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Tips and tricks: IMA and IMV dissection with LigaSure AdvanceTM

Authors

Abstract

This video shows a series of technical tips and tricks for the identification, dissection and ligation of the main vascular elements during a laparoscopic left colonic resection using the LigaSure Advance™.

Classification

tips and tricks

Keywords

tips and tricks, IMA, IMV dissection, Ligasure Advance, colon, cancer

Media type

Duration

14'00''

Publication

2008-09

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Audio

Subtitles

E-publication

WeBSurg.com, Sept 2008;8(09).
URL: http://www.websurg.com/doi-vd01en2351.htm

Tips and tricks: IMA and IMV dissection with LigaSure AdvanceTM

1. Exposure 00'19''

We have the promontory there. We keep as much peritoneum as possible: this is mainly for the end of the procedure when we have to close the gap. If we keep more peritoneum anterior to the aorta, it is easier to close. Then we open using this new device that is the LigaSure Advance™. The main advantage is to be able to seal, cut using bipolar and monopolar cautery as you see now. The main goal at this moment is to divide the IMA at its origin. To do so, we use traction and counter-traction to expose the root of the mesosigmoid. For exposure, we have used only the positioning of the patient who is in a Trendelenburg, right lateral tilt. Before we put a pillow lateral and on the left.

2. Dissection of the inferior mesenteric artery 02'21''

We do the dissection.I reduce the power of the monopolar device. I will use 15 Watts. Now we are close on the back of the vascular sheet. We can see it very well there and we will dissect staying close to the vascular sheet. We open this vascular sheet there and continue lower. In order to find the right plane, we must have a good traction on the mesentery due to the shape of the device. We have the nerve running there, branches of the nerves that are running to the plexus. We remove this node. We remove the other part. So we are dissecting slowly. We can use at this moment the monopolar system because we are sure that there is no contact except at the tip. This will facilitate the division. You can see the plexus trunk and probably here the division of the beginning of the left colic artery not far here and we will divide there.

3. Division of the inferior mesenteric artery 05'07''

Division can be done using the LigaSure without tension with a 2cm distance. The only limit is the quality of the vessels, in elderly patients especially. We ask the assistant to change traction. And we can divide. These are the branches, which have been divided.

4. Inferior mesenteric vein dissection and division 06'00''

We now have to continue. When we have divided the plexus branches, we have to continue dissecting and go behind the IMV, which is lateral to the duodenojejunal junction. You see it very well there. This is the duodenojejunal junction and this is the IMV trunk not far. We must keep as much peritoneum as possible in order to close the gap at the end without danger to the bowel. You see the vein is there. This is the IMV running lateral to the duodenojejunal junction. When we dissect it, we can dissect very high, sometimes we have to keep the left colic vessels, the left colic vein and we will do it in this case; I think it’s not an oncologic problem. The only thing is if we do the dissection, we have to do it close to the vein, particularly back to it because if we don’t, we will be behind the fascia and it’s why we do the dissection staying close to the vein. You see the left colic vessels and we will divide the vein too. We use 20 Watts here.

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