Stenotic anastomosis after sigmoidectomy: laparoscopic redo

This recording of a live case reveals all the key technical steps in laparoscopic revision of an anastomotic stenosis following a prior sigmoidectomy.

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Stenotic   anastomosis   after   sigmoidectomy:   laparoscopic   redo

Authors
J Leroy, J Marescaux
Abstract
This recording of a live case reveals all the key technical steps in laparoscopic revision of an anastomotic stenosis following a prior sigmoidectomy.
Keywords
stenosis, anastomosis, sigmoidectomy, laparoscopy, redo, laparoscopic revision
Media type
Duration
18'40''
Publication
2008-02
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Feb 2008;8(02).
URL: http://www.websurg.com/doi-vd01en2250.htm

Stenotic   anastomosis   after   sigmoidectomy:   laparoscopic   redo

5. Mobilisation of sigmoid colon and rectum 02'18''
I have to get the posterior mobilization now. This stenosis is approximately there, I have to free laterally the sigmoid, then medially first to evaluate the quality of the colon. We can see that this colon is mobile, it can move down very easily. Soon we will put a bougie in the rectal stump but the problem is that first in this case to free the colon in the right plane, we use a lateral approach. I will free the pelvis more. The problem is to know where the limit of the mesosigmoid is. The problem is to find the ureter in this case. I want to expose more like this later. I don’t know what it is, I think it was for the vein. The aim is to find the plane posteriorly, but not too posterior, we need to stay anterior to the Toldt’s fascia to be sure that I’m not dissecting too posteriorly. I think this is the right plane that I am finding now, it is anterior to the kidney. Normally the ureter is more medial, due to the previous surgery, it is not sure that I have the right plane, for that it is necessary to have a lateral view. There is an edema, this explains why it is not easy, perhaps we will do on the other side. I think the rectal stump is there, we have to confirm that with a bougie. It is dangerous to have an injury of the ureter, vessels, nerves. The plane is probably there, I will use hydro-dissection. I am now using a 10mm Ligasure device. I think I have found a way anterior to the presacral fascia, I don’t know if it is in the rectum or in the presacral space. Push your bougie. This is the rectum, so I have found the posterior rectal stump, I need to find it anteriorly. I think I am in the right plane of the rectum there, I must find laterally now. I think that in order to continue the dissection it is better to get more access - there is fibrotic tissue, I am not far from the rectal stump – and be sure that we are far from the nerve and from the ureter too even if we know there is sometimes a modification of the anatomy during this kind of fibrotic tissue, abscess, fistula. We are now in softer tissue, I will put stitches on this. We are preparing the rectal stump, it is important that there is no fibrotic tissues. I think that if there is ischemia, it is not on the rectal stump but on the descending colon or there was a fistula with local ischemia, because it is a very limited stenosis.