Laparoscopic sigmoidectomy for acute diverticulitis (Hinchey stage IIb)

This video presents the laparoscopic treatment of a perforated acute diverticulitis of the sigmoid colon. The patient has a Hinchey stage IIb peritonitis. Because of a stable clinical presentation, a laparoscopic treatment was offered. The cavity of the abscess is opened and cleaned. Local inflammation makes the dissection planes more difficult to define and the progression of the mobilization can be challenging. A sigmoidectomy is then carried out with a primary anastomosis.

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Laparoscopic sigmoidectomy for acute diverticulitis (Hinchey stage IIb)

Authors

J Leroy, J Marescaux

Abstract

This video presents the laparoscopic treatment of a perforated acute diverticulitis of the sigmoid colon. The patient has a Hinchey stage IIb peritonitis. Because of a stable clinical presentation, a laparoscopic treatment was offered. The cavity of the abscess is opened and cleaned. Local inflammation makes the dissection planes more difficult to define and the progression of the mobilization can be challenging. A sigmoidectomy is then carried out with a primary anastomosis.

Classification

basic techniques

Keywords

Laparoscopy, sigmoidectomy, acute diverticulitis, Hinchey stage IIb

Media type

Surgical video

Duration

16'37''

Publication

2008-11

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E-publication

WeBSurg.com, Nov 2008;8(11).
URL: http://www.websurg.com/doi-vd01en2399.htm

Laparoscopic sigmoidectomy for acute diverticulitis (Hinchey stage IIb)

1. Freeing of adhesions and mobilization of sigmoid colon 00'11''

The purpose of this film is to show a complex diverticulitis and the strategy to perform a laparoscopic sigmoidectomy procedure. First, after panoramic exploration of the abdominal cavity, we have a fixation of the small bowel on the right side of the mesosigmoid due to an abscess, and the 1st step is to unstick the bowel fixed to the meso by respecting the bowel. The difficulty of this step is to find the right plane and we have used different techniques, first hydrodissection that can facilitate the opening of the planes, and the 10mm Ligasure device not using electrocautery but using the jaws of the instrument as 2 fingers to do a digitoclasy. After freeing of the small bowel, we complete the dissection by division of the mesosigmoid, not dividing the IMA, but the branches of the IMA.

2. Division of mesenteric vessels 02'00''

First the sigmoid branches, and later as you will see, we will divide the superior rectal vessels. We continue the dissection in a non-inflammatory place, and this is easier using the 10mm Ligasure Atlas® device, and as you see the vessels and the surrounding tissues are very thick. That’s why we use no traction on the structures to be sure that bleeding is controlled by the sealing. To complete hemostasis, we use a loop around the vessels just divided. We continue the dissection using a medial approach and the objective is to find the plane anterior to the Toldt’s - Gerota’s fascia. The danger at this time is to injure the ureter. That’s why it’s necessary to identify it and divide anterior to the Toldt’s fascia. At this moment, it’s time to free the lateral attachments as we see, it’s very thick peritoneum, inflammatory tissue to avoid the risk of opening a small abscess, we prefer to incise the peritoneum and find the retroperitoneal plane staying away from the inflammatory tissue. It is sometimes useful to use a 10mm Ligasure Atlas® device to divide attachments and also use it as a device that will do the dissection of this plane as a finger.When we reach the lateral attachments close to the uterine tube and ovary, the 10mm Ligasure device is useful and we have to retract the genital structures and also remain at a distance from the ureter. To complete the dissection of the rectum, we have to divide the rectum at a distance from the inflammatory tissue. It’s why we complete the dissection as we do in TME: removing the mesorectum and doing the dissection between the presacral fascia and the propria fascia of the rectum. Lower at the level of the mid-rectum, we come back to the mesorectum to perform a division of the mesorectum and it’s at this stage that a bleeding occurred. We control it immediately with the Ligasure not only sealing it but also placing a loop that is probably better than using a sealing in inflammatory thick tissue. This loop is easy to apply and we can continue the dissection when hemostasis is controlled. We wash the abdominal cavity to get a better view and we divide the mesorectum coming closer to the rectum. We can use in this case a conical dissection of the mesorectum because it’s not a cancer case and the division of the meso is done slowly and safely. The problem is the attachment to the lateral side of the pelvis that we have to free and after it is done, we have a complete view on the pelvis and the pelvic structures, and particularly on the iliac vessels on the left, on the ureter. Freeing of the upper rectum is done coming closer and closer onto the bowel. Anteriorly we have to divide the meso keeping the vascularization of the rectum. When we are on the mid-rectum and we have completed the dissection of the surrounding tissue, we can divide the rectum using an Endo-GIA linear stapler in this case but before doing so, it is necessary to completely free the rectum anteriorly, laterally, and posteriorly in order to apply the stapler on the bowel only and not on the surrounding tissue and particularly the omental loop and the fat, meso and tissue. This is not an easy step as you can see. It’s why using curved instruments as mini-shears roticulators, using a zero degree scope and a right lateral approach, we can complete the division of the surrounding tissue safely.

3. Division of distal colon and mobilization of sigmoid colon 09'13''

The best is to keep a perfect view of the surgical field during this dissection. Once completely free, the mid-rectum can be divided using a linear stapler and we have to control the extremity of the stapler to be sure that we are not grasping the ureter or the uterine tube. This is important particularly in this case but it’s probably less dangerous than the stapler applied in easy cases where the uterine tube is mobile. We can then continue with the mobilization of the descending colon and the splenic flexure to be sure that we will do a tension-free anastomosis. For that, it is not necessary to always divide the inferior mesenteric vessels at their origin but in inflammatory tissue, it is often necessary to divide the vessels. The lateral freeing is not enough in the majority of cases. You now see the opening of the lesser sac after we have divided the attachments of the omentum and transverse colon. Lateral freeing of the attachments of the omentum and the splenic flexure is done slowly and finally we will divide the attachments of the transverse mesocolon to the pancreas using this lateral approach. This is done using the Ligasure Atlas® device. When we have finished the lateral freeing of the descending colon and the splenic flexure, we control the possibility to do a tension-free anastomosis and verify that we can take down the descending colon. In this case, it doesn’t seem easy to do.

4. Division of proximal colon 12'45''

Before doing the anastomosis, we select the segment that will be removed. The choice is not done on the segment we can take down but we choose the best segment for the anastomosis and afterwards we will further mobilize the colon if necessary. In inflammatory diverticulitis with huge pseudo-tumoral sigmoids, I prefer to divide the proximal colon and remove the segment of colon separately. We have evaluated the possibility of taking down the descending colon and it was not sufficiently mobilized, so we decide to divide the IMV. The IMV is divided using the Ligasure Atlas® device with enough distance from the pancreas to avoid injuring it. Because it’s very thick tissues, we prefer to complete hemostasis putting a loop on the IMV and this is done immediately to be sure that we will not have a bleeding outside of the operative field.

5. Extraction 14'27''

The descending colon can now come easily in the pelvis and we decide at this moment to remove the sigmoid. To do so, we have introduced a plastic wound protector through the suprapubic incision in place of the suprapubic trocar and we have removed the segment introduced in the Endo-catch® plastic bag.

6. Colorectal anastomosis and closure of the peritoneal window 15'08''

So we use a double protection that facilitates the extraction because we can do manipulation inside the plastic bag without danger. Then, we have introduced the anvil of the circular stapler in the proximal colon through the suprapubic incision always protected by the plastic wound protector and reintroduced the proximal colon with the anvil inside the abdomen. Then, we do the colorectal anastomosis under laparoscopic control using the PCEEA™ DST™ circular stapler (diameter 28) and we verify the anastomosis respecting the protocol of closure and stapling recommended by the manufacturer. We also close the mesenteric gap using staples. This is done from the lateral side to the duodenojejunal junction towards the pelvic rim. Then we wash, and close without drainage.