Laparoscopic sigmoidectomy in a patient with Hinchey stage II diverticulitis

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Laparoscopic sigmoidectomy in a patient with Hinchey stage II diverticulitis

Authors

M Simone, J Marescaux

Keywords

sigmoïdite diverticulaire, adhérences pariétales, abcès périsigmoïdien

Media type

Surgical video

Duration

11'00''

Publication

2006-06

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E-publication

WeBSurg.com, Jun 2006;6(06).
URL: http://www.websurg.com/doi-vd01en1749.htm

Laparoscopic sigmoidectomy in a patient with Hinchey stage II diverticulitis

1. Case description and trocar placement 00'11''

This 39-year-old male patient is undergoing a laparoscopic sigmoidectomy. He presented with abdominal pain that was predominant in the left iliac fossa. Sigmoid diverticulitis was confirmed on CAT-scan despite IV antibiotic therapy and a CT-guided abscess drainage. The patient’s abdomen remained tense and concern for continued clinical decline wanted exploration and anticipated sigmoid resection.

2. Adhesiolysis 00'39''

This is an obese patient having a BMI of 33 with no prior abdominal surgery or medical disease. The acute advanced stage of the disease can be treated surgically as an emergency. The surgical options may vary depending on the preoperative factors, the patient\\\\'s condition, and the intraoperative staging of peritonitis. These all contribute to the peritonitis scoring system. There are many different staging systems depending on the stage of presentation of intra-abdominal pathology for evaluating and treating. Among these systems, the Hinchey classification, is utilized in the guidelines for treatment of diverticular disease by the American Society of Colon and Rectal Surgeons. It is the most commonly used tool for making the surgical decision. In the present case, the patient has Hinchey stage II diverticulitis with an abscess noted on CAT-scan to be paracolic as well as extending anteriorly to the anterior abdominal wall as seen with the reaction of the omentum on this video. In this case, 5 trocars are used as it is the standard practice for the left colon and rectal surgeries. The WeBSurg chapter on sigmoid diverticulitis further illustrates these positions. We do utilize improvisation as in this case as the left mid-clavicular port cannot immediately be placed due to the adhesions. Several landmarks are utilized for proper trocar placement: the costal margin, the xiphoid process, the anterior superior iliac spines, and the pubis; we make a median line crossing the umbilicus, pubis, and xiphoid process; there are also 2 additional vertical lines representing the mid-clavicular line to the right and left and finally one horizontal line crossing the umbilicus. These are the essential landmarks for trocar placement. As the sigmoid colon is situated near the left iliac fossa, sufficient distance away from this landmark should be kept. The colon and the greater omentum have now been freed from the anterior abdominal wall as you’ve seen. The LigaSure® device is utilized as we take care not to injure the colon during the dissection. In addition, concern for potential colo-colonic fistula requires meticulous dissection. We utilize either the monopolar scissors or the vessel sealing device (LigaSure®). This sealing device is particularly useful as the 10mm-sized Atlas model can be used as well as a finger to dissect and mobilize the strong adhesions between the colon as you saw.

3. Mobilization of sigmoid colon 03'29''

The surgeon starts the procedure utilizing the 2 operating trocars that are situated in the right mid-clavicular line. Once the sigmoid colon has been freed anteriorly, adhesions with the omentum are dissected and the omentum is retracted cephalad and out of the way. Typically we will place the small bowel as well as the omentum cephalad and to the right to enable for better visualization. You can see here we now perform the step in addition to maintaining the patient in a Trendelenburg position with moderate right tilt. The sigmoid colon has significant adhesions as well along the left paracolic gutter. These adhesions need to be lyzed prior to proper medial vascular approach as we attempt to retract the sigmoid colon anteriorly to aid in visualization of the vessels of the mesentery. However, we find it difficult to do so due to these acute inflammatory adhesions. Currently, we are utilizing scissors and monopolar cautery to aid in the freeing of these adhesions. One must take care to avoid injury to the ureter, genital vessels, and other retroperitoneal structures during this dissection.

4. Lateral dissection 05'10''

Once finding a plane outside the acute inflammatory tissue, we advance this plane both cephalad up towards the splenic flexure and then continue caudad. Again, the use of the LigaSure device proves useful as it itself can be used as a blunt dissector. This dissection continues. We will return to our trocar placement. As can be seen, the surgeon’s hand, dominant hand is utilizing the 12mm trocar in the right mid-clavicular line below the umbilicus. His left hand is being utilized to aid in retraction with the 5mm device. The optical trocar is approximately 2 centimetres cephalad to the umbilicus. Keeping this appropriate distance away from the tissue that is being dissected, we go a long way in aiding the surgeon during the procedure. As the optical trocar being too close to the dissected tissue, we make the dissection extremely difficult. The left ureter is identified.

5. Resection of sigmoid colon 06'48''

We now have proper mobilization laterally. We begin our procedure with a medial approach. After the utilization of the scissors and monopolar cautery to open the peritoneum, we will then dissect further with the LigaSure device. Another advantage to the medial approach in addition to others that have been well documented in the literature is that we’re starting in tissue that is not inflamed during our dissection now going medial to lateral. With this dissection in non-inflamed tissue, we can maintain dissection in the appropriate plane just anterior to the Toldt’s fascia. We know that treatment of patient with a diverticular abscess depends on the magnitude and location of the abscess in addition to the patient’s clinical condition at the time of diagnosis. As this patient failed conservative management, operative management was indeed required. Although there’s evidence to maintain that Hinchey class II diverticulitis should be treated in a dual stage procedure, there are no reports noting successful completion of our single stage procedure, particularly with the laparoscopic approach for this disease. As noted, the left ureter is identified as we continue over the sacral promontory down into the pelvis. Particularly important for a young 39-year-old male, proper dissection down to the termination of the sigmoid is appropriate as it has been noted that leaving a remnant of the sigmoid, recurrent disease can occur. Now that we are at the proximal rectum and out of the inflammatory tissue, we will utilize an Endo-GIA through the right 12mm trocar and dissect the distal end of the specimen.

6. Extraction of sigmoid colon 09'28''

Further mobilization is then done prior to extraction of the specimen through an enlargement of the suprapubic port site to approximately 5cm.

7. Anastomosis 09'55''

After extraction, removal and placement of the anvil with the purse-string device, we will then advance the end-to-end stapling device through the anus and the trocar is then advanced adjacent to the staple line, trocar removed, and the anvil and the device are then advanced toward each other after appropriately checking for any twist. After firing the device, its removal, and confirmation of concentric doughnuts of tissue, we will then perform an insufflation test. Upon completion of this, and noting appropriate hemostasis, the procedure will be complete. The patient did extremely well and was noted to be discharged approximately 4 and a half days after the procedure.