Advance® device is used with a 5mm scope.

3. Exposure of sigmoid mesocolon 00'48''

In these pictures, the first step is the exposure of the sigmoid mesocolon as well as the division of sigmoid vascular branches preserving the superior rectal vessels according to the protocol used conventionally for this type of pathology.

4. Medial division 01'08''

Division is carried out medially.

5. Lateral dissection 01'15''

Then it is completed laterally opening the colo-parietal attachment using the 10mm Ligasure Atlas® device. Dissection is continued cephalad. And in this case, it is necessary to continue the dissection paying attention to preserve the network of marginal vessels and mobilize the descending colon and the splenic flexure in order to perform the anastomosis on the portion that carries as few diverticula as possible on the descending colon.

6. Medial dissection of splenic flexure 02'04''

Here the beginning of the medial dissection of the splenic flexure is visible. This step consists in opening the root of the transverse mesocolon lateral to the duodenojejunal flexure. This root is opened on the anterior aspect of the pancreas in carefully staying proximal to the peritoneum and distal to the pancreas to avoid any pancreatic injury. Here we can clearly see that the root of the transverse mesocolon becomes free once divided and sealed using the Ligasure Atlas® device. As only three ports are used, the exposure is slightly more difficult. However, thanks to the patient’s perfect muscle relaxation, and thanks to the slight reverse Trendelenburg position, the left superior portion of the abdominal cavity may be exposed.

7. Completion of splenic flexure mobilization 03'17''

The mobilization of the splenic flexure is completed not only by the division of the lateral attachments and of the phrenicocolic ligament, but also by the division of the superior attachments between the colon and the omentum or between the stomach and the omentum if we wish to preserve the omentum. Here the division is achieved from right to left staying in contact to the left transverse colon but sufficiently distally to avoid any colonic wound. Therefore, the last remaining attachments of the splenic flexure are taken down, hence achieving the complete freeing of the left colon and of the splenic flexure. Our attention then turns to the distal portion of the sigmoid colon, slightly above the colorectal junction.

8. Ligation of lower sigmoid colon 04'16''

The lower sigmoid colon is ligated just above the colorectal junction using extracorporeal knots (of the EndoSuture System type). This allows a perfect tying and securing of the knot in place. The rectal stump is washed using a Betadine solution.

9. Opening of lower sigmoid colon 04'40''

Then the lower sigmoid colon is opened just above the colorectal junction and the rectal wall is suspended by introducing a thread through the right iliac fossa port. This thread is knotted and maintained externally by a forceps to exert traction.

10. Transanal anvil introduction 05'02''

Then the anvil of the 28mm DST PCEEA circular stapler is grasped. The anvil is then pushed into the rectal lumen transanally. Beforehand, a thread has been connected to the tip of the anvil: this thread is used as a landmark. Our attention then turns to the proximal portion of the sigmoid colon.

11. Proximal colon incision and anvil positioning 05'35''

An incision is performed on the anterior taenia at the level of the proximal portion of the sigmoid colon. The anvil is introduced through this incision. It is pushed into the proximal colon, i.e. the descending colon. It may be slightly difficult to push the anvil because of the colonic non-compliance.

12. Proximal colon division 06'08''

Then the colon is divided underneath the anvil’s tip using a linear stapler. Thanks to a large Polysorb size 2 suture – the thread can stay in place or otherwise it is cut and caught in the stapled area. Once the thread has been cut, the anvil is taken out. The air tightness is ensured using a purse-string fashioned with a Vicryl loop. Our attention then turns to the sigmoid colon that has just been divided. The proximal extremity of the colon is re-approximated with a Vicryl loop, which is kept as long as possible. This will serve as a landmark to easily find the colonic extremity inside the bag.

13. Introduction of extraction bag 07'10''

Then an Endo-Catch II extraction bag with a 15mm introducer is pushed through the anus. The bowel segment to be resected is introduced within the bag, maintaining the Vicryl thread’s end landmark externally. This thread’s end must stay out of the extraction bag. The bag is closed and the introducer is removed according to the manufacturer’s recommendations. Then the bag is progressively pulled out. The bag is maintained open and the landmark thread is used for traction purposes; this helps to bring one of the colonic extremities externally. This facilitates the colonic extraction without exerting any pressure on the sphincter. Once the bag has been emptied, it is taken out easily through the anus. The rectal stump still needs to be closed.

14. Rectal stump closure 08'53''

To do so, a new re-cut is achieved just underneath the colorectal junction and the segment that has just been cut is placed inside another bag, small in size. This bag is taken out through a 12mm port introduction site.

15. Colorectal anastomosis 09'09''

The colorectal anastomosis still needs to be completed. It is performed conventionally using the 28mm DST PCEEA circular stapler. Once we have checked that there is neither twist nor tension, the anastomosis is complete. The doughnuts are controlled and an air test is performed.