Preservation of superior rectal vessels: laparoscopic sigmoidectomy for diverticulosis

This video shows and explains the performance of laparoscopic sigmoidectomy for benign disease in the elective setting.

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Preservation of superior rectal vessels: laparoscopic sigmoidectomy for diverticulosis

Authors

J Leroy, J Marescaux

Abstract

This video shows and explains the performance of laparoscopic sigmoidectomy for benign disease in the elective setting.

Keywords

preservation, superior rectal vessels, laparoscopy, sigmoidectomy, diverticulosis

Media type

Surgical video

Duration

17'50''

Publication

2008-05

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E-publication

WeBSurg.com, May 2008;8(05).
URL: http://www.websurg.com/doi-vd01en2341.htm

Preservation of superior rectal vessels: laparoscopic sigmoidectomy for diverticulosis

1. Operative set-up and trocar positioning 09'39''

This is an easy case for beginners to perform a sigmoidectomy. This is a female patient with a BMI of 21. She has no adhesions. We will use 4 trocars (we could use 3): one trocar (trocar A) for the scope just above the umbilicus, 2 operating trocars B and C on the right mid-clavicular line at the level of the umbilicus 8 to 10cm lower, a 12mm port to introduce the stapler, a 5mm trocar in a suprapubic position in the midline for the manipulation and exposure of the sigmoid loop, and also where we’ll do the extraction of the specimen through a small suprapubic incision. The right arm of the patient alongside the body. The surgeon stands lateral to the body; the 1st assistant’s holding the camera lateral to the right shoulder or the patient’s head; the 2nd assistant, between the patient’s legs, will be in charge of exposure and the anastomosis using the stapling device trans-anally. The 1st step of the procedure is exposure. We will first use a good positioning of the patient on the table. Before the start of the operation, we placed a pillow on the left side to have a small right lateral tilt of the operating table.

2. Operation commencement with exposure 02'22''

The bowel is falling slowly due to the position only. This can be helped using the Trendelenburg position and the lateral tilt. This is now the exploration of the sigmoid loop. We have to remove the loop and the colorectal junction in order to treat the disease. Because it is a benign disease, we will keep the vascularization of the rectum. We will divide the mesentery only this way.

3. Dissection and division of mesentery (medial approach) 03'11''

This is an ideal case. I will keep the vascularization of the descending colon. This is also facilitated by the use of the Ligasure device. I’m dividing the mesentery. This is the 10mm Ligasure Atlas® that is doing a sealing of the tissue, particularly of the mesentery and vessels before cutting. You also use the 10mm for a lot of blunt dissection, don’t you? 10mm is more adapted for big mesenteries like this one. We don’t need to do such a selective dissection, particularly useful in colonic resection. We’ll complete the exposure. I have to remove the lateral fixation.

4. Lateral mobilization of left colon 05'30''

I love to use monopolar scissors. When we are in the right plane, we see very well the Toldt’s and Gerota’s fascia. We have to complete the lateral freeing. The danger at this level is for the ureter. That’s why sometimes we have to seize it.

5. Identification of left ureter 06'27''

Here’s the ureter. We now have to prepare the colorectal junction.

6. Preparation of colorectal junction (distal transection margin) 06'51''

I’m dividing the mesentery going close to the bowel and the rectum. I have kept the vascularization of the rectum. This is better for the vascularization since 80% of the vascular supply of the rectum is coming from the inferior mesenteric vessels but we have also sympathetic nerves around the vessels. It’s essential to keep both the vascularization and innervation. I’m continuing the dissection to be on the rectum. Anteriorly we are at a distance from the anterior tenia. I’m dividing around. It’s approximately at the pouch of Douglas that we have to do this. This is the sigmoid probably. The jaws of the device are not hot. You see we are around the Douglas’s pouch and it is the limit where we’ll finish the dissection. We’ll complete this anteriorly. We can see the vessels beating, these are the superior rectal vessels. We can do a sharper dissection of the vessels although it’s not necessary. Why is it better to do such a dissection in benign disease? First because we are at distance from the nerves, from the ureter and we keep the vascularization of the rectum, so there is less risk of injury of the plexus, particularly in young male patients.

7. Distal transection 09'39''

This can be a problem related to anejaculation in 10 to 15% of cases, and especially when you are inexperienced with this kind of surgery. When it is a benign disease, it is not good to sacrifice the plexus. In this case, we can use a 45 stapler.

8. Proximal mobilization 10'27''

Now I have finished dissecting the mesentery. We will not remove all the diverticulum. The dissection can be done easily at this level. We begin the division of the mesentery inside towards the forceps and we will keep the vascularization of the proximal colon. In diverticular disease, we have to remove the pathologic area with the abscess and also remove the colorectal junction. Here are the vessels beating. We will divide approximately there outside or we can divide just above and we will remove around 30cm. We have freed laterally. We will do a small incision and put a plastic wound protector with a ring inside. I’m pushing the ring inside.

9. Extracorporeal delivery of specimen 12'18''

I’m pulling on the colon, which is coming outside. And you see where the division is. We can pull more if we want. We’ll complete outside close to the bowel. I’m preparing the bowel as we do in open surgery.

10. Preparation for re-anastomosis 13'00''

We’ll use the purse-string at least at a distance of 1cm because we’ll do the anastomosis. This is a 28 circular anvil that we introduce here as you see and we’ll close the purse-string removing all the forceps. You have to catch it on the plastic part and not on the metallic part. We can double this. Let’s remove this. Then we push inside the bowel. We twist. We close and maintain the closure with a purse-string. The anvil is falling in the pelvis. It’s what I call the “flirt” between the rectal stump and the anvil. This means we have a sufficient mobilization of the colon to do a tension-free anastomosis. We clean the rectal stump. We are underneath the Douglas’s pouch. This is the rectum.

11. Intracorporeal re-anastomosis 15'14''

We wash the plane and verify that there is no leak. We sometimes have had leaks at the crossing between the 2 staple lines. This is a good test to check that there is no leak. We will place the circular stapler inside. It’s pushing in the rectal stump. We grasp this with a forceps. It’s not sliding. We push and connect it above the red ring, which is behind. We have the green eye and we can fire now. We now twist and click and now we can pull without twisting. We will verify the ring, the distal and proximal ones. They are complete. We do an air test. We put saline in the pelvis and do a compression and close. There is no bubble.