Management of colonic perforation during trocar placement in bariatric surgery

Complications related to first trocar placement are rare when performing laparoscopic procedures. In case of anterior procedures, gaining access to the abdominal cavity could be very difficult. This video demonstrates the management of colonic perforation during trocar placement in bariatric surgery.

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Management of colonic perforation during trocar placement in bariatric surgery

Authors

M Vix, J Marescaux

Abstract

Complications related to first trocar placement are rare when performing laparoscopic procedures. In case of anterior procedures, gaining access to the abdominal cavity could be very difficult. This video demonstrates the management of colonic perforation during trocar placement in bariatric surgery.

Classification

clinical cases

Keywords

colonic perforation, trocar placement, bariatric surgery

Media type

Surgical video

Duration

09'02''

Publication

2010-10

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E-publication

WeBSurg.com, Oct 2010;10(10).
URL: http://www.websurg.com/doi-vd01en2930.htm

Management of colonic perforation during trocar placement in bariatric surgery

1. Introduction 00'18''

This is the case of a 45-year-old woman who benefited from the removal of a gastric band 6 months earlier. An extensive bariatric workup has been performed. The decision to carry out a gastric bypass was made in agreement with the patient. When the gastric bypass was initiated, the patient’s BMI was 50.

2. Patient position 00'39''

The patient is installed in the French position, both legs apart and the surgeon standing in between. The first trocar is placed one hand’s breadth and a half below the xiphoid appendix. It is introduced through an open coelioscopy. The skin incision is carried out. The dissection of the subcutaneous skin is carried out until the fascia, which is incised. A Kocher forceps is placed on one of the incision margins, and the dissection is performed cautiously using scissors in order to enter the abdomen almost under visual control.

3. First port introduction and abdominal cavity exploration 01'16''

Here the introduction of the first trocar can be seen. It is relatively difficult to achieve. The insufflation is not immediately adequate. There are a few adhesions around this trocar. All of a sudden, the aspect of a mucosa, which is visible through this first trocar, can be seen. Attempts to identify a few anatomical landmarks are made. At one time, it looks as if stools can be seen along with a colonic wound. The trocar is cautiously withdrawn in order to place it at the edge of the peritoneum. The remaining of the abdominal cavity can be explored. A second trocar is then placed on the left mid-clavicular line under visual control. This trocar is placed away from the adhesions —they are relatively few—, and a 5mm trocar is placed on the left anterior axillary line to allow for the dissection of the different adhesions.

4. Dissection of adhesions 02'31''

The first step is to dissect the adhesions fixing the stomach and the colon to the anterior wall. However, this maneuver is slowed down in order to find the anterior colonic orifice. The exploration is carried on cautiously. A relatively more blood-red area can be seen. It seems to be related to the trocar introduction problems. Here an omental band is meticulously divided using monopolar current and division without coagulation.

5. Identification of anterior colonic orifice 03'22''

The anterior colonic orifice starts to be visible. At this moment, the position is changed into a more ergonomic one by adding a 12mm umbilical trocar, which will be placed opposite the colonic orifice to be sutured. A 5mm trocar is placed on the right mid-clavicular line to allow for an easier manipulation and suturing. By changing the vision axis, the colonic wall is immediately accessed. A few adhesions are taken down in order to present more distinct wound margins before starting the suture. The dissection is meticulously performed to stay in contact to the colonic wall.

6. Orifice suturing 04'29''

The suture is then started using a Polysorb 2/0 thread. A first thread is placed at the far left and a second thread is placed at the far right. They are not knotted in order to position the third thread in the safest and most adapted way. The different knots are then tied, hence closing the anterior colonic orifice. As soon as the anterior colonic orifice has been closed, it is essential to control if the wound has not been transfixing. The lesser sac is first searched for. Here attempts are made to find the plane between the omental adhesions and the round ligament in order to re-identify a plane allowing to approach the lesser sac. The dissection is carried out using the monopolar hook. The anterior surface of the stomach is visualized and the dissection will leave in place the adhesions suspending the stomach in order to gain access between the colon and the stomach in the lesser sac. The plane is identified and the dissection of the plane is started. When the beginning of the lesser sac is visualized, the examination of this region allows to find the presence of salts deposited by the scissors that accidentally caused the injury.

7. Identification of posterior colonic orifice 06'36''

And, very rapidly, a posterior colonic orifice is found hidden underneath the omental fat. The dissection of this omentum is pursued until completely cleaning the colonic wall and reaching the wound margins that will be sutured. This dissection is performed partly using the Ligasure® device and partly using the hook. The latter helps to better identify the planes and obtain a more precise dissection in this area. The dissection should be performed in order to obtain sufficient margins for suturing.

8. Orifice suturing 07'36''

Here the orifice is perfectly identified and three stitches of Polysorb 2/0 material are placed in the same manner as for the anterior orifice – namely one stitch on the far left, one stitch on the right, and finally a median stitch. The knots are not tied immediately in order to have a better view of the orifice throughout the placement of the three stitches. The colonic perforation is therefore closed by anterior and posterior stitches. The extent of adhesions closing off the superior portion of the stomach is controlled. Once the suture of the colonic orifices has been completed, the decision is made not to perform the gastric bypass that was anticipated in order to obtain an easier postoperative outcome. The patient will be awakened. We will explain her why the procedure did not take place. The gastric bypass will be performed two months after this procedure.