Laparoscopic sigmoidectomy for diverticulitis

Laparoscopic resection of the sigmoid colon is considered as a feasible option to open surgery. This is the case of a 40-year-old lady with previous episodes of diverticulitis. She has had no previous surgery and a CT-scan at the time of her admission showed that there was an acute diverticulitis. The patient was managed conservatively. A laparoscopic sigmoidectomy is showed in this video.

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Laparoscopic   sigmoidectomy   for   diverticulitis

Authors
J Leroy, J Marescaux
Abstract
Laparoscopic resection of the sigmoid colon is considered as a feasible option to open surgery. This is the case of a 40-year-old lady with previous episodes of diverticulitis. She has had no previous surgery and a CT-scan at the time of her admission showed that there was an acute diverticulitis. The patient was managed conservatively. A laparoscopic sigmoidectomy is showed in this video.
Keywords
Laparoscopic sigmoidectomy for diverticulitis
Media type
Duration
19'52''
Publication
2006-02
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Feb 2006;6(02).
URL: http://www.websurg.com/doi-vd01en1720.htm

Laparoscopic   sigmoidectomy   for   diverticulitis

1. Case presentation 00'03''
This is the case of a 40-year-old lady with previous episodes of diverticulitis. She’s had no previous surgery and a CT-scan at the time of her admission showed that there was an acute diverticulitis. She was managed conservatively and her symptoms settled. Further to this, a barium enema was performed, and this confirmed the diagnosis of diverticulitis. All patients are marked in this fashion, irrespective of what type of abdominal surgery they are having. This is to ensure active and correct port site placement. The 1st port is always the supra-umbilical port and it is through this port that the pneumoperitoneum is established. A laparoscopy can be performed and the diagnosis confirmed. The operating port, B and C, which is a 10mm port, and then the other ports which are 5mm ports. The anatomical landmarks are now illustrated: costal margin, iliac spines, and the pubis. By drawing these lines, we can accurately identify where the ports are going to be placed. It also allows reproduction of the procedure on every occasion. The cables are placed on the patient’s left and then brought superiorly. This is to ensure that there are no cables between the surgeon and the patient, which might subsequently get in the way. The supra-umbilical incision is made and this is for the optic port through which the pneumoperitoneum will also be established. A laparoscopy is performed. You can see here there is probably the scar from a ruptured cyst on the liver, and then the laparoscopy is completed and the diagnosis confirmed. In the mid-clavicular line level with the umbilicus, the first operating port is inserted. This is done under direct vision at all times. Next, in the left-sided mid-clavicular line also level with the umbilicus, is placed one of the ports for retraction of the colon during the procedure. It is again introduced under direct vision. One hand’s breadth below the port being introduced on the right-hand side is placed the 2nd operating port. This can be a 5 or 10mm depending on the instruments used. Further to this, a port is placed in the right upper quadrant. This is another 5mm port introduced under direct vision for retraction purposes. The final port to be introduced is another 5mm port suprapubically. By the introduction of a forceps, we can ensure that the peritoneum is kept under tension to allow safe introduction of the suprapubic port.
2. Exposure and mobilization 04'28''
The patient is placed in a lithotomy position with a head down tilt. Then the patient is placed with a slight tilt towards the operating surgeon. This is in order to ensure that the small bowel is lifted up away from the operating area. This is a critical maneuver to ensure that there is good vision in order to perform the sigmoidectomy. First, the omentum is lifted cranially and then this is followed by the small bowel. By using the left-sided port as well as that on the right-hand side of the umbilicus, the transverse colon can be lifted up over the liver. In order to keep the small bowel out of the pelvis, the left-sided retractor is placed in underneath the small bowel mesentery in order to tent the small bowel mesentery up to maintain the tension on the small bowel and prevent it from going back down into the pelvis. This is an essential part of the procedure in order to try and ensure that the vessels can be seen, divided so that at all times the small bowel is out of the operative field. So with the use of the head down tilt and the tilt of the patient towards the surgeon, you are standing on the right-hand side of the patient, the small bowel can be encouraged to move cranially and to the right-hand side. And now we can see the sigmoid and the sigmoid vessels are coming into view. This patient is not obese; therefore we can see the vessels; we can identify exactly where the dissection is going to proceed and precisely the landmarks that we’re looking at.
3. Dissection and division of the vessels 06'45''
So dissection and division of the vessels: the IMA, the superior rectal artery, the left colic artery, and the sigmoid branches as well. So you can see here the landmarks: the mesosigmoid, the vessels, and then, this is exactly how it’s going to start with division of the peritoneum, division of the peritoneum overlying these vessels so that they can be dissected out, controlled and taken at exactly the point that the surgeon wants. So tension is placed on the sigmoid. Then the peritoneum is divided using diathermy scissors. But other power tools can be used for this as well. By traction and counter-traction, the peritoneum can be divided under tension and then stripped away from the mesentery. This will allow identification of mesenteric vessels. As this is a case of diverticular disease, and not malignant disease, the vessels can be taken up slightly higher in the mesentery than will be necessary for a patient having a resection for cancer. The vessels can be individually identified and at all times it’s the traction and counter-traction, the traction placed by the assistant using the suprapubic port to lift up and tent up the sigmoid, and the operator using both hands to ensure that tension is placed on the tissue prior to dividing the peritoneum. The use of monopolar diathermy and scissors means that the natural planes are utilized. Other techniques using power tools are also possible and work very well. So now the vessels are demonstrated. It’s important to try and develop the plane inferior to the vessels, which will take us through to the other side of the colon. At all times here, we’re doing a medial to lateral approach, but sometimes in difficult cases, one needs to combine both the medial and lateral dissection. You can start medially and then go laterally, and this can help to open up the space behind the vessels. This is behind the vessels but above Toldt’s fascia so that Toldt’s fascia is left intact and the ureter is left below Toldt’s fascia undisturbed. Out of the picture here, the assistant using the suprapubic port is hoping to lift up the sigmoid towards the ceiling, towards the abdominal wall. This ensures that the tension is maintained. Other ports can be used at any time in order to make sure that the planes are opened up and that traction and counter-traction is kept so that we can ensure, we can see exactly which planes need to be dissected and then open them up as that happens.In this case, individual sigmoid branches are being demonstrated. This is a diagrammatic representation of the sigmoid and rectal vessels. The vessels are individually clipped and divided. Once again a power tool can be used in order to do this. A laparoscopic approach is ideal for patients who suffered with recurrent bouts of diverticular disease. It is minimally invasive. There’s a short hospital stay. Patients have an improved quality of life postoperatively and also a faster return to work. The extent of the resection really is to cover and remove the diseased section of bowel. Sometimes this extends high up on the descending colon or into the transverse colon. But in these cases, it should be taken simply back to an area of colon, which is malleable, which is supple, where a good anastomosis can be made. So what we can see here now is when the peritoneum is being lifted upwards in order to reveal the posterior plane, which is in front of Toldt’s fascia, but behind the colon. This is a natural embryological plane that is utilized really in all aspects of laparoscopic colorectal surgery. In this case, we’ve left intact the superior rectal artery. We’re now developing the plane which is taking us behind the sigmoid vessels, but in front of the superior rectal vessels. The more classic dissection for malignant disease will be to go behind the inferior mesenteric artery and open up the plane from there. But in this case, we can take the vessels closer to the bowel. In complicated diverticular disease where there are abscesses, a mass perhaps even a colovesical fistula, this is more challenging for laparoscopic surgery. It’s certainly possible but we would not recommend it for people who are at the beginning of their experience but to build up experience prior to tackling these more complex cases. So the next step is to identify those areas where we are going to divide the bowel and also then to extend the dissection laterally at all times being aware of the ureter and gonadal vessels.So the peritoneum is divided on the right-hand side in order to demonstrate the position at the top of the rectum where the division of the rectum is going to take place. The superior rectal vessels can be seen inferiorly here in their own package of tissue. The reason for this is if there is a significant amount of bleeding, it does make it much more difficult to see the planes, to continue the dissection safely in a stepwise fashion. Monopolar diathermy is very useful in order to preserve a clean field but also very handy is bipolar diathermy, this can be utilized if there is some bleeding and often works extremely well to prevent or stop that bleeding very quickly. You can see the shears here are being turned to face the camera just to give a greater area which the diathermy can be used over rather than just the blade itself. So we can see the posterior wall of the bowel now and now the peritoneal reflection on the left-hand side is being divided to take us down on to the posterior aspect of the rectum. You can see once again the superior rectal vessels are preserved and now the posterior aspect of the bowel wall is cleaned. Once again, that twist is being placed on the scissors to provide this large surface area to undertake the diathermy. This is a main sigmoid branch that can be seen and the choice is now being taken as to where precisely to resect the colon. This is a mild case of diverticular disease which helps with the dissection; this means the tissues are well preserved without any evidence of local complications, and this makes it an excellent case in the demonstration of the dissection. There’s now a window which is being made behind the colon so that distally the area of the division has been identified and now proximally that has been identified as well.
4. Stapling and resection 18'44''
Now the peritoneum is being divided and there’s a window posteriorly behind the colon. We can now decide at what point the colon is to be divided and then of course it will be anastomosed at the colorectal junction.The right iliac fossa port is enlarged in order to take a 10mm trocar. Through this, the linear stapler can be introduced. The colon is then placed in the jaws and divided. Often it takes a couple of firings of the staple gun. In order to remove this specimen, a suprapubic incision is made. A wound guard is placed into the suprapubic incision, and then the colon by making sure that it’s attached to either retractor can be pulled through that incision. We can then check that the proximal colon is well vascularized and can divide it at the point of choice. So the grasper takes the distal end of the colon. The incision will then be made in the suprapubic area. The retractor still has in its jaws the distal end of the colon. Therefore, once the incision has been made, and the wound protector introduced simply by removing the retractor, the colon is delivered. We can then identify the area for proximal division. This is done using a purse-string, suture first of all and then division of the colon, distal to this; then in due course, the anvil is introduced and the colon drawn back into the abdominal cavity. The pneumoperitoneum can then be re-established by twisting the wound guard re-applying the apparatus that’s seen here for placing the purse-string and re-insufflating the abdominal cavity.