Laparoscopic sigmoidectomy for cancer in an obese male patient (BMI=32)

We present a laparoscopic sigmoidectomy in an obese patient using the AirSeal device. This trocar uses a different approach: instead of establishing a seal around each instrument, this trocar offers a totally open passage from the outside to the intra-abdominal space – i.e. no diaphragm, valves, gels, etc. — and maintains the pneumoperitoneum using a pressure barrier.

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Laparoscopic sigmoidectomy for cancer in an obese male patient (BMI=32)

Authors

J Leroy, J Marescaux

Abstract

We present a laparoscopic sigmoidectomy in an obese patient using the AirSeal device. This trocar uses a different approach: instead of establishing a seal around each instrument, this trocar offers a totally open passage from the outside to the intra-abdominal space – i.e. no diaphragm, valves, gels, etc. — and maintains the pneumoperitoneum using a pressure barrier.

Classification

complex cases

Keywords

laparoscopy, sigmoidectomy for cancer, obese patient, male, BMI of 32

Media type

Surgical video

Duration

15'00''

Publication

2008-10

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E-publication

WeBSurg.com, Oct 2008;8(10).
URL: http://www.websurg.com/doi-vd01en2411.htm

Laparoscopic sigmoidectomy for cancer in an obese male patient (BMI=32)

1. Air-seal device presentation 00'15''

The purpose of this video is to show the laparoscopic sigmoidectomy using a new device, which will facilitate the different steps of the procedure. First, in an obese patient with a BMI of over 30, we will use the new Airseal trocar manufactured by Surgiquest; the advantage of using it is that the valve is made by the pressure of the gas, and there is no contact between the lens and the scope in order to ease the cleaning and get better vision through the scope. We also use the Anchorport by Surgiquest that can be easily introduced through the abdominal wall and that can be well fixed using the elasticity and the silicone used for the trocars.

2. Medial approach 01'37''

Following exposure of the bowel, the peritoneum is opened on the right side of the sigmoid mesocolon; this is done from the anterior part of the sacral promontory towards the third duodenum close to the duodenojejunal junction. This peritoneal opening is made using the Ligasure Advance® monopolar probe, 2mm distal to the device. We carefully and slowly continue the dissection using the Valleylab monopolar mode for the dissection. The danger if used blindly is that it can injure, but as you can see in this case, we use the tip and there is a bleeding; we control it easily with the device because it can also grasp and seal atraumatically the vessels that have just been injured.

3. Inferior mesenteric artery (IMA) ligation 02'57''

The IMA is divided 2cm proximal to the aorta, we complete the sealing by putting a clip or a loop particularly in elder patients because when you have atherosclerosis, sealing is sometimes dangerous with the risk of postoperative bleeding. However, our experience of that is limited because in 4 years of using the Ligasure, we have had only 1 case of postoperative bleeding and it was well controlled.

4. Dissection and ligation of the inferior mesenteric vein (IMV) 03'43''

We complete the dissection of the IMA, then of the IMV, and skeletonization is minimal, and we try to keep the surrounding tissue as this will avoid injury of the vein and we will manage to keep enough stump of the vein to do what we did with the artery: we put a loop around and with surrounding tissue, we tighten the loop but not too much, only enough to close and complete the closure with the sealing. When we have divided the vessels, we complete the dissection of the attachments of the descending colon and of the sigmoid mesocolon. The aim is to find the right plane, anterior to the Toldt’s fascia. It is easy using traction and counter-traction, using tools that divide the attachments. We do this medial posterior dissection until we reach the posterior and lateral attachments of the descending colon. The same is carried out for the root of the sigmoid mesocolon; we complete the dissection using adequate traction and counter-traction.

5. Lateral approach 05'27''

In obese patients, the small bowel is occasionally not far from the dissected area. This is why we use tools that facilitate dissection, such as curved mini-shears roticulating scissors manufactured by Covidien, but also by using well protected tips to avoid contact with the lateral tissue. Here you can see the division of the lateral attachments using monopolar scissors, with low energy: between 15 and 25 Watts using a Valleylab generator, enough to divide the attachments. It is mainly the traction applied by the instrument to the left that allows the division of the attachments. You can see the same maneuver with the Ligasure advance®: we perform the division of the lateral attachment of the upper part of the mesorectum.

6. Colorectal junction dissection and division 06'52''

The tumor of the sigmoid colon is high enough so we will do the division of the rectum at the colorectal junction. This is why by using the 5mm Ligasure Advance® device, we seal and divide the tissue till we reach the bowel, and more specifically the colorectal junction. The advantages of the plastic jaws are that we have a good protection during contact, no hyperthermia in contact with the right and blue part of the device, temperature is applied only between the jaws and lateral to the jaws, not in contact with the jaws of the instrument. When we have finished dissecting the colorectal junction and because this is a tumor of the sigmoid colon, we ligate the bowel underneath the tumor. This is to respect oncological principles proposed by authors who want to close the bowel underneath the tumor in order to wash the distal rectum with betadine solution before applying the linear stapler (Endo-GIA 60mm); this will be carried out after washing the rectal stump. We check that there has indeed been a complete division and closure of the rectal stump with the stapler before dividing with scissors.

7. Splenic flexure mobilization 09'06''

We then have to mobilize the descending colon; some authors advise doing the mobilization of the splenic flexure immediately; personally I prefer to do this at the end of the procedure because I will mobilize no more than is necessary using mainly lateral mobilization from caudad to cephalad and by dividing proximally to the bowel the colo-omental attachments. We do this laterally until we open the lesser sac, we see the stomach, anterior to the pancreas. After we have mobilized sufficiently, we turn the splenic flexure to take down the descending colon. When we have set the limits of the segment to be divided.

8. Proximal colon division 10'13''

We proceed with the division of the meso and because this is an obese patient, we will divide more distally and keep a segment of colon that will be pulled through the incision. The resection will be done higher but as you will see inside the abdomen to preserve the vascularization.

9. Extraction 10'51''

To perform the extraction, we easily introduce around the suprapubic trocar a plastic wound protector through which we push an Endo-catch bag with a diameter of 15mm, a big bag for large specimens. The segment of colon is placed in the bag, which is closed and pulled through the plastic wound protector: this facilitates the extraction, especially in obese patients, and allows manipulation of the specimen inside the bag without risk of contamination of the abdominal wall and does not need the incision to be enlarged for extraction. When we pull the proximal colon that we have mobilized before. However, with not enough mobilization to extract it out and due to the thickness of the abdominal wall, it is difficult to do a complete extraction. This is why we have kept a length of colon, that we open extracorporeally without pulling too much on the meso that is very thick and fragile as vessels could be damaged.

10. Anvil placement 12'31''

We have attached the shaft of the anvil to the circular stapler using 2 sutures, and we push the anvil proximally in the descending colon. Under laparoscopic control and while maintaining the colon outside, inside the abdomen with the stapler we divide on the suture line underneath the anvil and through the ligature of Polysorb material (blue one easy to find and identify). We see it very well and incise not just above but close to the suture line to introduce a hook and to find the suture and pull on it to have the anvil come immediately. We remove the tip of the anvil and after we have checked that there are no leaks around the anvil, we can close using a loop and connect the stapler to the anvil.

11. Colorectal anastomosis 14'00''

When we have introduced the spike in the rectal stump, we check that there are no twists, we close the stapler, fire, remove, respect, control the donuts.

12. Air-seal test 14'35''

We do an air test to make sure that there are no bubbles and eventually do a colonoscopy as proposed by Morris Franklin from San Antonio.

13. Mesenteric gap closure 14'50''

Finally, we have to close the mesenteric gap using sutures, or as in this case, staples with the Multifire Endo Hernia™ (Autosuture®) and we re-approximate the peritoneum that we had incised at the beginning of the procedure to the mesocolon, which is why you have to keep enough peritoneum to have an easy closure without tension.