Sigmoidectomy, laparoscopic

  • Universitätsklinik Lübeck

    Dr. Tilman Laubert

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  • Descending and sigmoid colon

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    • Splenic flexure anchored to diaphragm via phrenocolic ligament 
    • Secondarily retroperitoneal location of descending colon
    • Transition from descending to sigmoid colon within left iliac fossa
    • Sigmoid located intraperitoneally (àsigmoid mesocolon)
    • Transition from sigmoid to rectum anterior to second / third sacral vertebra
  • Blood supply

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    • Superior (medial colic artery) and inferior mesenteric artery (left colic artery) anastomose close to the splenic flexure(arc of Riolan)
    • Arterial blood supply of the left hemicolon, sigmoid and upper rectum by the inferior mesenteric artery (left colic artery, sigmoid arteries with marginal artery of Drummond, superior rectal artery)
    • Venous drainage into the portal system mirrors the arterial blood supply
  • Topography

    • Cephalocaudad the descending colon is in close relation with the spleen (splenic flexure), omental bursa (dorsomedial to splenic flexure), left kidney, and the pancreatic tail (cephalic segment of descending colon)
    • The root of the sigmoid mesocolon courses mediad from the left iliac fossa crossing the common iliac vessels, ureter and the ovarian/testicular vessels
    • The ureter crosses the psoas muscle from superolateral to inferomedial
    • The ureter courses below the Gerota fascia posterior to the descending colon
  • Universitätsklinikum Schleswig-Holstein

    Dr. Hamed Esnaaashari

  • Campus Lübeck

    Herr Prof. Dr. med. Hans-Peter Bruch

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 27.04.2009
  • Universitätsklinikum Schleswig-Holstein

    Dr. Hamed Esnaaashari

  • Campus Lübeck

    Herr Prof. Dr. med. Hans-Peter Bruch

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  • Creating the pneumoperitoneum and placing the trocars

    46-6

    Make a medial skin incision about 3cm superior to the umbilicus. Introduce the trocar for the laparoscope (T1) into the abdominal cavity through a minilaparotomy and create the pneumoperitoneum. After gross inspection of the abdominal cavity, introduce the working trocars (T3, T3, T2) under direct view.

    Note:

    Be aware that creating the pneumoperitoneum with a Veress needle may risk injury to large intraabdominal blood vessels.

  • Mobilizing the sigmoid

    Position the patient right lateral recumbent.

    Dissecting on the Gerota facia divide the embryonic adhesions between peritoneum and sigmoid toward the splenic fissure. Left ureter and left- iliac vessels must be positively identified.

  • Mobilizing the splenic flexure

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    Reposition the patient to reverse Trendelenburg while still in right lateral recumbent. Start freeing the descending colon and splenic flexure laterally from the left. In doing so, pull the descending colon mediad and successively divide the colonic adhesion with the Gerota fascia. 

    Starting in the middle of the transverse colon dissect the greater omentum off it, which will free the splenic flexure and open up the lesser sac. During this dissection the splenocolic ligament and attachments between the pancreas and colon will also be divided. Finally, the left colon including its splenic flexure has been freed from all posterior structures, allowing a tension-free anastomosis.

    Tips:

    • Abrupt traction on the colon may result in injury to the spleen.
    • Dissection is facilitated by bringing the OR table from Trendelenburg (head low) back to level while still keeping the patient in right lateral recumbent.
  • Tubular Dissection of the mesosigmoid

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    Undo the reverse Trendelenburg and the right lateral recumbent. Incise the mesosigmoid medially, introduce the retractor and divide the mesosigmoid close to the sigmoid colon while maintaining traction antiroad and keeping the mesentery under constant exposure. Carry the dissection upstream of the rectosigmoid transition (identifiable by the disappearance of the omental appendices and taeniae of colon). Dissection along the colon will ensure that the inferior mesenteric artery and its main branches are spared.

    Caution:

    • Identification of left ureter and ovarian/testicular vessels
  • Dividing the upper rectum

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    Determine the levels of division. The proximal level should be upstream of the inflamed or diverticular bowel segment. Position an intestinal clamp at the level of the planned distal level of division. After transanal irrigation (wash-out), insert the stapler preferably at right angles to the course of the rectum. 

    In some cases a second stapler may be required to completely transect the tissue. Grasp the margin of the proximal division with atraumatic forceps and remove the intestinal clamp.

    Caution: 

    • Avoid accidental trapping of tissue in the stapler when transecting the rectum.
  • Extracorporeal sigmoid transection

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    Return the patient back from Trendelenburg. Enlarge the trocar incision (T2) in the left lower quadrant by about 4cm. Exteriorize the specimen, together with the trocar, onto the abdominal wall. This is facilitated by distending the incision Roux retractors. Dissect the mesocolon down to the intestinal wall and check for adequate perfusion of the marginal artery of Drummond. The following video clip demonstrates application of the crushing purse-string clamp and the subsequent purse-string suture. This is followed by transection of the sigmoid with straight scissors and handing off the specimen to histopathology.

  • Inserting the anvil and interiorizing the bowel

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    Next clean the intestinal lumen. Introduce the anvil into the intestinal lumen and secure it with the prepared purse-string suture. After the bowel has interiorized, close the abdominal wall in layers by layer and recreate the pneumoperitoneum.

  • Colonic anastomosis

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    After atraumatic dilation of the anus carefully introduce the circular stapler transanally into the rectum. Extend the stapler shaft only after exact position in the rectum. Perforation of the rectal stump should be in its center and immediately adjacent to the staple line. Push the anvil shaft onto the stapler shaft until it clicks. Avoid a colonic rotation to the left by checking the taenia libera along the whole length of the mobilized colon. Only then close the stapler and fire it, thereby completing the anastomosis. Gently pull back the stapler and check for the presence of two complete “doughnuts”. 

    Caution: 

    • Avoid accidental trapping of tissue or organs of the lesser pelvis in the stapler when transecting the rectum.

    Return the patient back to light Trendelenburg position, fill up the lesser pelvis with irrigation fluid and transanally insufflate the rectum with 100ml of air.

    Note: 

    • Any rising bubbles would indicate primary anastomotic failure.
    • Suction the irrigation fluid and drain the lesser pelvis with an Easy-Flow drain.
  • Universitätsklinikum Schleswig-Holstein

    Dr. Hamed Esnaaashari

  • Campus Lübeck

    Herr Prof. Dr. med. Hans-Peter Bruch

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  • Intraoperative complications

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  • Postoperative complications

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  • MVZ St. Marien Köln - Ärztliche Leiterin

    Edith Leisten

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  • Summary of the literature

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  • Ongoing trials on this topic

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  • References on this topic

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  • Reviews

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  • Guidelines

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  • Literature search

    Literature search under: http://www.pubmed.com