Laparoscopic sigmoidectomy for sigmoid diverticulitis in an obese (BMI=39) female patient

This video demonstrates the laparoscopic approach to sigmoid resection following previous attacks of diverticulitis. The medial vascular approach is employed, although in this case the inferior mesenteric artery is preserved. Obesity presents particular problems of reduced space and difficulty in identification of structures because of visceral adiposity. This video is suitable for advanced laparoscopic digestive surgeons. The authors use the medial vascular approach, preserving the inferior mesenteric artery. The obese patient presents the dual challenge of reduced space and difficulty in identifying structures. The authors gain exposure of the mesosigmoid, and initially incise the peritoneum to divide the vessels, respecting the superior rectal vessels. They divide only the sigmoid vessels to preserve the superior rectal artery and vein.

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Laparoscopic sigmoidectomy for sigmoid diverticulitis in an obese (BMI=39) female patient

Authors

J Leroy, J Marescaux

Abstract

This video demonstrates the laparoscopic approach to sigmoid resection following previous attacks of diverticulitis. The medial vascular approach is employed, although in this case the inferior mesenteric artery is preserved. Obesity presents particular problems of reduced space and difficulty in identification of structures because of visceral adiposity. This video is suitable for advanced laparoscopic digestive surgeons.

The authors use the medial vascular approach, preserving the inferior mesenteric artery. The obese patient presents the dual challenge of reduced space and difficulty in identifying structures. The authors gain exposure of the mesosigmoid, and initially incise the peritoneum to divide the vessels, respecting the superior rectal vessels. They divide only the sigmoid vessels to preserve the superior rectal artery and vein.

Keywords

sigmoid, diverticulitis, obesity

Media type

Surgical video

Duration

21'38''

Publication

2007-06

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E-publication

WeBSurg.com, Jun 2007;7(06).
URL: http://www.websurg.com/doi-vd01en2124.htm

Laparoscopic sigmoidectomy for sigmoid diverticulitis in an obese (BMI=39) female patient

1. Trocar placement 00'20''

This is the case of a female patient with a previous surgical history of appendectomy. Adhesion of the omentum to the right side of the abdominal cavity was observed. First I want to show you the different landmarks I use. The rib, the pubis, the anterior superior iliac spine, left and right, the midline, the mid-clavicular line on the left, the anterior axillary line on the right and left, the horizontal line at the level of the umbilicus. So first I put my optical trocar using the mini-open technique just above the umbilicus; two working trocars, B and C. My left hand will be on the B with a forceps, it is a 5 mm trocar. The C, 8-10 cm lower on the mid-clavicular line; right iliac fossa is a working trocar for a 12 mm instrument eventually stapler. Trocar D is used to retract the proximal bowel, to expose the sigmoid mesocolon, to free the splenic flexure. Trocar E, suprapubic, is where I will do the extraction of the specimen; it is more cosmetic, less painful but don’t hesitate to put a trocar to facilitate exposure of the sigmoid mesocolon.

2. Exposure 02'30''

We push the omentum above maximally I cannot on the right because you remember it is fixed. This is the dilated transverse colon. We now have to expose the small bowel. There is a long mesentery which is good and facilitates exposure. We try to find the proximal jejunum. This is the route of the mesentery, I’m sliding under the loop, sliding like this. To have orthostatic exposure maintaining only the forceps due to its position in angulation with the back of the abdominal cavity. We can eventually create more space by putting more small bowel above like this. I have exposed the sigmoid mesocolon, the aorta is not far.

3. Medial vascular approach 04'40''

I will begin the procedure using a medial approach. Firstly I divide the peritoneum, divide the vessels whilst respecting the superior rectal vessels; I will divide only the sigmoid vessels. Your plan is to preserve the superior rectal artery and vein, and take the individual vessels outside them. Can you explain where you are, do you have any anatomical landmarks? Yes there are two. I divide the peritoneum, not all the sigmoid mesocolon.

4. Lateral mobilization of sigmoid colon 05'55''

I use LigaSure to divide the meso. Now we have traction and counter-traction and the monopolar diathermy works beautifully. If you decide to preserve the inferior mesenteric artery, I guess it will be better to begin first what you are doing now, that is the lateral mobilization, then to take the vessels in this way? Yes. You will be sure to avoid any injury of the ureter? No I’m not sure. In diverticulitis, we have fixation on the left side, sometimes adhesions which are difficult to free; in women particularly we have a risk for the genital vessels in case of adhesions. Mehran Anvari: If you had a case with a perforation, with a lateral abscess would you use infrared ureteric stent? Yes, it’s better and helpful to do so. You can see that we have the vessels and we will divide them. The vessels are located on this side, the aorta is there, the IMA, and the sigmoid vessels, the sigmoid trunk that I have divided. I don’t skeletonise the trunk for sigmoid diverticulitis. This is the right plane. I am anterior to the Gerota’s fascia, Toldt’s fascia. Maybe using the lateral approach we can see the root of the sigmoid mesocolon.

5. Division of colorectal junction 09'45''

Can you tell us where you decide to cut the rectum, what is your way of doing it? The best landmark is probably the Douglas’ pouch here. We are on the rectum at this level. I have difficulties in exposure. If the position is right, we won’t have difficulties in inserting the stapler. Are you using the 45 Endo-GIA? Yes the roticulator. How do you decide to take down the splenic flexure or not?

6. Mobilization of splenic flexure 11'30''

Do you do first the distal step? I do the splenic flexure first though tiring it is than to do the difficult sigmoidectomy. The problem is for beginners, if you have a difficult sigmoiditis, it might be more difficult to do it first and then to go back to the splenic angle. I must wait enough time to avoid a complex pelvis. Toldt’s fascia is anterior to Gerota’s. This is the tail of the pancreas. This is a very good example of the difficulty of this plane. In that case, many people would continue posterior to the pancreas… Here the pancreas comes in the meso and this is the first time that happens to me when doing this lateral approach. It can happen sometimes. This is the division of the colo-omental ligament. The key is to open the lesser sac which is opened now. It’s enough mobilization now.

7. Proximal division of sigmoid colon 16'00''

So it is mobilization using a lateral approach with division of the colo-omental attachment. If you have a lot of diverticula on the splenic flexure and descending colon, you have to remove the colorectal junction. I use a plastic drape. I put one finger around the trocar. I push the ring of the plastic drape, pull to have a good positioning of the ring. I’m pulling the colon through. How do you know that the vascularization is good enough? I have the color first (we cannot see the vessels because it’s fatty). We can put a Babcock to be sure that the colon will not fall. You don’t do any laxative preoperatively, you just do enema, is that right? Yes, maybe a fibre diet a few days before. It depends if there’s no constipation, you can do it 2 days before. It’s not necessary to have more. Do you always do an end-to-end anastomosis, ever a side-to-end? Not always, no. When do you do a side-to-end?

8. Colo-rectal anastomosis 19'30''

The anvil is falling easily in the pelvis. We will do the air test now. I’m closing the bowel. We have no bubble. We will close the gap which is short.