Three trocar sigmoidectomy for diverticulitis with transanal extraction

The combination of laparoscopy and specimen extraction through a natural orifice has the potential to decrease wound complications and to improve postoperative recovery. The objective of this film is to demonstrate the possibilities of specimen extraction of a sigmoid diverticulitis transanally with reduction of abdominal openings that may sometimes induce incisional hernias and postoperative pain. In this case, a laparoscopic three-port technique is performed: one 12mm optical port situated in the umbilicus, and two right iliac fossa ports (one 5mm port placed in the right flank, and a 12mm port in the right iliac fossa for introduction of staplers).

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Three trocar sigmoidectomy for diverticulitis with transanal extraction

Authors

J Leroy, J Marescaux

Abstract

The combination of laparoscopy and specimen extraction through a natural orifice has the potential to decrease wound complications and to improve postoperative recovery.
The objective of this film is to demonstrate the possibilities of specimen extraction of a sigmoid diverticulitis transanally with reduction of abdominal openings that may sometimes induce incisional hernias and postoperative pain.
In this case, a laparoscopic three-port technique is performed: one 12mm optical port situated in the umbilicus, and two right iliac fossa ports (one 5mm port placed in the right flank, and a 12mm port in the right iliac fossa for introduction of staplers).

Classification

tips and tricks

Keywords

Three trocar sigmoidectomy, diverticulitis, transanal extraction

Media type

Surgical video

Duration

09'50''

Publication

2009-06

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E-publication

WeBSurg.com, Jun 2009;9(06).
URL: http://www.websurg.com/doi-vd01en2643.htm

Three trocar sigmoidectomy for diverticulitis with transanal extraction

1. Introduction 00'01''

The objective of this film is to demonstrate the possibilities of specimen extraction of a sigmoid diverticulitis transanally with reduction of abdominal openings that may sometimes induce incisional hernias and postoperative pain. Three ports are used in this procedure: one 12mm optical port situated in the umbilicus, and two right iliac fossa ports (one 5mm port placed in the right flank, and a 12mm port in the right iliac fossa for introduction of staplers).

2. Uterus suspension 00'35''

The first step consists in suspending the uterus thanks to transparietal threads leaning on the right and left round ligaments.

3. Division of the sigmoid mesocolon 00'42''

Then the sigmoid mesocolon is divided using the 10mm LigaSure Atlas® device, paying attention to preserve the vascular supply of the rectum. Only the sigmoid branches will be divided as we usually do in benign colonic pathologies.

4. Mobilization of the descending colon 01'40''

The descending colon will be mobilized; hence its lateral attachments are divided until the splenic flexure is reached. This is achieved in order to obtain a tension-free anastomosis on the descending colon. The sigmoid mesocolon is divided until the next area to be divided and that is situated at the junction between the descending colon and the sigmoid colon.

5. Anvil introduction 02'35''

Then the anvil of the DST EEA circular stapler is introduced in the colon. This anvil is connected to a thread that will help to manipulate the anvil into the colonic lumen. The anvil is grasped using a forceps introduced in the colonoscope. It is then pushed into the colonic lumen with the help of laparoscopic instruments. In this case, the problem lies in the narrowness of the colon and the difficulty in pushing the anvil without risk on a very spastic colon, as can be observed in specific kinds of diverticulitis. The decision is made to open the colon and exteriorize the anvil in order to reintroduce it more cephalad in the lumen of the proximal colon. This maneuver is carried out without any difficulty when the colon is compliant. As can be seen in these pictures, the anvil is grasped by its shaft and the whole system is pushed while preserving the anvil, by grasping the plastic parts and not the metal parts. The head of the anvil is pushed towards the proximal part of the colon. Its tip is pushed towards the distal part before dividing underneath the tip. In this case, the thread has been kept.

6. Division of the sigmoid colon 04'38''

Then the division of the sigmoid portion must be carried out at the colorectal junction. Once the rectal stump has been cleaned using a Betadine solution, the rectum is divided fairly high as another cut will then be performed. One of the colonic extremities, and in this case its distal part is closed using a Vicryl loop whose thread is kept long enough.

7. Endo-catch II insertion 05'33''

An Endo-catch II extraction bag is introduced through the anus. The bag’s introducer is 15mm in diameter, which is little traumatic for the anus. Then the bowel segment is introduced into the bag while keeping the thread that holds one of the colonic extremities outside the bag.

8. Specimen extraction 06'07''

Then the introducer is removed and the bag is pulled through the anus and opened outside. The extremity of the colon is pulled to progressively reduce the specimen volume inside the bag, which will facilitate the extraction without causing any trauma to the rectum. Once the extraction is complete, the colon and the upper rectum still needs to be further divided just underneath the rectosigmoid junction that will be resected as is routinely done in the treatment of sigmoid diverticulosis. Once the division has been achieved, the fragment of remaining colon is placed in a small-sized bag introduced through the 12mm right iliac fossa port before being extracted by the same port either immediately or at the end of the procedure. In this case, it is extracted after removing the tip of the anvil, which will itself be retrieved through the same port. How shall we remove this tip and bring the anvil into an ideal position? We will do this by opening the colon close to the stapling line with monopolar scissors to find the anvil’s tip and pulling on it. Therefore, closure can be completed in order to ensure a perfect air tightness using a suture loop.

9. Anastomosis 08'12''

Here, the whole system needs to be connected together in order to perform a mechanical end-to-end anastomosis according to the technique described by Knight and Griffen. The absence of torsion and tension is ruled out. The proximal and distal donuts are controlled: these are integral and thick. At the end of the procedure, lavage of the abdominal cavity is carried out. Trocar introduction sites are also controlled. By checking the incisions, we see that only three incisions have been necessary in order to achieve this type of procedure. The size of the incisions may be reduced to diameters of 5mm for right iliac fossa ports, with only one 12mm port placed at the umbilicus.