Technical tips for laparoscopic sigmoidectomy

This didactic video describes the principles of sigmoid colon resection. Different operative strategies are presented; contrasting the key steps in resection for neoplastic and non-neoplastic conditions. The vascular approach is emphasized, and super-selective vascular dissection of the inferior mesenteric artery (IMA) and its branches are shown.

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Technical tips for laparoscopic sigmoidectomy

Authors

M Simone, J Leroy, J Marescaux

Abstract

This didactic video describes the principles of sigmoid colon resection. Different operative strategies are presented; contrasting the key steps in resection for neoplastic and non-neoplastic conditions. The vascular approach is emphasized, and super-selective vascular dissection of the inferior mesenteric artery (IMA) and its branches are shown.

Classification

tips and tricks

Keywords

tips, sigmoid, colon, sigmoidectomy

Media type

Surgical video

Duration

14'00''

Publication

2006-12

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E-publication

WeBSurg.com, Dec 2006;6(12).
URL: http://www.websurg.com/doi-vd01en2050.htm

Technical tips for laparoscopic sigmoidectomy

1. Patient and trocar positioning 00'12''

The patient is placed supine with the legs in stirrups. The surgeon and 2nd assistant stand to the right of the patient, with the 1st assistant between the legs. One optical trocar and 5 X 5mm working trocars are used. Adequate anesthesia, including paralysis, is essential in order to allow the peritoneal cavity to distend with carbon dioxide gas insufflation. This provides an adequate working space. Three ports are used for retraction as shown. The surgeon usually works through trocars B and C. For mobilization of the splenic flexure, trocar D can sometimes be used. The table and the patient must be adequately supported and be able to tilt into a steep Trendelenburg position. This allows the viscera to fall to the superior aspect of the peritoneal cavity by gravity. We also favour a right tilt in order to assist in mobilisation of the small bowel to the right side of the abdomen. Here, we can observe trocar and instrument placement in a schematic fashion. Following a full peritoneal exploration, we begin the surgery by first confirming that the aortic bifurcation can be well seen. In thin patients, this is readily appreciated.

2. Case 1: Skeletonization of the inferior mesenteric vessels in diverticulitis 01'42''

In this case we perform a sigmoidectomy for diverticulitis. We start by opening the sigmoid mesocolon at its base, from the medial side. The sigmoid colon is retracted anteriorly and to the left and the inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) are visualised. Dissection proceeds on a wide front in order to expose a generous length of the IMA, so that all the sigmoid branches can be visualised. In this medial approach, the inferior mesenteric artery is always identified early. In this case, the surgery is for a non-neoplastic condition, and we preserve the IMA and IMV, performing a super-selective dissection of the sigmoid trunk and other sigmoid branches. The schematic demonstrates the inferior mesenteric artery and its branches. The inferior mesenteric artery is progressively skeletonised along its anterior surface, dividing each branch individually. The same is done for the inferior mesenteric vein.

3. Dissection along Toldt\'s fascia 03'42''

Once the vascular dissection is completed, dissection continues posteriorly along Toldt’s fascia. This is an avascular plane and if this fascia is not breached, then injury to the gonadal vessels and ureter will be avoided. We continue the vascular dissection distally to the first rectal branch and laterally we continue the dissection to the lateral surface along Toldt’s fascia. It is important to apply good retraction so that the space is visualised well and can be divided, as in this case with a pair of scissors. Here we observe the distal limit of the dissection, the first rectal branch.

4. Lateral dissection 05'25''

As shown in the schematic, we now proceed with the dissection laterally, and you can see that we have already divided the lateral attachments coming through from the medial side.

5. Superior dissection 05'45''

Superiorly, the vascular dissection is continued towards the left colic artery. This artery is then traced to the wall of the descending colon, it is then necessary to divide the marginal artery that forms the mesenteric arcade, as well as the border vessels of the colon. Once this is done, our dissection is complete.

6. Case 2: Dissection with Ligasure for diverticulitis 06'45''

In the next case, a similar vascular approach is employed in another case of sigmoidectomy for diverticulitis. In this case, the vascular dissection and division is performed with a LigaSure device. In contrast to the previous case, this sigmoid colon is bulky and the mesocolon is shortened by the inflammatory process. The sigmoid trunk is found early and divided, but the plane anterior to the inferior mesenteric vessels is not well seen. In order to clearly expose the mesocolon, we divide the lateral adhesions of the sigmoid colon.

7. Division of IMA 07'45''

Following this, the sigmoid colon can be retracted anteriorly and to the left using a grasper placed through trocar D and in this case, we proceed to divide the IMA and follow the plane of dissection just behind the artery. Laterally, this plane will be continued anterior to Toldt’s fascia as demonstrated before.

8. Lateral dissection 08'07''

The LigaSure device is very useful for haemostasis as well as for dissection. It can be used to seal vessels up to 7mm in diameter. Once the dissection is completed from the medial side, we release the lateral attachments according to the white line of Toldt.

9. Case 3: Oncologic approach for sigmoid cancer 08'48''

Now in our final case, we demonstrate the oncologic approach to sigmoidectomy. Observe the enlarged lymph nodes and the tumour mass which hangs down into the pelvis. We do not handle the tumour at this stage and leave it to hang in the pelvis. We start with the vascular dissection first as before. The aortic bifurcation is well seen and the dissection starts from the sacral promontory upwards along the right side of the aorta to the duodenojejunal junction. We perform a radical resection. However, the principles of medial vascular mobilisation and dissection along the retroperitoneal plane remain the same.

10. High ligation of IMA 10'00''

Here we observe progressive opening of the layers of the retroperitoneum until we identify the inferior mesenteric artery. This artery is then skeletonised and divided at its origin. This is important in order to complete the lymphadenectomy.

11. Dissection of left hypogastric nerve 10'45''

Once the artery is divided, we follow the plane of dissection immediately posterior to the artery. In this thin patient, the structures are visualised very clearly. You can see the left hypogastric nerve passing close to the left of the IMA, so it is vital to identify it early and sweep it downwards on a broad front so that it is not inadvertently injured during the dissection. This nerve carries sympathetic fibres and it is important for bladder and sexual function.

12. IMV division 11'25''

Once this nerve is dissected free, we then dissect the inferior mesenteric vein. The dissection always proceeds along Toldt’s fascia. Notice how the LigaSure can be used to coagulate and divide the inferior mesenteric vein.

13. Dissection along Toldt\'s fascia 11'50''

This LigaSure is now used as a gentle retractor to peel away the layers. Posteriorly lies the genital vein, and more medially, the ureter. These structures are left in the retroperitoneum under their protective fascial covering. As we continue along the retroperitoneal plane, we once again arrive at the lateral attachments.

14. Division of lateral attachments 13'00''

For cancer cases, it is our preference to divide the specimen and first place it in a waterproof bag.

15. Specimen extraction 13'00''

The schematic now demonstrates how the specimen is extracted. We usually enlarge the suprapubic port, and use a wound protector. The anvil of a circular stapling device is introduced into the proximal end of the colon and returned to the peritoneal cavity. After a lavage of the rectal stump, a circular stapler is introduced from below. The anastomosis is then completed as shown and finally it is checked. The anastomosis is now checked by insufflating air, and this is checked under water. Finally, we can also use a scope for assessment of the anastomotic line.

16. Anastomosis 13'15''