Laparoscopic rectosigmoid resection for endometriosis

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Laparoscopic rectosigmoid resection for endometriosis

Authors

J Leroy, J Marescaux

Keywords

laparoscopy,rectosigmoid resection,endometriosis

Media type

Surgical video

Duration

25'00''

Publication

2004-12

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E-publication

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1666.htm

Laparoscopic rectosigmoid resection for endometriosis

1. Case presentation and trocar placement 00'08''

This is the case of a 30-year-old patient with problems of sterility due to endometriosis operated upon a few years ago via laparoscopy and small Pfannenstiel incision, for ovarian endometriosis and a left adnexectomy was performed. The BMI of this patient is 19, which is exceptional in our practice; the patient is in a supine position with her right arm along the body, left arm at a right angle, the laparoscopic unit is on the left, all the team is on the right side of the patient, I and the assistant are seated between the legs of the patient. We use a few trocars, we can use less but I want to show you the anatomy very well, so we will use them for exposure. Usually for colon surgery, I use 5 trocars, it is particularly important in obese patients to have more exposure for laparoscopic surgery but not only. The patient is in a Trendelenburg position, with a 20-25 degree right lateral tilt, I have drawn the ribs on the abdominal wall, the pubis, left and right anterior superior iliac spines, the midline, the anterior axillary line, right and left mid-clavicular line. First, I have introduced a 12mm trocar using the mini-open technique for the zero degree, 10mm scope. First working trocar for my left hand at the crossing between the mid-clavicular line and horizontal line through the umbilicus 8 to 10cm lower, I introduce another trocar, always on the mid-clavicular line, it is the trocar C; it is a 12mm working trocar in which we will place the stapler and a 10mm Ligasure device. This is the scar of the Pfannenstiel incision performed a few years ago, I will extract the specimen through this incision. I have introduced a 5mm trocar on the midline through this scar. The trocar D is at the crossing of the left mid-clavicular line and horizontal line through the umbilicus. I introduce in this trocar a retractor for the proximal small bowel that maintains the small bowel up. Trocar E will be used to introduce forceps or retractor to expose the pelvis even more.

2. Exposure 03'50''

First of all, I retract the small bowel cephalad and keep it there using the forceps introduced in the trocar D on the left. This is a forceps that is positioned without grasping on the back, not on the bowel, and I push on the right the small bowel. You have to imagine the root of the mesentery that is the limit of the duodenojejunal junction and ileocecal junction and we push the small bowel laterally to the right and we have to keep it as such. You see the vena cava, with the pressure due to the pneumoperitoneum. If we change the Trendelenburg position, we will see more blood. We have done the panoramic exploration of the abdominal cavity, we have seen nothing in the supramesocolic area, on liver as well, there were no adhesions, particularly on the Pfannenstiel incision. We have a stenosis about 10cm in length at the top of the sigmoid loop and we have the same sight after exposure because there is a very compliant proximal sigmoid loop, distal is also good. This is the rectum, we have the right ovary; we have found a small endometriotic nodule that we will treat at the end.

3. Colorectal dissection 06'13''

I am dissecting close to the sigmoid colon because I want to respect the superior rectal vessels. 80% of the vascularization is done thanks to the superior rectal vessels; so in benign diseases we respect this vascularization. It is not only for the vascularization but also for the innervation because the nerves are around, so functionally it is better to keep the venous and arterial vascular supply. We have used a conventional bowel preparation with no fibres for one week and an enema yesterday and this morning. No postoperative treatment, it depends though, if we have an abscess, we will use some but in this case just prophylaxis, flash during the induction for the anaesthesia. I am using the bipolar Ligasure but with pressure, I never use a monopolar. I don’t use hooks but scissors. In this case, these are the vessels, we have to use Harmonic scissors. The design of the 10mm instrument is a security for the dissection. Here’s the ureter. I am dissecting by using it like a finger, I am not creating a round plane. I have to divide the vessels now. My device is always in the same trocar for the dissection of this area. Do you do imaging of the ureter before the operation for severe endometriotic cases? We have MRI so they have had this analysis but it is important to know because as you know, there is a big risk of ureteral stenosis and endometriosis too. It is only as for digitoclasia, I am using a 10mm instrument to separate the nodule, there is a big nodule. I am using the instrument. Normally when I operate this kind of patients they are prepared by the gynecologist. For this type of dissection, I only use Johan forceps, no dissector but why not? It’s a matter of practice. I am sure that the ureter is here now, I see it moving but will see it better. This was probably the lumbo-ovarian ligament. I have to continue my sigmoid dissection, it is not an easy case. I don’t think we can dissect them separately. There was a question before the start of the procedure, is it possible to dissect and preserve the sigmoid? I don’t think so, I cannot say why but it is impossible to have a dissection of this and make sure there is no nodule inside between the loop. A new section lower if I find more endometriosis. Slowly I am getting close to the rectum. This is the Douglas’ pouch, there is probably a nodule but I’m not sure where the limit is, I will resect this and I will probably do the division of the rectum just under this. I can’t understand why you start from the bowel instead of starting from the lateral, remove all the endometriosis and leave the bowel as the last step? I use a medial approach because the anatomy is easier to recognize, I will have landmarks and it is particularly interesting for the ureter because if I want to begin laterally, I will have difficulties to find it. As you have seen, I did have difficulties laterally. I also want to show that you can have a lateral or medial approach, if you are more comfortable with the lateral one I am not against it, we chose medial because we have chosen to do a vascular approach, then we continue the dissection opening the different planes that we discover using a medial approach. We don’t have to retract the colon because it is lateral, we don’t have to manipulate the colon so it is better in case of tumors. I want to find the inferior limit of the rectum; for that, it is necessary to dissect the rectum laterally; the limit between the rectum and the nodule. This is the nodule, a big one. Before finishing the dissection on the left, I have to see the ureter before; on the right, I think I have enough distance. This is the rectum here, the uterus is here, the plexus is probably not far. This is probably the nerve. I operated on a young patient like this, I saw and preserved the nerve during the dissection, I used Harmonic scissors and not monopolar ones, postoperatively there was a homogeneous urinary bladder. Progressively got good results but it is a danger. I’m dissecting around.

4. Rectal division 16'50''

We have finally transected the rectum at a distance from the nodule, I will show you now where the nodule is. We did the division of the rectum here, the nodule is 1-2cm above, this is the nodule and the fixed sigmoid loop and with stenosis. There is endometriosis, I felt it with the palpator. I think it is the same lesion that I have separated with my device. This is the limit where I will do the resection, you see we have the blue part, ischemic one, and the vascularized part, we see the vessels are beating on this proximal part. The thing is to respect a good vascularization.

5. Exteriorization and division of colon 19'22''

I will do the exteriorization at the suprapubic area, I perform a small local transverse incision such as the Pfannenstiel one. I will use the wound protector, it is a plastic drape with a plastic ring. I catch the distal extremity of the colon, introduce my finger round the forceps and also use the forceps as a retractor. You’ll have the confirmation that there is also endocolic endometriosis, this is why the patient had rectorrhagy before. We will open the specimen and show you later. I apply a purse-string. We will introduce a circular stapler. It is bleeding, pink, good vascularization.

6. Anastomosis 21'07''

For the anvil, we will use one 31mm in size. Close the purse-string. We complete the preparation as we do in open surgery, it is not specific to laparoscopy. It is important because we have had bleeding from the small vessels that retract when we apply the circular stapler. Better to check that there are no vessels as we are here, it is very important to prepare the stump. My preparation is finished, I reintroduce this, lift the ring that is fixed back on to the abdominal wall and I lock to have airtightness. I use this to be atraumatic, I push until the device is locked, close the red and blue part. We check that there are no twists. We tighten the device and we fire, twice because we also have to cut the staples. The anastomosis is complete. We insufflate. There are no bubbles. We will now remove the endometriotic cyst.