Laparoscopic colectomy with ileorectostomy - general and visceral surgery

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  • Inserting the Veress needle and trocar placement

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    Due to obesity and a periumbilical scar, establish the pneumoperitoneum by inserting the Veress needle subcostally in the left epigastrium. First, by blunt scissor dissection fashion the channel for a 10mm trocar in the right mid-abdomen and insert the trocar. Now, under direct vision insert another 10 mm trocar at the umbilicus and a 5 mm trocar in the right lower quadrant. Through this 5 mm trocar clear the adhesions with the median umbilical ligament as far as the bladder while staying close to the abdominal wall. Then, insert a 12 mm trocar in the suprasymphyseal region of the planned Pfannenstiel incision. Insert another two 5 mm trocars in the left middle abdomen and left epigastrium, in the latter case at the site of the Veress needle.

  • Dissecting the ileocecal junction

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    First, mobilize the terminal ileum, cecum, and ascending colon from inferior and laterally while sparing the Gerota fascia.

    Note: While dissecting the right hemicolon, the surgeon and first assistant stand to the left of the patient facing the monitor on the patient's right side. From the time of dissecting the left hemicolon (step 7) until the end of the operation, the sides are switched, with a second monitor now positioned on the left side of the patient.

  • Mobilizing the ascending colon and taking down the hepatic flexure

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    On the Gerota fascia, fully mobilize the ascending colon with its mesenteric root up to the duodenum and expose the latter completely. Dissect the hepatic flexure laterally and superiorly and divide adhesions to the gallbladder and a double-barrel configuration between the ascending and transverse colon.

  • Taking down the greater omentum

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    Now, transect the gastrocolic ligament and open the omental bursa. Leave the greater omentum in place and detach it from the transverse colon from left to right.

  • Dividing the ileocolic vessels

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    Make an incision in an avascular window of the mesocolon between the middle colic and ileocolic arteries. Now locate the ileocolic vessels in the mesocolon and divide them one by one with the THUNDERBEAT surgical energy device.

  • Dividing the right mesocolon

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    After having completely mobilized the distal ileum, divide the right mesocolon, step by step and close to the intestinal wall, with the THUNDERBEAT up the middle colic vessels. Having divided these, focus next on the left hemicolon.

  • Mobilizing the left hemicolon and dissecting the upper rectum

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    Start dissecting the left hemicolon by opening the upper mesorectum/mesosigmoid mediad and expose the inferior mesenteric artery with its sigmoid branches. Next, pull the sigmoid mediad and take it down from the lateral abdominal wall while identifying and sparing the left ureter and Gerota fascia. Free the colon with its mesocolon from the retroperitoneum along this fascia.

  • Taking down the splenic flexure

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    The splenic flexure also presents with a double-barrel formation which has to be freed in the first step. Follow this by taking down any adhesions with the spleen and pancreas and also by continuing to transect the mesocolon as far as the inferior mesenteric artery.

  • Transecting the upper rectum

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    While sparing the inferior mesenteric artery already exposed in step 7, coagulate and transect the vessels originating here step by step with the THUNDERBEAT surgical energy device until the muscle tube of the upper rectum is exposed, which is then transected  with a 60 mm angulated endo-GIA stapler.

  • Colonoscopy of the rectal stump and recovering the colon through a Pfannenstiel incision

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    First, check by colonoscopy that the rectal stump is absolutely free of any polyps. Likewise, check that the vessels are transected along the entire colonic frame. Then, extend the suprasymphyseal trocar incision like a Pfannenstiel mini-incision for recovery of the colon. After insertion of a wound edge protector, pull out the entire colon starting with the cul-de-sac rectum.

  • Transecting the ileum, placing the purse string suture

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  • Anastomosis

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  • Checking the anastomosis, closing the mesenteric window, placing drains and terminating the operation

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