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A didactic case of diverticular disease: laparoscopic approach

Authors

Abstract

This video demonstrates a simple sigmoidectomy for diverticular disease in which the surgeon preserved the superior rectal artery and only divides the left colic vessel.
The anastomosis is made using an EEN end-to-end.

Classification

routine cases

Keywords

sigmoidectomy,laparoscopic treatment,diverticular disease,sigmoid colectomy, preservation superior rectal vessels

Media type

Duration

14'00''

Publication

2005-11

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Audio

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E-publication

WeBSurg.com, Nov 2005;5(11).
URL: http://www.websurg.com/doi-vd01en1869.htm

A didactic case of diverticular disease: laparoscopic approach

1. Trocar placement 00'11''

Optical trocar A in supraumbilical position on the midline. I always use the same landmarks, midline, right and left mid-clavicular line, left and right anterior axillary line, pubis, anterior superior iliac spine. I then introduced trocar B and trocar C, my working trocars for my left and right hands, trocar D for the retractor and working trocar for the splenic flexure if I have to mobilise it. Suprapubic trocar on the midline to expose because I will do the extraction through the suprapubic trocar using a small incision with a plastic wound protector. I am on the right side, my first assistant holds the camera and is lateral to the right shoulder and the second assistant is between the legs to expose and help me with the anastomosis.

2. Exploration and exposure 01'36''

We are lucky because we have the possibility to retract, we have to free the small bowel a little that is fixed here. This is to have a better exposure. Here is the right ureter, here is the bowel. The sigmoid loop with diverticula, it is not a long and complex procedure. I think I will do the anastomosis close to here.

3. Medial approach 02'45''

I am dividing the meso, I have seen the promontory and here it is, I am dividing the peritoneum to find the vessels behind not far from the bowel because it is a benign disease so we will keep the rectum’s vascularisation. Why use 10mm instruments but you see it is not traumatic. I will do lateral freeing using scissors.

4. Lateral mobilization 04'20''

We have to show the ureter, it is just here.

5. Resection of sigmoid mesocolon 04'36''

We have freed now, better in this case because there were some adhesions, we will complete the dissection. I will ask the assistant holding the camera to expose and retract using the forceps. I can also use the monopolar scissors. In benign disease, we don’t have to divide the inferior mesenteric vessels as we do for cancer. Sigmoidectomy for cancer for example is completely different because we do the vascular approach at the origin of the IME. You see the Douglas’ pouch.

6. Mesorectum resection and rectal division 06'17''

I use these scissors as a hook. I think we can do the anastomosis on this side, it is not necessary in this case to do a mobilisation of the splenic flexure. You see I have the landmark that is this forceps fixed on the bowel, and I am going straight in the direction of the forceps in order to divide the meso and not the bowel. For cancer, I also divide the sigmoid or the descending colon. I will do the anastomosis 1 to 5cm above this limit.

7. Extraction 08'15''

Now I know the limit and I will do the extraction of the bowel through the small incision. I cannot put my hand in this incision but it is suprapubic. Here is the wound protector, a sheet with a plastic ring, we introduce it around the forceps. I put my finger into the abdomen and using my forceps as a second finger to retract and I push the sheet, pull on the outside sheet. We are ready to do the extraction.

8. Preparation of anastomosis 09'31''

It is well vascularised, we can see the vessels beating. We are now putting the purse string on. We have removed around 30cm. Why did you change the incision for exteriorisation from the right side to the suprapubic incision? I changed so I will keep my trocar, this incision is less painful than in the past, that is important but it is also more cosmetic. This is similar to the open, nothing to do with laparoscopy. I lift the sheet and put the clamp to have good water-tightness.

9. Anastomosis 12'00''

We check that there are no twists, no traction or tension. We will show you the system that helped us to introduce the stapler. This instrument is around 20cm long. We are now performing the water test. The test is good.

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