WebSurg中文版尚未完成，翻譯工作進行中！

Vascular approach in sigmoidectomy for diverticulitis

WebSurg是個虛擬大學，可在世界各地透過網路取得。我們的目標是提供外科醫師、科學協會及醫學產業第一個腹腔鏡及其最新發展之線上持續醫學教育的平台，包括NOTES和機器人手術。

瀏覽全世界
虛擬大學
繁體中文 ▼

Vascular   approach   in   sigmoidectomy   for   diverticulitis

作者群
J Leroy
關鍵字
operation,sigmoidectomy,sigmoid colon resection,vessels
媒體類型
期間
11'00''
刊物
2004-09
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1155e.htm

Vascular   approach   in   sigmoidectomy   for   diverticulitis

1. Cae presentation 00'22''
My goal is to find the inferior mesenteric vessels. Remember it’s a benign disease. I will respect the vascularization of the proximal left colon and of the descending colon but I want to locate the vessels first. The aorta is here. I think it’s the trunk of the inferior mesenteric artery. I now complete my dissection. I think the artery is running here. I think it’s the inferior mesenteric and perhaps the superior rectal artery but I’ll discover more progressively. Do you think there is any danger of dissecting the nerves like this? I was starting to have the discussion with you about whether in diverticulitis and when you know it’s not cancer, is it necessary to be behind the inferior mesenteric artery? Then, of course, there is a risk to the nerves though I have watched you doing beautifully a high ligation as for cancer but it was a question of policy, which I’m interested in because in diverticulitis I personally stay in front of the inferior mesenteric artery and superior rectal artery and take the best so long as I’m sure it’s not cancer. I stay in front of the artery in which case of course there is no need even to see the nerves. If one has had a good endoscopy and a good investigation and you’re sure you’re not dealing with cancer, I personally would take the vessels anterior to the inferior mesenteric artery and superior rectal artery. I summarize my understanding of this that many of us in open surgery would find it very easy to remain in front of the main vessels, the inferior mesenteric artery and the superior rectal continuation but in laparoscopic surgery, it’s easier to get into the same plane as you would with cancer but perhaps invariably in diverticulitis I suppose preserve the ascending left colic artery and so I think it’s not a big matter really although it is the whole strategy of the operation that is different as I would do it in an open case where I would not go near the nerves, I would go further forward but of course this is not very important. This is the left colic artery. On the left, it crosses the superior rectal vein and inferior mesenteric vein. The aorta lies behind the fatty tissue. Here’s the inferior mesenteric artery and the superior rectal artery; probably we have a sigmoid artery coming from the left colic artery or a lot of branches coming from the superior rectal artery. But the trunks are completely divided along this artery. I’m not close to the aorta, I’m not behind the superior rectal vessels or inferior mesenteric vessels so I have to dissect against the vessels to understand very well the course of all the branches. Is it your strategy in diverticulitis to stay in front of or to go behind the superior rectal artery? 10 years ago, I described that it was easier to begin at the origin of the inferior mesenteric artery as in cancer but actually I always dissect in front the inferior mesenteric vessels, I don’t dissect behind. Provided you’re certain that you’re dealing with a benign disease I suppose. Yes! If it was cancer, you would be behind I presume. Yes! When I come across a difficulty, that is when the mesentery is inflammatory sometimes I want to find my landmark behind but not a posterior dissection, only to find vessels. Another surgeon expresses a different opinion. He finds it easier to get into the plane between the superior rectal vessels and the nerves and to lift that part of the specimen forward of the nerve in diverticulitis as in cancer. Perhaps we have a sigmoid vessel coming from the left colic artery and you see we have a trunk, it is the left colic artery and the sigmoid artery is here and just behind we have the sigmoid vein. To divide the sigmoid vessels, we have to divide here. So that is the sigmoid artery coming off the ascending left colic. Yes! So as you have seen, I have divided the vessels. I am just behind Toldt’s fascia and it’s not the good plane. You see we see very well the ureter and the genital vessels. When we see too well, it’s that we’re not in front of Toldt’s fascia: we have to be behind. It’s not an error but Toldt’s fascia is here. It covers all the structures and we have to dissect anteriorly like this. The sigmoid vessels are here. Here’s the inferior mesenteric vein with the sigmoid vein that was divided. Probably we’ll have small branches for the lower rectum and perhaps it’s one of the branches for the low sigmoid and we’ll have the division of the superior rectal vessels in 2 branches at the level of the promontory probably here. So I divide the vessels. You see we have small vessels that come from the superior rectal vessels and get around the rectum, artery and vein. So you see the promontory is here, we have the right ureter, the right iliac vessels, left probably behind, but we have not dissected the vessels, we’re in front of the Toldt’s fascia, the superior rectal vessels are against the promontory without fatty tissue. Have you got special advice for deciding what is the optimal level in diverticular disease? I think the best test is when you introduce your stapler if you’re not able to push it at the distal part of your rectal stump, it’s because you’re too high in your section and now to find it as I said, it’s anteriorly you have the end of the anterior tenia and posteriorly, just under the first superior rectal branch coming from the superior rectal vessel.