Laparoscopic sigmoidectomy for diverticulitis with associated hysterectomy

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Laparoscopic sigmoidectomy for diverticulitis with associated hysterectomy

Authors

J Leroy, J Marescaux

Media type

Surgical video

Duration

15'00''

Publication

2005-02

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E-publication

WeBSurg.com, Feb 2005;5(02).
URL: http://www.websurg.com/doi-vd01en1655.htm

Laparoscopic sigmoidectomy for diverticulitis with associated hysterectomy

1. Case presention 00'02''

This is the case of a 50-year-old female with recurrent bouts of sigmoiditis now presenting for elective sigmoid resection. In addition, the patient has a history of fibroid disease within her uterus, and as well will have a hysterectomy performed during this procedure.

2. Exposure 00'22''

Here you see gross video laparoscopic examination of the abdomen with retraction of the omentum and now small bowel out of the way. Our trocars were placed earlier in our standard 5 position technique as noted on other sigmoid resection videos in WeBSurg. Here you see the gentle retraction of the small bowel into the right upper quadrant. In cases when small bowel retraction is difficult, such as in the morbidly obese or thick mesenteric patients, the small bowel can be stacked upon with retractor such as is shown here. This effectively makes a static operative field during the procedure making rearrangements to this small bowel retraction minimal. Here you see the fibroid uterus and the sigmoid colon which has associated sigmoid diverticula.

3. Medial approach 01'37''

We will begin presenting the mesentery of the sigmoid colon in preparation for our medial approach and dissection. As this is benign disease, we take care to note the aorta and where we believe the mesenteric vasculature is, and begin our dissection with the Ligasure 10mm device. The Ligasure device in addition to being able to be used as a cautery device for vessels up to 7mm and also serves as a functional finger in dissecting through the mesentery. Here we have created a window through the mesentery and begin our dissection down to the rectum, which is the area of course where there is no associated sigmoid diverticular disease and the point at which we will make our anastomosis.

4. Lateral dissection 02'43''

Lateral attachments are now taken down as the medial dissection is nearly complete. Once again, you see the 10mm Ligasure device being used as a blunt dissector. An important property of this device is that it remains relatively cool despite its cautery device function. Here we see an inflammatory adhesion between the adnexa and the sigmoid colon, and we use a Ligasure device to lyse these adhesions.

5. Rectal disection and division 03'23''

Further dissection to the proximal rectum is then done to an area below the involved sigmoid disease. Despite film editing, the operative field remains stagnant without small bowel getting in the way. This is further emphasized as exposure is key to maintaining efficient operative times and decreased injury to related organs such as the small bowel during this procedure. We introduce the GIA device in preparation for the resection of the sigmoid colon. Full length of the colon to be excised is then judged above the sigmoid diverticular segment, and now dissection to the point at which we will make the proximal limb of the resection is now dissected to with the Ligasure device. The mesentery of this region is now dissected with the Ligasure device and the field is noted to be hemostatic.

6. Exteriorization and colon division 04'40''

The suprapubic port is now enlarged to approximately 4cm and now preparation will be made for removal of the specimen through the wound protector for the end-to-end anastomosis. The purse-string device aids in this process.

7. Anastomosis 05'00''

The colon is then retracted back into the abdomen and we reuse the purse-string device again for temporary closure of the enlarged suprapubic incision. The resection is completed outside the patient and a purse-string device is utilized along with the 31mm anvil placement in the distal left colon. The anvil and stapling device are attached. Here you now see the EEA device advanced trans-rectally and the female end deployed through the stapled end of the rectum noting proper orientation of the colon as well as no tension on the anastomosis, the device will be fired. Once the EEA device is removed and the confirmation of the anastomosis is made, further track of the anastomosis will be done with insufflation of the rectum trans-anally.

8. Hysterectomy 06'05''

The dissection now begins for the hysterectomy beginning with the right suspensory ligament of the ovary and the broad ligament, once again using the Ligasure device. We note good hemostasis during the procedure. The dissection then continues to the left adnexa. Here you see the anterior ligament of the uterus and the Ligasure device being utilized briefly here. Then dissection of the cardinal ligaments is performed bilaterally. Monopolar scissors are used to divide the cervix. We are performing a supracervical hysterectomy. It is noted in the literature that less sexual dysfunction is noted after this procedure. Prior to the procedure, the patient had a dilatation and curettage procedure to confirm that no carcinoma elements with the cause of a significant pain from her uterus after the left cardinal ligament is divided with the Ligasure device, the remainder of the broad ligament is taken down as you see. 2/0 permanent sutures are then used to approximate the cervical canal. Extracorporeal knot-tying is then done. Reperitonealization is then completed with 2/0 absorbable suture. Another technique of knot-tying is illustrated here with an intracorporeal knot-tying technique. The uterus was removed through the suprapubic incision as was used for the sigmoid colon specimen. After the aspiration of the irrigant in the pelvis, hemostasis is appreciated and the procedure is complete.