Laparoscopic total colectomy for disseminated polyposis in an obese male patient (BMI=32)

Authors

Abstract

This video presents the case of an obese male patient with rectorrhagia caused by disseminated polyposis. A stepwise approach is applied. The landmarks are identified in a detailed way.

Classification

basic techniques

Keywords

laparoscopy, total colectomy, disseminated polyposis, obese male patient, BMI of 32

Media type

Duration

23'00''

Publication

2008-10

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E-publication

WeBSurg.com, Oct 2008;8(10).
URL: http://www.websurg.com/doi-vd01en2374.htm

Laparoscopic total colectomy for disseminated polyposis in an obese male patient (BMI=32)

1. Clinical case presentation 00'11''

This video demonstrates a laparoscopic total colectomy for disseminated polyposis in an obese male patient (BMI=32).

2. Exposure 00'21''

The first step is to expose the mesocolon. First, we retract the omentum cephalad above the transverse colon. This is clearly visible here. In this case, we will grasp the mesocolon like this. We put the patient head up, with a left lateral tilt. We see the ileocolic vessels very well. To be sure that we are in the right position, we must locate the ileocaecal junction. We see it very well here and the duodenojejunal junction that we will see now there. So we have the root of the mesentery in this axis; above it is the transverse mesocolon.

3. Mesocolic division 01'28''

We will rapidly see the duodenum. Vessels are just behind. We see the vein very well and the artery just above. The artery is white; the vein is blue as in anatomy books. This is good to perform hemostasis. We can control very well. Perhaps we have the colica media and another left branch there. You see the duodenojejunal junction is there and I’m just above it. Anterior to the pancreas, it is where I will find the lesser sac more easily. I think it is posterior to the transverse mesocolon. We see the stomach coming. We must not be too close to the pancreas. I will begin to divide the attachments of the omentum to the stomach using a posterior approach. This is the stomach falling down and to better understand, the duodenum is there. And we are dividing the omental attachments. It is easy to remove the omentum; we reach the superior limit. If we consider there is a risk of cancer, we have to remove so for teaching it’s better to do like this. You see it’s the posterior dissection I did before. We finish it on the right side. So we have now this. We have to continue the division. This is the stomach, the duodenum, the omentum. I’m dividing the attachments of the transverse mesocolon. I think the most difficult step of the procedure is the division of the attachments of the transverse mesocolon and the omentum. We free the colica media from the duodenum, pancreas and stomach. In my opinion, it is the main difficulty of this procedure. I’m in the right position for doing it and to finish the freeing of the lateral and posterior attachments of the right transverse mesocolon.

4. Pancreatic identification 08'18''

Back to the anatomy now: here’s the head of the pancreas, which is covered by the fascia, here’s the stomach; we will continue to free it when we’ll be doing the left division. Now I have to finish the freeing of the caecum. I’m pushing the transverse colon back and cephalad. You will retract with this forceps in the left hypochondrium.

5. Division of the lateral attachments of the ascending colon 09'12''

I’m dividing the lateral and posterior attachments of the caecum and I will soon reach the lateral dissection from the superior ascending colon. It is necessary to stay in the right plane. I’m pushing the caecum medially and cephalad to find the medial plane we did to dissect. Here’s the duodenum. Before continuing the dissection of the left colon, we’ll put the patient head down. We see here the transverse mesocolon anterior to the pancreas. I have finished that and I’ll do the division of the transverse mesocolon on the left like this. You grasp like this. Here’s the duodenojejunal junction and the pancreas is there. We’ll divide at a distance from the pancreas. The danger is to have the tail of the pancreas that is moving up. It’s why we must be careful not to go too rapidly opening the plane to be sure we’re really at a distance from the pancreas. I’ve seen very mobile tails of the pancreas that can be very far from the back. We’ll change and expose as we usually do but keep the inferior mesenteric vessels. So we divide the peritoneum first so we’ll respect more the plexuses and the vascularization of the rectum. You see the ureter there. The ureter is always coming in my direction. You have to change your grasping now. So we’re dividing the mesentery at a distance from the aorta. This is the Toldt’s and Gerota’s fascia, these are branches coming from the descending colon. I’m going to the IMV and we will respect it. It is not necessary to divide it. This will facilitate the drainage of the rectum. You see that when we are in the right plane, it is only necessary to use traction, counter-traction.

6. Left colic artery ligation 15'08''

We change exposure and we see very well where we want to go. Here is the left colic artery. We are at a distance from the pancreas. We have not to dissect close to the pancreas. Just behind the fatty tissue, you can have the tail of the pancreas. I don’t think it is in this case. But caution must be exercised during the dissection, particularly when there are inflammatory problems in this area.

7. Lateral approach 16'17''

We will use a lateral approach. For the freeing, it is safer. I have to join the division of the omentum I did by a medial lateral approach and complete the lateral freeing of the splenic flexure. We have completely freed and detached this colon from the stomach. We will look down now because we have to finish the division of the descending colon at the level of the promontory.

8. Superior rectal vessel ligation 17'39''

I have to divide keeping the superior rectal vessels. We see them beating there.

9. Colon extraction (through abdominal wall) 18'14''

The last difficulty is that we have to make sure that the ileum is mobilized sufficiently. This is a ring 7cm in diameter. So we now pull the transverse colon outside. The ileo-caecum is coming now with the ileum. This is the appendectomy. We see that the ileum is well vascularized.

10. Distal ileum preparation 19'01''

We reintroduce this.

11. Anastomosis 20'06''

We connect the ring and maintain the tension on. We remove one corner and need to verify that the mesentery is well positioned. We will be at around 2cm distance from the anastomosis so there is less risk for ischemia between the 2 stapling lines. We can fire. You can pull slowly. This is the rectal stump and this is the ileal one. The doughnuts of the ring are very thick and complete.

12. Air-test 21'24''

We will perform an air test. We fill the pelvis with saline. And without bubbles we clamp the small bowel. There are no bubbles. And now we will close the mesenteric gap laterally to avoid incarceration of the small bowel.

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