Totally minimally invasive surgical management of Hinchey IIA diverticulitis

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Totally minimally invasive surgical management of Hinchey IIA diverticulitis

Authors

J Leroy, J Marescaux

Keywords

diverticulitis,colorectal surgery,sigmoid colon

Media type

Surgical video

Duration

06'00''

Publication

2004-04

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E-publication

WeBSurg.com, Apr 2004;4(04).
URL: http://www.websurg.com/doi-vd01en1540e.htm

Totally minimally invasive surgical management of Hinchey IIA diverticulitis

1. Trocar placement and exposure 00'09''

This video will demonstrate successful totally minimally invasive treatment of a patient with Hinchey grade 2 diverticulitis. The case is that of a 72-year-old woman who presented for the first time with acute abdominal syndrome. The patient had multiple co-morbidity and was on corticosteroid treatment. Initial ultrasound examination showed left ureteric obstruction. CT examination then revealed a left-sided pelvic abscess secondary to perforated diverticulum. This is the CT of the patient showing the size and location of the pelvic abscess. Initial treatment was CT-guided percutaneous drainage of the abscess. The patient the received IV antibiotics and acute illness was controlled. This image shows the CT-guided percutaneous drainage. This is a single contrast enema study showing the location of the drain.

2. Tumor dissection 01'01''

The patient then underwent laparoscopic sigmoid colectomy with primary anastomosis, thus completing the totally minimally invasive treatment of this condition. Now to the operating room. This is the base unit for the infrared ureteral stents. The last 20cm of the stent is serrated in order to create a dispersion effect of the light. The illuminated stents are inserted during preoperative cystoscopy. Now to the intraoperative laparoscopic view. As expected, there are multiple abdominal and pelvic adhesions, which need to be divided in order to create a right exposure. This is done using diathermy scissors and blunt dissection. Loops of small bowel are carefully freed from the dense post-inflammatory phlegmon. Here is the bladder and uterus. The position of the right ureter is clearly indicated by the infrared stent. There is tissue overlying the left ureter. The dissection is now continued in the left iliac fossa in order to isolate the sigmoid colon for resection. The operation is made easier due to the fact that the active inflammation has settled. The Ligasure coagulation device is particularly useful here as secure hemostasis is achieved during dissection of the vascular rich tissue. The Ligasure device is also used as a tool for blunt dissection.

3. Extraction and closure 02'55''

As the infrared light is not visible here, the surgeon is reassured that the ureter will not be damaged during this dissection. Here is the sigmoid colon. The pathological tissue of the abscess cavity is visible immediately underneath this. The ureteral stent is clearly visible and the dissection is continued adjacent to this area taking care not to damage the ureter. The sigmoid colon has now been isolated. The area of the rectosigmoid junction is then tidied up in order to accommodate the linear stapling device in preparation for division at this level. The Endo-GIA is now introduced and the rectosigmoid junction is divided. Once the distal end is freed, the dissection is continued towards the splenic flexure. The descending colon is mobilized in order to allow for a tension-free anastomosis. The dissection is continued cephalad in the mesocolon. Now to the medial aspect of the descending colon. Care is taken not to damage this large branch of the inferior mesenteric vein. The peritoneum here is further freed using the same principles of dissection. The dissection is continued in order to achieve medial mobilization of the colon. Now that the descending colon is mobilized, the sigmoid resection can follow. Here the empty left iliac fossa is visible. This is the sigmoid colon and part of the abscess wall. A biopsy is taken from the remaining abscess wall for analysis in order to exclude cancer. Here is the length of colon to be resected. The proximal line of division is made bare by careful dissection prior to division. Following this, a suprapubic trocar incision on the abdominal wall is extended and the wound protector is applied prior to exteriorization of the resection specimen. The blind end of the colon is then pulled out of the abdominal cavity through the incision for extracorporeal division. After resection, the anvil of a circular stapling device is secured to the divided end of the colon using a purse-string stitch. Once the bowel is reintroduced, the body of the circular stapling device is introduced per-rectally and is combined with the anvil as shown here. The device is then fired and then removed together with the donuts of colonic tissue. An air leak test is performed to check the anastomosis. This is the end of the operation and the patient is discharged from hospital on the 6th postoperative day without any complications.