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Laparoscopic approach for sigmoid diverticulitis using LigaSure in a female patient with previous hysterectomy

Authors

J Leroy, J Marescaux

Keywords

sigmoidectomy, laparoscopic treatment, diverticular disease

Media type

Duration

24'40''

Publication

2006-02

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E-publication

WeBSurg.com, Feb 2006;6(02).
URL: http://www.websurg.com/doi-vd01en1873.htm

Laparoscopic approach for sigmoid diverticulitis using LigaSure in a female patient with previous hysterectomy

1. Trocar placement 00'10''

Now to trocar placement. Midline. Left and right mid-clavicular line. Left and right anterior axillary line. Horizontal line through the umbilicus, pubis, anterior superior iliac spine. I have drawn the scar. Now Pfannenstiel incision because the patient had a previous hysterectomy and appendicectomy through a McBurney’s incision. The patient is in supine position, right arm alongside the body. All the team is on the right side. The laparoscopic unit is on the left. One assistant stands between the patient’s legs. We will put the patient in Trendelenburg position

2. Exploration and exposure 01'10''

and use gravity to better expose the pelvis and use a right lateral tilt too. You can see the pelvis with the transverse colon falling in the pelvis, sigmoid with good compliant bowel and omentum, stomach, spleen, left liver, pancreas too, right liver, bladder, and the hepatic flexure. And you can see the diverticulum here. The 1st step is to retract the omentum cephalad. We will retract the small bowel. This is the renal vein, the duodenum and we do the exploration. There are adhesions in the pelvis. We have the right ovarian. This is the diverticulum, strong and rigid when palpated. This is the posterior fixation and we will not touch this.

3. Sigmoid mobilization 02'50''

We can do the anastomosis in this area and we will remove the whole sigmoid loop. Did you see the ureter moving? We will free laterally when we have a doubt about this. Since I have no electrocautery, I’m using scissors. We have 2 screens, among which one above the patient’s head for the assistant standing between the patient’s legs. The ureter is here. This is the Fallopian uterine tube. There are adhesions to it. I have found the correct plane. Normally when it is an obese patient, we’ll do the complete dissection using a medial approach. This is not completely medial in this case. The goal is to free completely this. I’ll have to remove this because we’ll have a necrosis and fever probably. You see that exposure is essential here. If there was a colovesical fistula from diverticular disease, how would you approach that sort of problem? It depends on the type of fistula, but for chronic fistulas, we first have to approach the meso entirely using laparoscopy and do it in one step, and we can resect the fistula and suture the urinary bladder and resect the bowel at the same time. In severe diverticular disease, do you do subtotal colectomy? Why so? It’s rare to get complication on the right side. No, we don’t. We perform a colectomy. The objective is to do the anastomosis under the colorectal junction. I’m using the instrument as a finger. This is the rectum.

4. Rectal and mesorectal dissection 10'20''

The device is warming laterally to the jaw, not anteriorly or posteriorly. If you’re coagulating, don’t do this way otherwise you’ll have the steam going to the bowel. Stay laterally. Did you experience any bleeding after surgery or using the Ligasure on inflammatory large blood vessels? No, I didn’t. We have had bleeding because we didn’t respect the sealing. Bleeding close to the anastomosis of the proximal colon, I use the Ligasure outside as a bipolar. I have not sealed. I did not respect the protocol of the device. I can do a bipolar coagulation and I haven’t finished. This is adhesion to the Fallopian tube. When I divide the IMA at its origin, I don’t do it close to the aorta. I will use this instrument to have a better retraction. It may be better to train with scissors to acquire a good technique and go faster but I’m trying to make a ligature of the IMA. Before using clips, I did a lot of ligatures using extracorporeal knots. This is my technique for hemostasis, it’s a twist on the vessel.

5. Rectal division 15'26''

I always put the blue cartridge anteriorly because I can lift and see better the application of the staples. This can be used as an atraumatic forceps. We can use it as a dissector to open and dissect between (for example for the prostate)

6. Division of sigmoid mesocolon 16'30''

and we will do the anastomosis approximately here. I will divide the mesentery. I will always divide the mesentery inside. To respect more the vascularization, I prefer doing a section like this and to complete afterwards outside this way. I respect more of the vascularization of the colon. Even if you do the anastomosis at this level, don’t do the division. I’m preserving more of the mesentery. It’s not important in this case, because the mesentery is very thin. In case of fat mesentery, if I want to reduce the size of my incision and to break the mesentery during the extraction through a small incision, it’s better to divide it inside. In diverticulitis, do you think we have to resect larger to release the left colic artery and vein? We used to have mechanical studies on this left flexure and left colon, and we do in diverticulitis larger resections. What is your opinion about it? Just for the left colic artery and vein, so we ligate it and we do larger resections. I’ll say yes if it is a diverticulosis in fatty patients, we regularly do it in 80% of cases but it’s not necessary; I’m not sure that it’s important to do a mobilization of the splenic flexure and large resection, it’s necessary to do the anastomosis on the compliant part of the colon, descending colon, it’s sufficient. What is important is reduce the risk of recurrence and to remove the colorectal junction; afterwards, you can do the anastomosis. You see this is the rigid part. I do if it’s necessary. I don’t think it is necessary in this case.

7. Extraction 18'58''

I pull the trocar, introduce my finger, I push between my fingers and I pull anteriorly and automatically the ring is well positioned. Now we can pull the bowel. We see the good vascularization of the bowel.

8. Preparation of anastomosis 20'01''

You see the vessels beating. Because we have a benign disease with an abscess, this is a trick to facilitate the exteriorization. If you squeeze the colon against the abdominal wall, you will get a higher risk of infection. You also see that the bowel is coming easily and stays easily outside. I put a Babcock forceps to prevent the bowel from falling. I begin to close the knot. Let’s reintroduce it. You see that it’s well protected. We’ll use a drape. It’s not necessary to close. We’ll do a complete mobilization.

9. Anastomosis 22'53''

It’s mainly because we sometimes have difficulty to push the circular stapler without the anvil in the upper part of the rectum and sigmoid colon. In open surgery, we have hands to help. Laparoscopically, we have no hands in the abdomen to do it. That’s why using visual control is essential. The new generation of PCEEA will be as Ethicon without removing the tip. We have good traction, good compliant bowel.

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