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Diverticulitis: laparoscopic sigmoidectomy with preservation of superior rectal vessels

Authors

Abstract

This live video shows the salient steps in sigmoid resection for diverticulitis. The important differences between operation for benign disease versus that for malignant disease are discussed in detail and emphasized at each juncture.

Keywords

diverticulitis, laparoscopy, sigmoidectomy, preservation, superior rectal vessels

Media type

Duration

17'11''

Publication

2007-11

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E-publication

WeBSurg.com, Nov 2007;7(11).
URL: http://www.websurg.com/doi-vd01en2170.htm

Diverticulitis: laparoscopic sigmoidectomy with preservation of superior rectal vessels

1. Case presentation 00'15''

Firstly, I want to show you the exposure. We are encountering difficulties in exposure because the small bowel is dilated. Therefore, we have chosen to retract the bowel to the right. You can see the bowel is moving so we are waiting for the antispasmodic agents to function. The exposure we have is sufficient to carry out the procedure. Here you can see the aorta. Through the sigmoid mesocolon we can see the IMV, the ureter just behind, the pancreas, the left colic vein and artery.

2. Vascular anatomy of the sigmoid 01'20''

I will preserve the vascularisation of the rectum, keeping the superior rectal vessels (artery and vein). I will divide the sigmoid branch only. How can I do if the view is impaired? Normally it’s at mid-distance between the mesenteric edge of the colon and the root of the sigmoid mesocolon. I use a 10mm LigaSure device.

3. Dissection of the sigmoid mesocolon 02'09''

I will divide the peritoneum first. I will not resect the descending colon. I will not remove all the diverticulum. The dissection will be performed very low. I will remove the colorectal junction. Except if we have diverticulitis on the descending colon, but we don’t. Colonic exploration is continued. Diverticulum is to be found on the transverse and right colon.

4. Initial lateral dissection of the sigmoid 03'15''

We then free the lateral attachments of the sigmoid colon to obtain a better view of the sigmoid mesocolon. My left hand plays an essential part doing the dissection.

5. Division of left colic artery with preservation of superior rectal artery 04'50''

6. Dissection of colorectal junction 06'37''

I’m now dissecting the colorectal junction. By approaching the bowel we perform a conical division of the mesorectum. It is not a TME dissection. We are not far from the Douglas’ pouch. The 10mm LigaSure device is being used so no risk of burn injuries is possible when we are in anterior and posterior planes. The steam is evacuated laterally in between the jaws where there is a potential risk of burns. The LigaSure device is used as a finger to find and free the plane. I commence medially by identification of the ureter and anatomical structures. We place a probe in the ureter to make sure we don’t have any injury.

7. Division of distal colon 08'30''

8. Proximal colonic mobilisation including splenic flexure 09'04''

9. Proximal mesenteric dissection including entry into lesser sac 10'51''

The anastomosis is performed at this level approximately, just above. The lateral attachments have been freed. We will open the lesser sac by a medial approach. This is why we divide the peritoneum always laterally to the IMV in the case of sigmoidectomy for diverticulitis. The pancreas is behind my forceps and I’m now dividing the peritoneum and I will open the lesser sac. So we keep the inferior mesenteric vein. We cut the branches. The lesser sac is now opened. The pancreas can be seen beautifully in the back of the lesser sac. Here we can see the root of the transverse mesocolon. The danger is also to dissect the mesocolon and injuring the marginal vessels. Therefore extreme caution must be taken at this stage. Here we can move down all the colon and remove the sigmoid colon and descending colon too. The mobilization is now complete

10. EXteriorisation of the sigmoid colon 13'26''

Now we can proceed with the extraction of the colon through a suprapubic incision. If you stay anterior to the fascia, the ureter is behind. In case of doubt, you have to take a closer look.

11. Resected specimen 14'46''

12. Insertion of stapler anvil 14'58''

I will use a 28 DST (new one): this is a specific anvil that will be put into the proximal colon.

13. Reinsertion of colon into peritoneum and restoration of pneumoperitoneum 15'22''

I reintroduce into the abdomen to see that the anvil stays not far without traction on the rectal stump. We have the option of mobilizing further if need be.

14. Introduction of circular stapler 15'54''

15. Completion of anastomosis 16'27''

What’s coming through is a spike. He’s grasping the blue area (the plastic bit). You must not grasp the tip but you have to cover the orange ring.

16. Anastomotic doughnuts 16'54''

You don’t need to twist or rotate.

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