Laparoscopic left colectomy for cancer: injury and control of IMA

Vascular injury is the most urgent type of trauma at laparoscopy. The objective of this film is to demonstrate the control and mechanism of an injury to the inferior mesenteric artery during its dissection at its origin. This dissection has been performed using monopolar scissors.

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Laparoscopic left colectomy for cancer: injury and control of IMA

Authors

J Leroy, J Marescaux

Abstract

Vascular injury is the most urgent type of trauma at laparoscopy. The objective of this film is to demonstrate the control and mechanism of an injury to the inferior mesenteric artery during its dissection at its origin. This dissection has been performed using monopolar scissors.

Classification

tips and tricks

Keywords

Laparoscopic left colectomy, cancer, injury, control of IMA, inferior mesenteric artery

Media type

Surgical video

Duration

08'50''

Publication

2009-09

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E-publication

WeBSurg.com, Sept 2009;9(09).
URL: http://www.websurg.com/doi-vd01en2724_1.htm

Laparoscopic left colectomy for cancer: injury and control of IMA

1. Introduction 00'17''

The objective of this film is to demonstrate the control and mechanism of an injury to the inferior mesenteric artery during its dissection at its origin. This dissection has been performed using monopolar scissors. The dissection along with the skeletonization of the artery is a commonly practiced technique to comply with oncologic principles. As can be seen here, this dissection is carried out easily. During dissection proximal to the origin of the artery, we notice that one of the blades of the monopolar scissors is in contact to the artery and causes a partial injury to the wall. A second application of the electrode further weakens the vessel with anterior division. The bleeding is immediately massive.

2. Control of the bleeding 01'40''

Control is first attempted using an atraumatic forceps that shows the importance of a two-handed approach for dissecting. An other atraumatic instrument such as a Johann forceps introduced suprapubically, and used to maintain the retraction of the sigmoid colon at the beginning of the procedure is now used to achieve a temporary trauma-free hemostasis. The maneuver is carried on in order to clean the vascular wound. At this time of the procedure, conversion may be applied in order to complete hemostasis but in this case, control is performed laparoscopically. Such a control requires a perfectly clear operative field. To do so, aspiration cannulas or possibly a gauze pad may be used in order to better clean blood-soaked tissues. During this dissection, one of the dangers is to perfectly dissect the artery at its origin in order to obtain a sufficiently long stump for the hemostasis and to respect nerve plexuses. It is therefore necessary to perfectly skeletonize the mesenteric artery to avoid any clipping or stapling or a cauterization ensuring hemostasis of the nerve plexuses. Dissection of the artery is therefore completed towards the aorta. We are slightly impaired by the presence of a small lymph node. However, it is not uneasy to continue the dissection. We simply carry out a dissection with scissors.

3. Clipping the artery 04'04''

Once we have been around the artery, a clip is applied on its proximal portion. Then a second clip is applied to ensure the hemostasis. Its distal portion is then clipped always by keeping contact to the artery. The injured area is clearly visible. Dissection of the artery is continued as proximal as possible and by respecting the nerve plexuses stuck onto the left posterior lateral aspect of the inferior mesenteric artery. Here the nerve plexus is clearly visible caudally and to the right as well as the skeletonized artery and the clips applied. Division in contact to the artery does not require thermal or electrical energy, but merely the cold blade of scissors. Skeletonization is made possible owing to a perfect exposure using traction placed with the suprapubic forceps. Dissection is achieved with two instruments activated by the surgeon. This surgery requires two hands. The distal end of the inferior mesenteric artery is clearly visible now. It is still in contact to the nerve plexus structures. The plexus is further freed with a division in contact to the posterior wall of the inferior mesenteric artery.