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Laparoscopic small bowel resection for Meckel's diverticulitis

Authors

F Costantino, E Triki, J Marescaux

Abstract

This video shows a case of laparoscopic segmental intestinal resection for Meckel's diverticulitis.

Classification

routine cases

Keywords

laparoscopy, small bowel, resection, Meckel's diverticulitis

Media type

Duration

12'10''

Publication

2008-07

Popular

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Audio

Subtitles

E-publication

WeBSurg.com, Jul 2008;8(07).
URL: http://www.websurg.com/doi-vd01en2364.htm

Laparoscopic small bowel resection for Meckel's diverticulitis

1. Case presentation and set-up 00'18''

This video shows a 40-year-old female patient. She consulted following 2 days of right abdominal pain. Her blood tests showed a hyperleukocytosis. The ultrasound exam confirmed the diagnosis of an acute appendicitis. The patient is placed in supine position. A 10mm optical trocar is placed at the umbilicus, and we also use two 5mm working trocars; the first is placed suprapubically, the second in the left iliac fossa.

2. Case commences 00'51''

We perform a panoramic exploration of the abdominal cavity, and we can observe macroscopically the presence of purulent liquid at the bottom of the Douglas’s pouch, associated with acute appendicitis.

3. Identification of Meckel\'s diverticulitis 01'04''

We begin by a routine exploration of the small bowel, which shows a localised inflamed Meckel’s diverticulitis, 40cm away from the ileocecal junction. We now go to the level of the appendix and decide to perform the appendicectomy laparoscopically.

4. Incidental appendectomy 01'23''

To perform this, we retract the appendix cephalad with a grasper. We then control the appendicular artery using progressive bipolar cautery: this procedure is continued until we free the meso-appendix completely. To complete the mobilisation of the appendix, we must free the posterior attachments of the appendix using a monopolar hook, which allows us to get a better exposure. We then introduce an Endo-bag in the abdominal cavity in order to extract the specimen and protect the abdominal wall from cell spillage during the extraction. We then proceed with the application of two Endo-loops (Vicryl 2/0) at the base of the appendix. We then perform the division of the appendix with scissors, and place the specimen in the Endo-bag. The Endo-bag is rested away from the operative field. Again, we unroll the small bowel to re-check the position of the Meckel’s diverticulitis.

5. Diverticulectomy 03'19''

Because of the inflammation of this diverticulum, we decide to perform an intestinal resection. In order to do this, we add a third 5mm trocar midway on the xipho-umbilical line. The objective of this third trocar is to have a triangulation which will allow us to complete the procedure. We tailor a window at the level of the distal mesentery. For this, we begin by the coagulation of the peritoneum with the help of a monopolar hook. This dissection is continued while preserving the small vessels and by creating the mesenteric window safely. For this window, we will place an Endo-GIA 60mm blue cartridge linear stapler. Here we can see the Endo-GIA being applied. We go 5cm distally to the Meckel’s diverticulum and fire the stapler. We place this specimen in the Endo-bag along with the previous resected specimen. We check the suture line and find a small bleeding, we control it using bipolar coagulation. We apply traction at the level of the previous intestinal division, we then go to the level of the proximal small bowel and mark it with a margin of 5cm to the Meckel’s diverticulum using a hook. We mark out the division zone using the hook, we then take the distal division line of the Meckel’s diverticulum and perform progressive division of the mesentery by coagulating the terminal arteries that are in contact with the small bowel. We perform this by using bipolar coagulation. Once the resection of the mesentery is over, we must perform the intestinal resection. For this, we use a 60mm linear stapler Endo-GIA with blue cartridge that will be applied at the site of the previous landmark, 5cm distally to the Meckel’s diverticulum. We are now going to restore bowel continuity, we think that the best way to do this is to perform the mechanical side-to-side small bowel anastomosis. We grasp the distal small bowel and apply a stitch on both extremities of the bowel and on the anti-mesenteric side. This suture is used to retract and expose the small bowel to perform the anastomosis. We perform a small enterotomy in the distal small bowel. We use the monopolar hook to perform the enterotomy in the proximal small bowel. This enterotomy allows the introduction of a mechanical linear stapler. We can now see that we are introducing the Endo-GIA 60mm mechanical linear stapler through the abdominal cavity. The Endo-GIA is introduced via the enterotomy to allow us to create a side-to-side mechanical isoperistaltic anastomosis. The procedure continues with the closure of the enterotomy. For this, we perform a running suture using Vicryl 2/0. To facilitate this procedure, we position a first stitch at the level of the inferior extremity of the enterotomy. This suture will allow us to manoeuvre and expose the enterotomy during its closure. Here we can see the application of the running suture at the level of the superior extremity, and we begin to perform the closure of this enterotomy very slowly. Once it is closed, we control the patency of the suture line macroscopically. To diminish the risk of internal hernias, we also perform the closure of the mesenteric defect. For this, we apply Vicryl 2/0 sutures.

6. Specimen removal and conclusion of case 11'54''

We now extract the specimens enclosed in the Endo-bag through the left iliac fossa trocar insertion site. No drain is placed. This concludes our procedure.

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