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Totally laparoscopic ileocaecal resection for distal ileal duplication

Gastrointestinal duplications are rare congenital anomalies, usually detected prenatally or in the first two years of life, although they can be diagnosed even in older age. Small bowel location is the most frequent (more than 50% of cases). The objective of this film is to demonstrate an ileocaeal resection for duplication of the terminal small bowel, which has been suggested during the CT-scan examination. It will be confirmed by the pathological examination and the histological study.

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Totally laparoscopic ileocaecal resection for distal ileal duplication

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J Leroy, J Marescaux

摘要

Gastrointestinal duplications are rare congenital anomalies, usually detected prenatally or in the first two years of life, although they can be diagnosed even in older age. Small bowel location is the most frequent (more than 50% of cases). The objective of this film is to demonstrate an ileocaeal resection for duplication of the terminal small bowel, which has been suggested during the CT-scan examination. It will be confirmed by the pathological examination and the histological study.

關鍵字

Totally laparoscopic, ileocaecal, resection, distal, ileal, duplication

媒體類型

手術影片

期間

17'00''

刊物

2010-09

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Sept 2010;10(09).
URL: http://www.websurg.com/doi-vd01en3024.htm

Totally laparoscopic ileocaecal resection for distal ileal duplication

1. Clinical case presentation 00'10''

The objective of this film is to demonstrate an ileocaecal resection for duplication of the terminal small bowel, which has been suggested during the CT-scan examination. It will be confirmed by the pathological examination and the histological study. A cystic dilatation is found. Initially, it was evocative of a hydro or pyosalpinx, but it was actually a duplication of the small bowel, as evidenced during the laparoscopic examination. The colorectal surgeon is asked by the gynecologist to manage the lesion.

2. Small bowel exploration and ileal lesion identification 01'11''

After laparoscopic examination of the entire small bowel, the cystic mass is found. It contains a semi-liquid substance, which involves the terminal small bowel, running parallel to and duplicating the bowel’s wall, as can be seen on these pictures. The remainder of the small bowel exploration has shown no other particular anomaly. A few sequels of pelvic adhesions coming from the gynecologic laparoscopic examination performed some months before will be freed. The small bowel is further explored in search for a Meckel’s diverticulum or any other bowel lesion. The exploration is carried out from the terminal small bowel until the duodenojejunal flexure. The caecum can be seen here, as well as the cystic mass that is attached to the terminal small bowel, close to the ileocaecal valve. An ileocaecal resection is decided upon. The terminal small bowel will be removed.

3. Small bowel division 02'36''

To do so, the small bowel is divided away from the duplicated area. A vascular Endo-GIA linear stapler, white cartridge 60mm length, is used to perform the division of the small bowel and the mesentery.

4. Mesentery dissection using the 5mm Blunt Tip Ligasure® 02'57''

The mesentery is then divided remaining in contact to the small bowel and the caecum. To do so, a new generation 5mm Ligasure® vessel-sealing device, also called Blunt Tip Ligasure®, is used. It allows performing an excellent division after coagulation, until reaching the extremity of the suture line. Once the mesentery has been divided, attention is turned to the mesocolon. The cystic mass can be clearly seen. It will be pushed towards the pelvis in order to facilitate the surgical maneuver.

5. Mesocolon division 04'04''

The mesocolon is divided at its distal portion.

6. Ileocolic vessels division 04'10''

The ileocolic vessels, which can be seen pulsating here, are divided. The network of marginal vessels is perfectly preserved.

7. Caecum division 04'18''

The caecum is then divided using two applications of a 60mm Endo-GIA linear stapler, blue cartridge. This allows for a clean resection of the caecum. Finally, an ileocolic anastomosis is performed between the distal small bowel and the ascending colon. Before the freeing of the ascending colon is completed, its lateral attachments are divided using the new generation 5mm Ligasure® device. This allows for an appropriate division and sealing with a perfect and clean hemostasis of the tissues thanks to the blade placed in between the two sealed areas.

8. Bowel segments approximation 05'27''

The ileocolic anastomosis is prepared between the terminal small bowel and the ascending colon. To do so, the two bowel segments are fixed together in an isoperistaltic fashion between the ileum and the ascending colon. A second stitch is necessary to perfectly bring the two bowel segments together. The second stitch is placed proximally on the small bowel and on the colon at the level of the anterior taenia, as can be seen on these pictures. As soon as the two bowel segments lean back against one another, the colonic wall is opened on the anterior taenia. The hook proves really efficacious for that purpose. A hemostasis of a submucosal vessel may be carried out at this point. The colonic mucosa is then opened. The same maneuver is carried out at the level of the small bowel wall.

9. Anastomosis 07'02''

Once the two bowel lumen have been opened in a sufficiently large way, the linear stapler is introduced. A side-to-side anastomosis is carried out with the aid of the sewing thread and thanks to the perfect angulation of the Endo-GIA linear stapler, blue cartridge. The hemostasis of the stapling line is controlled.

10. Defect closure 07'38''

Next, the stapler’s introduction site is perfectly explored and exposed in order to achieve a single layer extramucosal suture by using Maxon® 3/0 absorbable monofilament. Two half-running sutures are placed from the angles of the suture line towards the center. They will be re-approximated at the medial portion of the division area. The advantage of using monofilament lies in the ability to pass and pull several threads, which slide perfectly in the colonic wall, hence avoiding any cutting effect that may occur with braided threads. This allows placing equal traction on the stitches of the running suture. A knot is tied on the short thread held by the left hand. The forceps holding the long thread is turned around the forceps that will be used to grasp the distal short suture thread. As can be seen here, the running sutures end facing one another, and after needle removal, a flat knot is tied intracorporeally. This allows placing the suture margins one opposite the other, hence avoiding any plication or cutting effect. For security reasons, the suture is completed by placing covering stitches at the division angle, as can be seen here. An extramucosal stitch is placed. Once again, the knot is tied intracorporeally as all sutures and knots that have been achieved in this video.

11. Mesenteric defect closure 11'08''

As routinely performed, it is also advisable to close the mesenteric defect. It is wise to keep the two bowel segments leaning against one another on the distal portion. It may also be necessary to cover the suture area at the level of the stapling line of the ascending colon. The mesenteric defect may be closed using a running suture or using the stapler. In this case, an Endo-Hernia stapler will be used to close the mesenteric defect. It will cover the incision area laterally. Here, the end of the running suture covering the distal stapling line at the ascending colon can be seen.

12. Specimen extraction 12'26''

The specimen, who had been temporarily placed in the pelvis, is extracted. It contains the cystic mass –initially thought to be a hydrosalpinx or a pyosalpinx–, a 20 to 30cm portion of the terminal small bowel and the caecum. A sufficiently large Endo-Catch™ II extraction plastic bag is introduced through a small suprapubic incision. This allows for specimen extraction using progressive traction, avoiding any risk of contamination of the abdominal cavity. The cystic mass is opened. It shows an encysted area that is not connected to the small bowel, which is actually a duplication of the small bowel’s wall. Otherwise, the small bowel shows no abnormality. The histological examination confirms the duplication of the small bowel.