Laparoscopic ileocolectomy for caecal perforated diverticulum using the Ligasure Advance®

This patient presents with a perforation of a caecal diverticulum. The right parietocolic ridge is dissected, using the monopolar tip of the Ligasure Advance device. Hemostasis can be performed with the same instrument, using the bipolar sealing part. A classic ileocolectomy is carried out and a totally intracorporeal latero-lateral anastomosis is performed.

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Laparoscopic ileocolectomy for caecal perforated diverticulum using the Ligasure Advance®

Authors

J Leroy, J Marescaux

Abstract

This patient presents with a perforation of a caecal diverticulum. The right parietocolic ridge is dissected, using the monopolar tip of the Ligasure Advance device. Hemostasis can be performed with the same instrument, using the bipolar sealing part. A classic ileocolectomy is carried out and a totally intracorporeal latero-lateral anastomosis is performed.

Classification

basic techniques

Keywords

laparoscopy, ileocolectomy, caecal perforated diverticulum, Ligasure Advance

Media type

Surgical video

Duration

20'51''

Publication

2008-11

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E-publication

WeBSurg.com, Nov 2008;8(11).
URL: http://www.websurg.com/doi-vd01en2362.htm

Laparoscopic ileocolectomy for caecal perforated diverticulum using the Ligasure Advance®

1. Dissection of caecum 00'10''

We have put the patient head down. This will facilitate the retraction of the omentum and the upper part of the abdominal cavity. We use a zero degree scope to have a better exposure. Here is the right flexure. There is no problem here. The problem is located posteriorly to the ileocaecum. The appendix is normal. This is the appendix. You can see the inflammatory area here. I will use the blade that you see here to free the attachments. I can control the power of the device and I can change it. Currently I have 10-15 Watts and I’ll use 15 Watts, which is sufficient to cut. I can increase that to 20 Watts. This is monopolar Valleylab current. In France, it is rare to have diverticulosis of the right colon. There is a doubt of appendicitis but the gastroenterologist showed an inflammatory diverticulum on the images. If I want to coagulate, I can do it this way. I think that there is a diverticulum behind. The ideal is to perform an ileocaecal resection.

2. Division of ileum 03'45''

This was a diverticulum; I have just cut it. It was fixed to the appendix. This is the opening and I will do an ileocaecal resection. We will begin the procedure. This is the ileum. I have freed the attachments. I will divide the ileum first. We make sure that we have not grasped or caught other structures than the small bowel and the mesentery. I use a white cartridge as you see and I cut. There is no risk of ischemia. Normally I use a blue cartridge but you see that we have divided the small bowel. When we divide, we have to respect the anatomy, particularly the vascularization. Don’t divide like this but shorter on the antimesenteric side than on the mesenteric side. This is to respect the anatomy. I will continue the division. You see if you have staples, if you lock, you will have no possibility to coagulate or to seal, it’s because you are in contact with metallic staples.

3. Division of mesentery 05'30''

You coagulate and you begin to cut. I continue the division of the mesentery. The LigaSure Advance® I use is a single use device. It’s not only a device to staple and divide structures. It’s also a device to dissect with monopolar cautery and to grasp. It’s a versatile instrument. It’s a knife and/or scissors too. I respect as much of the vascular supply as possible; this is why I’m dissecting close to the mesenteric side of the bowel. You see I’m using bipolar cautery. We will soon finish the dissection. Now I want to dissect posteriorly the fixation. I have to be sure that I am anterior to the retroperitoneal structures, particularly the ureter. But the ureter is more medial but if we have a doubt, we have to see it. These are the posterior attachments of the ascending colon. I’m freeing them. You see the mesentery, the appendix, the ileum (5cm of ileum) and the ascending colon and I will divide the colon now, the ileocaecum. I have kept as much vascular supply as possible. The appendix is always fixed posteriorly there. It’s why I have some difficulties. This was where there was the diverticulum. So I have to remove more. I will do some more posterior freeing. The best is to have one more trocar to better expose. The main problem when we do an ileocaecal resection or a right colectomy is to respect the vascularization of the colon. We will keep and in benign disease we have to stay close to the mesenteric or mesocolic side of the colon to respect the marginal vessels.

4. Division of right colon 10'45''

This is the mesenteric side keeping the marginal vessels. You see the difference in color. This is why it is important to have a good camera because if we don’t recognize the structures, it’s difficult. You see I have the omentum to complete the division. Be sure that you take the side that is well vascularized. So we now keep the ileocaecum in the pelvis.

5. Intracorporeal anastomosis 12'10''

Now how to find the stump of the small bowel? We have to follow the line of the mesentery and we do this way. I will put the 2 segments together. We can free more if we want it. We keep this like it. See the 2nd one, at a minimum 2cm distance of the stapling line distally. It’s a landmark to keep a pulley to avoid cutting the tissue and the nodes. It’s unnecessary to tighten too much; this is only to maintain 2 segments of bowel close. This is a side-to-side isoperistaltic position. We remove this. First I have to palpate. I will use an angulation like this one. Now we have to close. There is one problem. If you close only the whole anterior part, you will get a danger. It’s why you have to verify posteriorly and to be sure that you have completely done the sutures. I want to be sure that we have the 2 angles of the sutures. We can also verify that there is no bleeding. We can also do the anastomosis through a small incision. I’m close to the suture to catch coming around. Catch, pull, watch. I’m pulling keeping a short thread ready to do another one. Extramucosal one. When I pull like this, the suture will slide and it is perfectly closed. I think it’s a good closure. Even if we have not had a re-operation for bowel obstruction due to incarceration of the small bowel after a right colectomy, this is a risk. We have had postoperative ileus probably due to partial incarceration of the bowel. In the left colon, we have had and we did a prospective study. This is the duodenum as you see here. We have 2 options: closing by a medial or by a lateral approach.

6. Closure of the peritoneal window 18'40''

I will close using a lateral approach. Can we always use the Ligasure for hemostasis and division of the vessels without any risk? I think, particularly for big arteries but also for vessels if we have arteriosclerosis, it is probably better to complete the procedure with a loop. I will close together.

7. Extraction 19'35''

Then we have to remove the specimen. We introduce the bag and put the specimen in the bag.