Perioperative management - Hybrid-NOTES - Sigmaresektion - general and visceral surgery
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Indications
NOTES (“natural orifice transluminal endoscopic surgery”) has the potential to further optimize MIS procedures.
Transvaginal procedures account for the majority of NOTES procedures.
The transvaginal route has been routinely used by gynecologists to access the abdominal cavity. The instruments are inserted via colpotomy into the abdominal cavity under direct vision. Due to the elasticity of the vaginal walls, larger-diameter instruments can be introduced and larger specimens extracted.
Genuine NOTES procedures are classified as experimental while the hybrid procedure demonstrated here with transvaginal specimen extraction and intracorporeal anastomosis is described in the current German guideline S2k on Diverticular disease/diverticulitisDiverticular disease/Diverticulitis of the German Society for Gastroenterology, Digestive and Metabolic Diseases and The German Society of General and Visceral Surgery.
Intraabdominal, laparoscopic sigmoid dissection necessitates additional access routes through the abdominal wall, which in the video is secured with 5 mm trocars and a 5 mm laparoscope for further minimization.
Compared with standard laparoscopic surgery, this promises less pain, less wound infections and less incisional hernias. In any case, the cosmetic results are definitely better.
In the case demonstrated here, sigmoidectomy in hybrid NOTES technique is indicated in stenosing sigmoid diverticulitis.
Contraindications
- General contraindications for laparoscopic procedures (e.g., intolerance of pneumoperitoneum, extreme patient positioning or presence of ileus)
- Generalized peritonitis
- Prior abdominal surgery and intestinal adhesions are not necessarily a contraindication for laparoscopic procedures, but may justify conversion to open surgery
Preoperative diagnostic work-up
Emergency diagnostic work-up
- Physical examination: Typical, almost pathognomonic, constellation of symptoms for diverticulitis are age >50 years; prior episodes; increased pain on movement; pain on palpation in left lower quadrant; differential diagnosis of irritable bowel syndrome
- Labor panel (inflammation), follow-up tests within 48 h since in complicated disease courses elevated inflammation parameters are seen only in the later course
- Cross-sectional imaging: Imaging modalities (US, CT) are crucial and indispensable for diagnosis of diverticular disease. Ultrasound is on par with CT and is therefore the imaging modality of choice Abdominal CT and contrast-enhanced CT of the rectum are reserved for unclear cases or poor visualization on US.
Supplementary diagnostic work-up in elective surgery
- Complete colonoscopy: Not required for diagnosis of diverticulitis, but strongly recommended before elective sigmoidectomy to rule out other significant findings. Early study (12-24 h) in the event of diverticular bleeding to localize bleeding and, if necessary, interventional treatment.
- Sphincter manometry is optional
- CT-colonography if colonoscopy failed or is not possible
Special preparation
- Orthograde colonic lavage
- Shaving of the abdominal wall
- Marking the best location for a possible stoma on the abdominal wall
In the operating room:
- Placement of indwelling catheter
- Single shot antibiotics (e.g., second generation cephalosporin + metronidazole)
- Trial positioning after mounting the patient supports on the OR table
Informed consent
- Bleeding/ secondary bleeding with need for allogeneic blood transfusion and possible revision surgery
- Staple line failure with local or generalized peritonitis and subsequent sepsis, reoperation, Hartmann procedure and stoma
- Intraabdominal abscess formation
- Injury to the iliac vessels, spleen, kidney, pancreas, left ureter
- Special complications due to transvaginal access, e.g., injury to rectum/bladder/adnexa when inserting trocar/extraction bag or wound edge protector
- Primary protective ileostomy or primary Hartmann procedure
- Conversion to open surgery
- Changes in stool habits
- Trocar site incisional hernia
- Risk of stapler injury to the sphincter
Anesthesia
Positioning
Operating room setup
Special instruments and fixation systems
Postoperative management
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