Laparoscopic sigmoid resection for acute stenosing sigmoiditis

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Laparoscopic   sigmoid   resection   for   acute   stenosing   sigmoiditis

Authors
J Leroy, J Marescaux
Keywords
laparoscopy,sigmoid colon resection,acute stenosing diverticulitis
Media type
Duration
25'00''
Publication
2003-11
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Nov 2003;3(11).
URL: http://www.websurg.com/doi-vd01en1516e.htm

Laparoscopic   sigmoid   resection   for   acute   stenosing   sigmoiditis

1. Case presentation 00'31''
Concerning the position of the trocars, I have drawn on the patient different vertical lines, the midline, mid-clavicular line to the left and to the right after insufflation of the abdominal cavity and a horizontal line through the umbilicus. The pubis, the xiphisternum, the ribs, and the angle is widely open, which is interesting for the dissection through the abdominal cavity. The first trocar was introduced just above the umbilicus, we can introduce it higher; it is a 12mm trocar introduced by a mini-open approach, it is a One-step trocar introduced with a needle and we dilate progressively to introduce a trocar. We then introduce trocar B at the crossing between the horizontal line and the right mid-clavicular line; it is a 5mm working trocar for my left hand. Trocar C is at this moment a 5mm trocar but I have to change and introduce a 12mm trocar. So we change the trocar inside and we will choose 5 or 10mm at the beginning. This trocar is also on the mid-clavicular line, 8 to 10cm lower than trocar B. Trocar D is introduced at the crossing between the left mid-clavicular line and the horizontal line through the umbilicus; it is the mirror image of trocar B. Trocar D is a trocar used for retraction to start with, then if we have to mobilize the splenic flexure, the trocar will be a working trocar to dissect. Trocar E is introduced in the suprapubic area, it’s at this level that we will do the extraction of the sigmoid and it is why I don’t hesitate to introduce a trocar in this area to better expose the root of the mesosigmoid. If I have difficulties to expose, particularly the ileocaecum, I will introduce another trocar to retract behind the ileocaecum my trocar B and C and maintain it in this position. Or/and, using also this trocar to expose very well the omentum during the mobilization of the splenic flexure. Here is the inside view, we have exposed more than the Trendelenburg position of the patient, we have particular adhesions between the mesocolon and the mesentery as you see here; we are in the pelvis and we have a big fixation, we have the appendix here, a little fix on the mesocolon, the sigmoid here and lateral fixations, fixations to the bladder, perhaps we will have an abscess, we have fixations here too, it is completely fixed, we will not free this. First, we have to expose the small bowel more; for that, we will put it more laterally to the right. You see we have small adhesions between the mesentery and I have here the small bowel, good bowel preparation, this is the duodenojejunal junction, we have the pancreas here. We see very well, it is not a complicated patient for exposure. Can you tell us how you prepare the patient and another thing is do you dare with this grasper to grasp the bowel on the seromuscularis or do you avoid that? We had some lesions of the bowel when you take it, especially when you remove the small bowel to the right, we had some lesions when we used these graspers? We use as you can see this giant forceps, it is fairly atraumatic and I think we can grasp bowel with this kind of forceps. Personally I do not like to use a Babcock, it is really dangerous to use them even if it is not a small size; they use 12mm, less traumatic perhaps than 5mm but I think it’s not really adapted for bowel procedures. If you have bleeding, you can use this giant forceps as a clamp, so it is interesting to have atraumatic instruments. This is the root, I will not dissect more because it is not necessary; you see this is exposure now. My technique is to respect the superior rectal vessels if I can. You see this is the sigmoid behind, we are on the left side. Can you tell us about the Ligasure instrument? This is a bipolar system that cuts and seals and controls the results automatically. I want to say that I do a medial approach. I don’t free the colon first as you see. I am at a distance to the retroperitoneal structures, I am in the meso. It is like Endo-GIA, you have sealing, coagulation between the jaws, the computer calculates according to the sickness and type of the tissues, you can seal vessels, you can seal different tissues such as fatty tissues, and I have a knife between. When you lock, you can also use it as scissors, there is a knife between. Will you divide all your vessels with that instrument or will you use clips as well? I have not used clips for 2 years, I do it all with this instrument, also the inferior mesenteric vessels. What do you think is the advantage of this instrument as compared to the Ultracision? I think it is better because it does not depend on the experience of the surgeon. When I look at your instrument, it seems to have less diffusion of the heat I think, if you compare with Ultracision. It is a 60 degree around, and it is a 10mm, and it is better than the 5mm that we have used but it is not adapted, particularly for this case. I will now free laterally because I have dissected enough. I am in the meso, I am not posterior to the meso except here, and you will understand why now a 10mm is better. Are you here over the arterial pedicle of the inferior mesentery or are you under it? I suppose I am anterior to it. Now thanks to your experience you are becoming an instinctive surgeon. We cannot do that with a 5mm, it is as a finger now, completely atraumatic too. I use digital dissection. I do not cut, it is only done with digitoclasy. This is a good example where people who don’t have Joël’s experience could do part of the procedure by laparoscopy, which is out of this inflammatory area and then make a Pfannenstiel incision or use Handport. This is quite difficult there are no planes, it is difficult to know where the structures are, difficult to be sure that you don’t make a hole in the colon. It is not dramatic to have a hole in the colon. You see this instrument is completely atraumatic. I am in the meso, I am not posterior to answer your question. As you can see here Joel is preserving the inferior mesenteric artery, he is between this artery and the bowel. This is a very difficult situation when you have this type of diverticulitis and most people probably not only for cancer but for easiness would choose to go under the inferior mesenteric artery. To go in this tissue directly in the inflammation, you have to be a very good expert. I am close to the bowel as you see. Now how do you know you are on the right level besides instinct? At this moment, I’m only dissecting. It’s compliant here. I have to open more here. For beginners, would you recommend seeing the ureter before doing that? The ureter is more medial so yes sure but don’t begin by this type of sigmoiditis. I was anterior to the meso so that means that I have to free laterally now, not a classic opening. I am on the left as you see, usually we have to cut at the limit between the anterior tenia and the anterior rectum. We will be sure we are in the right level when we introduce the stapler; if you cannot push it very high, it is because you are not in the right level. We can secure this dissection and probably it’d be interesting for the ureter. It is necessary to have contact, it is not sealing, it is coagulation. It is different from Ultracision, you cannot cut without current with Ultracision and this is like dissecting with a finger. We have to better understand this loop. Can you tell us where you go here? I have the lateral limit. The advantage of the Ligasure device is that wherever you go, it always looks right. This is the peritoneum, this is the root of the mesosigmoid, this is the peritoneum, it is not a dissection. The loops of the sigmoid were really mobile before, this is a left colic vessel, I don’t think it is necessary to dissect too much to do the anastomosis and I try to stay anterior to Toldt’s fascia. This is the left colic artery, we are on the Treitz’s angle. I think that if we do the anastomosis at this level, it will be good. First, I want to divide this to be sure that I have to mobilize more. So you see it is a lateral mobilization of the descending colon. The only problem I have is that sometimes I am obliged to put another 5mm trocar. I can probably use the lateral trocar D, so I want to have 2 assistants, one less. I coagulate only, I don’t seal in this healthy tissue. We can see here that you are very close to the colonic wall. It is a lateral approach, I think we have mobilized enough. I can show you that we can also seal the bowel, I did that but it is not recommended by the company. We have to divide the meso inside because if it is a huge meso, you can break the vessels when you do the extraction through a small incision. I will do the incision in the suprapubic area. Here we have the plastic drape with a ring, I use my finger and the instrument to dilate the incision and I push the ring and we now pull the specimen through the drape. We have to mobilize more. We leave part of the colon inside to have more freeing or possibilities, I check where we can pull more. There are stools inside but no liquid, I place a Babcock on the colon to maintain it. There are no differences with open surgery. We fix the ring and lock to have airtightness. See the vascularization? I maintain this like this with a fenestrated forceps, pull with my left hand so it is not complicated to remove as you see. With this I can grasp and catch the shaft easily and change the orientation of the assistant.