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Unusual voluminous inflammatory diverticulum of the sigmoid colon: laparoscopic management

In this video, we show the case of a 70-year-old male patient who had several attacks during the last weeks, abdominal pain, and fever. After CT-scan, he was diagnosed a perisigmoid abscess. We diagnosed a lot of diverticula and we made a diagnosis of sigmoiditis with perisigmoid abscess. So this is the Hinchey II two pelvic abscess. We began the medical treatment and finally we had several attacks and did a new examination, a new CT-scan, and an endoscopy and not a sigmoid abscess, but a voluminous diverticulum with an abscess, was diagnosed. So it was decided to operate on the patient.

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Unusual voluminous inflammatory diverticulum of the sigmoid colon: laparoscopic management

作者群

J Leroy, J Marescaux

摘要

In this video, we show the case of a 70-year-old male patient who had several attacks during the last weeks, abdominal pain, and fever. After CT-scan, he was diagnosed a perisigmoid abscess. We diagnosed a lot of diverticula and we made a diagnosis of sigmoiditis with perisigmoid abscess. So this is the Hinchey II two pelvic abscess. We began the medical treatment and finally we had several attacks and did a new examination, a new CT-scan, and an endoscopy and not a sigmoid abscess, but a voluminous diverticulum with an abscess, was diagnosed. So it was decided to operate on the patient.

關鍵字

Voluminous inflammatory diverticulum, sigmoid colon, laparoscopy, Hinchey II, sigmoid abscess

媒體類型

手術影片

期間

26'00''

刊物

2010-12

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Dec 2010;10(12).
URL: http://www.websurg.com/doi-vd01en3048.htm

Unusual voluminous inflammatory diverticulum of the sigmoid colon: laparoscopic management

1. Clinical case presentation 00'18''

This is a 70-year-old male patient who had several attacks during the last weeks, abdominal pain, and fever. After CT-scan, he was diagnosed a perisigmoid abscess. We diagnosed a lot of diverticula and we made a diagnosis of sigmoiditis with perisigmoid abscess. So this is the Hinchey II two pelvic abscess. We began the medical treatment and finally we had several attacks and did a new examination, a new CT-scan, and an endoscopy and not a sigmoid abscess, but a voluminous diverticulum with an abscess, was diagnosed. So it was decided to operate the patient.

2. Trocars introduction 01'16''

To do so, we begin putting a trocar using a mini-open approach just above the umbilicus in the midline. Two other trocars are put on the right side of the midclavicular line, one at the crossing of the umbilical line and the other 10cm below, just above adhesions due to previous surgery with appendicectomy, and another one —because we have some difficulty to expose— on the left side of the midclavicular line, at the level of the umbilicus.

3. Front landmark viewing 01'51''

This is the front landmark, anterior axillary line, midclavicular line, midline, horizontal line through the umbilicus. The pubis is down, the xiphoid sternum is up. This is the position we have till now. Probably we will have another trocar, suprapubic. Regarding the position of the patient, we have the team on the right side of the patient, one assistant between his legs with lithotomy position, right arm along the body, laparoscopic items on the left, and a Trendelenburg position with right lateral tilt has been used till now.

4. Exploration of abdominal cavity 02'40''

We do a panoramic exploration until we incise the abdominal cavity. We have found this: no peritonitis, some adhesions in the right iliac fossa. We do not free completely the caecum, we have freed only the adhesions to the anterior wall to put the trocar. We keep the adhesions to maintain the caecum in this position. Then, we find the sigmoid and we push the small bowel up and laterally to the right, but not the whole small bowel, as you see, as a part is fixed in the pelvis. The sigmoid has many diverticula. We see adhesions of the distal small bowel to the sigmoid or the mass. We have a limit of mass there, so perhaps it is coming from the mesentery, stuck to the sigmoid.

5. Pelvic exploration 03'53''

We complete the exploration of the pelvis now. We move the camera down. There is no abscess in the pelvis, as you see, no adhesions. It is probably, in my opinion, a diverticulum with infixion in the diverticulum and the small bowel fixed to it after a lot of inflammation.

6. Start of dissection 04'19''

We begin the procedure using monopolar scissors and using traction and counter-traction. I am using the shape of the instrument. You see that there is some edema between. It is an electronic, very small 2mm instrument, blue and white. There is no current, so no lateral thermal risk. The shape is used to penetrate and to complete the cooperation of the tissue. We can use interesting tools as peanut swabs and automatic retractors such as the endoscopic finger. I use bipolar coagulation. I have a trigger on the instrument to change the power. I am using 15 Watts at this moment. The shape is very useful. It is rotative and allows to slide on the tissue and to be between the mesentery and the wall of what we suppose it is a diverticulum. Till now, it seems that there is no perforation, no abscess in the mesentery. Now we are not far from the iliac vessels, you see? The iliac vessels are there. I would like to do a small bowel resection, but perhaps it will not be necessary, I do not know. I think this will finish by a small bowel resection. It is more fixed on this part, as you see. I have just a question, Joël: what is the difference between the blue and the white jaws? It is only to recognize the up and down. Blue, you have the blade. White, you do not. And the monopolar can be activated only if it is close. If I push the button, I cannot activate. If I lock, I can activate. And I can control with the lateral trigger the power from 5 to 45. So you are changing the power? I can change myself, yes. So it is necessary to push more, but I can use less energy in contact. Perhaps it is not enough, so I use 10 Watts now and it is more active. And this is independent to the Ligasure®, which is a possibility too. I use the Ligasure® now and I cut between the two bars in order to have a better exposure, like this. Thanks to the shape of the instrument, it is easier, safer and faster.

7. Division of sigmoid vessels 10'10''

I think this is a diverticulum. I can dissect more, but I will remove the sigmoid. You see my assistant is grasping this. Now I will use a new generation Ligasure Blunt Tip®. It is a fantastic minifinger. As you see, we are working with two hands. I am dividing the meso, keeping the vascularization of the rectum. We divide only the sigmoid vessels. The advantage is to dissect at distance of the original IMA and to better preserve the nerve. I will do a lateral freeing using the front technique. Can I ask you a question, please? What was the reason behind dissecting the medial bit of the mesentery first and not mobilizing the peritoneum and lifting the colon? I completely agree. In this case, we propose a medial approach, but we can free laterally. So you could recommend a mixed approach? In this case, particularly, it is not an oncologic problem, but some times, there are a lot of adhesions laterally, so it is better to begin medially. Sometimes, when there are adhesions in inflammatory sigmoiditis, the lateral approach is very difficult. It seems not easy for you at the beginning. But Joël, I have a question from a upper GI surgeon: when I look at that, it is sometimes difficult to work in the meso at the origin of the mesocolon so if you are treating diverticulitis, is it easier to work really close to the colon in order to avoid all the retroperitoneum? No it’s right in acute cases, we have a lot of edema, inflammation. It’s why thanks to the Ligasure®, it is fantastic because we can do what it was not possible to do in the past. You see this is a right plane. It is the fascia in front of the vascular sheet. The vascular sheet is behind. See the vessels are beating. I’m doing less traction. See this is the vascular sheet and I will divide all the branches crossing this space. I am now close to the bowel. So I’m doing the dissection. It’s not far from the limit of the Douglas’ pouch. These are the genital vessels, yes or no? we will see. I’m freeing and I have to free. These are the genital vessels. Imagine where the aorta is. I will show you soon. I’m dividing the lateral attachments of the sigmoid. See it is as a finger doing the dissection. I want to free by a lateral approach. We can free by a medial approach. Here is the spleen. It seems the colon is compliant with not so many diverticula. I will remove this so I’m dividing the meso like this. See when you have not completely divided the vessels, don’t use traction. You have to finish because if you cut half of the vessels, hemostasis is not finished. So I can divide now. The aorta is there and if I want to find the ureter, it is there. So it is important to free and to see if the colon, the splenic flexure can be taken down. If it is fixed posteriorly, I will do – if I have some difficulties, I will use a medial approach to free but I want to turn the colon as we did in the past in open procedures not doing a medial approach systematically. I think it is the tail of the pancreas. See I’m determining the limit where I will do the traction. So we will see if I have to free and to mobilize more, I will do after. Now I have to divide distally to see. We will remove all this segment. Remember there are adhesions there. It’s not the rectum so I don’t have to free. Why? Because there is more risk of bleeding and it’s not necessary in order to do the anastomosis in good conditions. I want to show you something. See very short stapling line. The problem, a lot of staples can fall. I will do this way.

8. Stapling 17'49''

Watch. I’m cutting. No staples fall or a few. How to do that? Put some oil on a swab, close without stapling and it is still stuck on the anvil.

9. Betadine test of rectal stump 18'16''

We do the betadine test. This is cleaning also the rectal stump and we verify that there is no leak. Sometimes at the crossing of two lines, you may have a small leak and you have to remove it when you put the stapler. Now I will remove using a small suprapubic incision.

10. Suprapubic incision 18'42''

This is the suprapubic incision in which we will introduce using a Pfannenstiel incision. These are the rectus muscles. I have just cut the aponeurosis; see I have my scissors putting my finger and I have a plastic wound protector. The diameter of the ring is 7cm. This is a classic plastic wound protector used for 30 years in laparotomy but with a small ring and we see that outside that it is maintained very well. So now I introduce forceps inside the sleeve.

11. Colon extraction 19'26''

See it is easy to introduce as in a trocar and I pull on the sigmoid through this and the segment of bowel is coming. The problem is the size —limited at this moment— and I’m increasing it to have easier possibilities, and we pull on the colon and you see we arrive on the pink part where I divide the meso. Why not divide at this moment outside? Because I will have traction on the meso and a risk of breaking the vessels. I’m sure because I have divided there the meso that the inside part is always inside without traction; I’m placing traction only on the colon. So the diverticulum is very voluminous, it’s not rigid, it’s very thick, 6cm. It’s 6 by 6 by 6. Why don’t I divide the colon inside? Well, I do it in cancer because I put all the segment into a plastic bag but I have no doubt. I don’t think it’s a cancer or very inflammatory in a huge meso to facilitate the extraction with a smaller incision. Because I can break inside the plastic bag, but in this case, I did like this because it’s easier, not necessary to do and cheaper. See the length resected – it’s 40cm. If we can pull at this level, probably we will have a tension-free colorectal anastomosis. It’s well vascularized, it’s bleeding. The mucosa is well colored. See they are trying to close properly the colon on the anvil. It’s only to show you. See it is circular. I lock this. Scissors. We remove. We’ll open now. See we have two areas where there are no staples, this one and that one. The danger if you close like this, this part is not included. You will have ears. Why? Because it’s why it’s necessary to put a forceps there to open it too rapidly, automatically this is not inside.

12. Colorectal anastomosis 23'05''

As you can see, we have introduced the DST PCEEA stapler transanally and we have connected together and now we will fire. What I want to show perhaps before it’s removed, so we will do an air test now. We will control the stapling line.