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Three-trocar laparoscopic sigmoidectomy with transanal extraction for diverticulitis and endometriosis

The combination of standard laparoscopy and specimen extraction through a natural orifice has the potential to decrease wound-related complications. The objective of this film is to demonstrate a three-trocar sigmoidectomy technique performed without any abdominal incision and with transanal extraction of the sigmoid colon followed by a fully laparoscopic colorectal anastomosis. This procedure was used for benign inflammatory conditions but not for malignant tumoral conditions.

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Three-trocar laparoscopic sigmoidectomy with transanal extraction for diverticulitis and endometriosis

作者群

J Leroy, J Marescaux

摘要

The combination of standard laparoscopy and specimen extraction through a natural orifice has the potential to decrease wound-related complications. The objective of this film is to demonstrate a three-trocar sigmoidectomy technique performed without any abdominal incision and with transanal extraction of the sigmoid colon followed by a fully laparoscopic colorectal anastomosis. This procedure was used for benign inflammatory conditions but not for malignant tumoral conditions.

關鍵字

Three-trocar laparoscopic sigmoidectomy with transanal extraction for diverticulitis and endometriosis

媒體類型

手術影片

期間

14'57''

刊物

2010-05

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, May 2010;10(05).
URL: http://www.websurg.com/doi-vd01en2933.htm

Three-trocar laparoscopic sigmoidectomy with transanal extraction for diverticulitis and endometriosis

1. Introduction 00'08''

The objective of this film is to demonstrate a three-trocar sigmoidectomy technique performed without any abdominal incision and with transanal extraction of the sigmoid colon followed by a fully laparoscopic colorectal anastomosis. This procedure was used for benign inflammatory conditions but not for malignant tumoral conditions. The team and patient positions are similar to standardized technique we previously showed in WeBSurg.

2. Trocar placement 00'58''

The three ports are positioned supra-umbilically, in the right iliac fossa and in the right flank respectively. They will allow access to the entire abdominal cavity thanks to a Trendelenburg position and a right tilt.

3. Freeing of adhesions 01'14''

After freeing of a few adhesions secondary to a gynecologic surgery (namely a laparoscopic tubal ligation), the root of the sigmoid mesocolon is exposed following the complete exploration of the abdominal cavity. A few lateral and anterior abdominal adhesions are taken down in this patient who has a gynecologic pathology as we will see later. Indeed, an endometriosis at the level of the low sigmoid is suspected.

4. Uterine suspension 02'04''

In order to best expose the pelvis, a uterine suspension is decided upon using monofilament transparietal stitches; these are passed through the wall, achieving a tracted suspension, the threads are knotted extracorporeally onto a swab in order to ensure an atraumatic tightening on the abdominal wall. This suspension is achieved to the right and to the left and help to optimally expose the pelvis without the need for an additional retractor.

5. Dissection of sigmoid mesocolon 02'53''

As we routinely do, the sigmoid colon will be resected by dividing the sigmoid mesocolon distally, away from the rectal vessels. Only the sigmoid branches of the sigmoid vessels will be divided, staying close to the colonic lumen. The lateral attachments of the sigmoid colon and of the descending colon are also taken down in order to obtain a greater compliance of the sigmoid colon and of the descending colon; this will help to obtain a tension-free anastomosis as well as to facilitate the extraction of the sigmoid specimen transanally. Division is further continued using the Ligasure Advance® device through the division of the sigmoid mesocolon proximally, whilst staying away from the colon in order to better preserve the vascular arch.

6. Caudal dissection preserving superior rectal vessels 04'23''

Caudal dissection is extended until the upper part of the rectum by preserving the superior rectal vessels and by simply dividing the sigmoid branches as well as the first superior rectal branch lower down. The advantage is to both preserve the rectum’s vascular supply and to work distally from the hypogastric nerve plexuses, which, ideally, should be preserved with fewer risks of neurovegetative nerve injuries (both on the urinary and genital planes; indeed in male patients, the risk is greater).

7. Identification and dissection of endometriotic nodule 05'05''

Here the endometriotic nodule can be seen. It attaches the Douglas’ pouch as well as the lower portion of the sigmoid colon or of the upper rectum on the posterior aspect of the Douglas’ pouch and the posterior vaginal wall. An excision is performed away from the nodule using the monopolar tip of the Ligasure Advance® device. Thanks to a correct anterior suspension of the uterus and to a posterior rectal counter-traction, the dissection plane is created, hence freeing the rectum on its anterior aspect as well as on its posterior aspect. Here the freeing of the anterior portion of the rectum can be observed. The anterior rectal portion has been fixed on to the posterior aspect of the posterior vaginal wall. The future division area still needs to be determined by removing the endometriotic nodule.

8. Extension of dissection to upper rectum 06'43''

The dissection is continued on the posterior aspect of the rectum by dividing the mesorectum and by progressively reaching the posterior surface of the rectal wall. The dissection is completed anteriorly and laterally to the left in order to skeletonize the upper rectum and best prepare the future anastomotic area. During this maneuver, reptation movements representative of the left ureter were visible. Consequently, the left ureter was far away.

9. Ligature application on upper rectum 07'33''

As soon as the rectal wall has been prepared, a ligature of the low sigmoid or of the upper rectum is performed using an extracorporeal loop. An extracorporeal knot is used. The thread is passed around the upper rectum and the exclusion maneuver is continued by a tightening of the loop.

10. Rectal opening after betadine lavage 08'06''

After a lavage of the rectum using a betadine solution, we open the rectum and attach the lateral wall with a lateral stitch, while keeping the thread externally to perform a suspension of the rectum. This thread will allow to use the suspension in the way as a traction grasper. We determine the area in which the proximal division will be performed by identifying the proximal end and by choosing an area of the descending colon that is supple, compliant and well-vascularized, usually situated at the colorectal junction.

11. Upper rectum division 08'58''

The upper rectum is then divided, the rectum’s suspension stitch allows to keep the latter well visible. Eventually, another traction is exerted through the trocar to re-exteriorize the rectum.

12. Transanal sigmoid extraction and anvil insertion 09'18''

A grasper is then introduced in the rectum through the anus. After having placed a loop on the distal part of the rectum, the rectum is exteriorized through the anus. We determine the area in which the next division will be performed and after having introduced the anvil of a 28mm PCEA DST circular stapler in a colonic incision situated above the inflammatory stenosis, the anvil is pushed in the proximal colon and the meso is then divided.

13. Proximal colon division 10'34''

The division of the mesentery is performed with the Ligasure Advance® device and the proximal portion is stapled. We see that the thread that had been attached to the anvil of the circular stapler is still there. We now need to find this thread in the colonic lumen in an intestinal preparation that is not as good as it could be.

14. Anvil extraction 11'09''

The anvil is exteriorized on the anti-mesentic border of the stapling zone. Ideally, it is preferable to introduce a gauze as we are doing now, and in any case to complete the closure by either performing a purse-string with a needle, or with a pre-shaped loop to tighten the anvil’s shaft. The tip then needs to be removed, placed in a bag and exteriorized through the anus. We also place a gauze that had been used to clean the anvil’s tip in the bag.

15. Rectal stump closure 12'19''

The rectal stump then remains to be closed. The closure is performed through a 12mm trocar that replaces the 5mm trocar situated in the right iliac fossa. We can also introduce the grasper through the 12mm umbilical trocar. We assess the tension, and check if the freeing of the left colon or of the splenic flexure needs to be completed. Here we free the descending colon that is attached to the transverse colon; this is performed in order to obtain a tension-free anastomosis at the level of the upper rectum. This could have been performed before, but after having done the extraction of the sigmoid colon, we can better assess the margins of the mobilization, thus avoiding an excessive mobilization that takes longer and increases morbidity.

16. Anastomosis 13'45''

The anastomosis is performed according to the Knight-Griffen technique, a trans-sutural end-to-end anastomosis using a 28mm PCEA DST circular stapler. As usual, a check of the doughnuts will be performed along with an air-test to control that there are no leakages. As the mesenteric defect was small, it will not be closed.