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Vidéos chirurgicales sur WeBSurg
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English - 17'00''
| 00'19'' | Case presentation
This patient is a 70-year-old man who recently had cardiac bypass surgery and he was anticoagulated postoperatively.
He presented with bleeding from the gastrointestinal tract and on further investigation with radiology and endoscopy, no cause was seen in the stomach or duodenum but this submucosal tumor with ulceration was seen in the first part of the small bowel just after the duodenum.
It appears to be in the proximal small bowel, and after complete imaging, particularly colonoscopy, CT-scanning and a small bowel enema, the patient is now ready for a section of the proximal small bowel and inspection of the abdominal cavity.
A problem with this patient is previous hip replacements making it impossible to abduct the thighs. Normally, the operator would stand between the legs for ergonomic reasons. In this case, the port position is very different as the operating team is on the left and the right of the patient and the table will be tilted to both sides to position the small bowel for better exposure of the area that we are interested in. The first trocar is introduced by open laparoscopy just above the umbilicus. This is an 11mm trocar and will be used for the camera. Next two trocars are placed in the mid-clavicular line B and C, and they will both be used for exposure. Two operating trocars, D and E, are inserted after the inferior epigastric vessels were identified by laparoscopy. These trocars are positioned so that they converge at the duodenojejunal flexure.
The duodenojejunal flexure is found by following the small bowel proximally after full exposure with the retractors. And here, just after the DJ flexure, a subserosal mass is found, which we know is also submucosal. Once we have isolated this segment of small bowel, we will resect it. Of note is that a pacemaker was fitted to this patient 3 weeks ago, and we will therefore use the ultrasonic dissector and not bipolar diathermy.
We will now begin with the resection of the small bowel and thereafter make the anastomosis.
The problem in this case is to gain adequate exposure of the duodenum to make anastomosis easy and eventually our aim will be to free the duodenojejunal angle. A window is opened posterior to the bowel through the mesentery.
And one can see the posterior view here through the mesentery. For this purpose, the ultrasonic scissors is used. Tissues are inflamed and easily damaged and good hemostasis is imperative also because of the cardiac condition and the anticoagulation. Here everyone can see the color difference in the devascularized bowel.
The division will be on the duodenum, quite close here. Again, the ultrasonic scissors are used and there is no bleeding.
Here is the duodenum then and it appears to be well below the tumor. Now for the final posterior dissection of the duodenum. And there we go. It is finished. Shortly the other limb will be divided. We have 2 options, either hand-sewn or a mechanical anastomosis. For a hand-sewn anastomosis, it is necessary to have a clean plane, anterior and posterior, in order to do an extramucosal anastomosis.
Mechanical anastomosis is also possible. The anvil of the circular stapler can be placed in the duodenum and the stapler itself in the distal small bowel to perform an end-to-side anastomosis.
The open end of the small bowel can then be closed with a linear stapler. This will of course require a lumen of adequate size to accept the stapler. A bag as well as a small swab for hemostasis is next introduced. The segment of small bowel is pushed into this plastic bag.
Another 12mm trocar is now introduced to the left of the midline allowing a closer view of the operative field.
Mobilization of the proximal small bowel is now completed. I can now take the circular stapler. We have prepared the proximal bowel, it is well mobilized for the anastomosis and we can introduce the anvil of the circular stapler.
It is introduced here laterally. Now it may be a problem as it can be difficult to introduce the circular anvil into the duodenum. But no, it fits easily without difficulty. Now an assistant pulls upwards on the anvil and this makes sure that the bowel is closed.
I shall finish securing the anvil with a loop.
The stapler is now introduced into the abdominal cavity, it goes through the same site, and this can be difficult. The difficulty is finding the lumen. There we go. The protective plastic sheath is held tight against the stapler on the outside to prevent the loss of the pneumoperitoneum.
It looks like a 25mm circular stapler is a good choice as it can be introduced with no difficulty.
This is enough, we can remove the spigot. Then anastomosis should be performed about 2cm or more from the end of the bowel to prevent ischemia.
Now we have to lock the anvil onto the stapler always under vision to be sure that it is done correctly. There we go. It is locked. There is a lot of tissue around the duodenal side, but this will be pushed out by the stapler. There we go. It should always be done under vision to be sure that the tissue is trapped in the jaws of the stapler. We must now verify the doughnuts. There is the distal one and here the somewhat thicker proximal, but it is clearly in continuity. One should always check that the duodenal side is circular. This is definitely an intact portion of duodenum, including the seromuscular layer. Next resection of the mesentery using a linear stapler like this. It might need one, two or three applications.
Now the bowel is also transected using the blue cartridge.
Let’s control the anastomosis, the color looks very good, the tumor may be a bit too big for this orifice, no there it goes, we will inspect it now.
And it is clear that the tumor was removed in total. This is a contrast study done 3 days after surgery, illustrating a good result with no leak. |
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Segmental resection of the duodenojejunal junction
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