Laparoscopic sigmoidectomy for acute diverticulitis: medial approach with extensive IMV dissection

Colonic diverticulosis is an increasingly common condition in Western societies. Sigmoid colectomy for diverticulitis can be technically challenging because of severe inflammation in the left lower quadrant and pelvis. We here present a standard elective sigmoidectomy, after episodes of diverticulitis treated medically.

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Laparoscopic sigmoidectomy for acute diverticulitis: medial approach with extensive IMV dissection

Authors

F Corcione, J Marescaux

Abstract

Colonic diverticulosis is an increasingly common condition in Western societies. Sigmoid colectomy for diverticulitis can be technically challenging because of severe inflammation in the left lower quadrant and pelvis.
We here present a standard elective sigmoidectomy, after episodes of diverticulitis treated medically.

Classification

basic techniques

Keywords

Laparoscopic sigmoidectomy for acute diverticulitis, medial approach, extensive IMV dissection

Media type

Surgical video

Duration

17'30''

Publication

2009-02

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E-publication

WeBSurg.com, Feb 2009;9(02).
URL: http://www.websurg.com/doi-vd01en2500.htm

Laparoscopic sigmoidectomy for acute diverticulitis: medial approach with extensive IMV dissection

1. Transverse colon mobilization 01'04''

Now I’m going to detach the omentum from the transverse colon. I use only the cold scissors for this dissection because it’s very close to the bowel and I’m afraid to damage the bowel wall. I think that in the learning curve, it’s much better to perform the colectomy for cancer than for diverticulitis. I finish the detachment of the omentum from the transverse colon in order to get the lesser sac. This is the posterior gastric wall. The pancreas is there. And now the patient is put in a Trendelenburg position. This is the right position to help the surgeon. We have other adhesions here. We have to detach them in order to move the bowel on the right and to have a good exposure of the Treitz’s ligament that is our landmark.

2. Treitz\' ligament identification and start of medial dissection 02'35''

We identify the Treitz’s ligament and we mobilize the first bowel to allow the bowel be pushed on the right. Now the assistant takes the mesenteric vein and we start to identify the passage between the anterior and the posterior peritoneum in a medial to lateral dissection and to identify these very important planes. Here it’s very dangerous because sometimes it’s the anastomosis between the middle colic artery and the left colic artery. So if you cut these arteries, there is a risk of postoperative ischemia of the colon. Now we have found the dissection layers and we can start safely to dissect the anterior from the posterior peritoneum. Now we are approaching the artery, there are some inflammatory nodes around just 2cm from the aorta, I go here, and then as for the section of the rectum, I go below the sacral promontory. Down this cord, the aorta is there. The sacral promontory is here, see the right iliac vessels here. This is the line of the aorta, this is the mesenteric artery. The lymphatic tissue we want to dissect before the dissection of the artery.

3. Inferior mesenteric artery dissection and clipping 04'57''

Because of the nodes, I go a bit lower down. Now I have the opportunity to put a clip. Now we have the discontinuity of the posterior plane that we prepared before because this artery comes from the extraperitoneal space. And now we have to join the intraperitoneal space here with the extraperitoneal space. There we have the nerve of the hypogastric plexus and we must try to avoid damaging it. As you can see here, we have very inflammatory nodes. It’s an inflammatory disease here. Here we have the nerve. In order to complete this dissection, I think it’s better to prepare down the space of dissection. Now we can look for the ureter, which is here in my opinion. We use a medial to lateral dissection until the left parietocolic gutter. The only difficulty of this dissection is naturally because of the inflammatory disease here but up and down it’s very easy. Now I change my hand. I work with the left hand. I try to come back to this inflammatory tumor. We can wash and clean the field. Now we go to the mesorectal fascia.

4. Inferior mesenteric vein dissection and clipping 08'18''

Now we’re going to dissect the vein and to mobilize the splenic flexure from the lower edge of the pancreas. As you can see now, we have the vein here. My grasper takes the mesocolon and lifts it so that we have all the mesocolon up. The pancreas is down and now we go to prepare the inferior edge of the pancreas and to dissect it from the mesocolon. Now all the splenic flexure is mobilized from the pancreas, which is there. The Gerota’s fascia is there. It was all prepared. Now we leave the splenic flexure completely and we go down to the rectum.

5. Rectal mobilization 10'00''

The goal is to arrive to the upper part of the rectum. So if you need to change your position, I think that it’s no problem. We have the rectum lifted by the grasper held by the assistant. We lift the sigmoid with the other hand. The nerve is always dissected and I think that we have reached our level of dissection. Now we prepare the right rectal artery.

6. Rectal division 13'59''

Now we stay for 10 seconds before cutting. Bariatric surgeons suggest closing the stapler before cutting in order to have a good tissue compression, and then we go to perform our mini-laparotomy.

7. Colon division 14'30''

I identify the peritoneum easily and then I am inside. The pubis is there. We will do a tension-free anastomosis. The tumor is there with this inflammatory disease of the nodes.

8. Anastomosis 16'06''

We section the colon, and then as you can see, we are ready for the anastomosis. I recommend you to look for the good position of the tenia of the colon; as you can see, we have the whole of the Gerota’s fascia free.