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Surgical Technique andDicult Situations fromThomas Schiedeck (Laparoscopic)
283
36
vein or splenic vein. Regarding this, it
should be ensured always to stay in the
correct anatomical plane.
> Specically with the omentum directly
attached to the spleen, it is important to
avoid any traction to the spleen to prevent
injury and bleeding.
Following the mobilisation of the omentum
from the spleen, the colonic mesentery has to
be dissected from the lower margin of the pancreas. e le colonic exure is brought down
stepwise from lateral to medial. e better this
is performed, the better the mobilisation of the
colonic exure will be. Complete mobilisation
of the splenic exure allows much easier identication and ligation of the inferior mesenteric
vein.
> The next step is the identication of the
inferior mesenteric artery by opening the
peritoneum from the medial aspect in the
height of the promontory. The incision of
the peritoneum should be performed
carefully because the right main branch and
the side branches of the hypogastric nerve
are localised nearby. The hypogastric nerve
should be identied immediately and
pushed away dorsally.
Aer this, the mesentery of the descending colon
will be completely mobilised out of the retroperitoneum heading up to the inferior mesenteric
vein at the inferior margin of the pancreas. e
vein should be completely and precisely prepared
and dissected between clips.
> During this step, it is important not to
dissect too deep into the mesentery of the
descending colon; otherwise, the main
branch of the inferior mesenteric vein can
be easily missed and confounded with a
mesenteric vein of the descending colon.
Furthermore, it is important not to injure
vessels of the medial arcade of the
transverse colon. The correct identication
of the vessels in the area of the medial colic
artery may be very dicult in some cases. If
in doubt, this step should be completed
using the incision at the extraction site (see
below).
> If it is acceptable with regard to the tumour,
the rectovesical space should not be
opened. Otherwise the risk of injuring the
nerves is rising notably, especially in male
patients.
> Transecting the rectum, any kind of
conisation of the mesorectum has to be
avoided. The mesorectum should be
transected in a right angular shape. For
placement of the stapler especially in cases
with a bulky and thick-walled rectum, it is
advisable to place an occlusion clamp in the
area of the planned resection line.
Afterwards the stapling device can be easily
placed parallel to the clamp.
> Sometimes it is necessary to use two or
three cartridges to transect the rectum
completely. In these situations, it is
absolutely necessary to follow the original
right angular transection line. Otherwise
stenosis of the rectal stump or reduced
blood supply of the anastomotic segment
may lead to diculties and complications.
5 e proximal end of the transected bowel
should be secured by a grasper.
5 Many times bleedings are occurring between
the staple lines. In almost all cases, these
bleedings are stopping spontaneously. Otherwise a 5mm clamp may be placed at the
bleeding area to apply pressure for some seconds. It is not advisable to give coagulation
directly to the stapled area because the energy
ow along the staples is uncalculable. It may
result in necrotic areas or leakages.
5 For the extraction of the specimen, the trocar
incision in the lower le abdomen is
enlarged.
> As an alternative, the extraction via the
periumbilical incision may be of advantage,
especially when an additional central
mobilisation of medial colic vessels is
necessary. Similarly the extraction through
a Pfannenstiel incision is favourable if
mobilisation of the rectum has to be
completed.
5 In all resections for malignant indication, the
incision at the extraction site must be covered
using a kind of wound protection. Surgical
transection through the muscles is seldom
necessary. Usually it is sucient to distract the
muscle bres.
T.H.K. Schiedeck and M. Schmerer
284
5 In the transverse colon (oral resection line), a
purse-string clamp is placed and the resection
completed. Before sending the specimen to
the pathologist, it should be opened at a side
table to prove the tumour localisation and
resection margins.
5 Aer this, a purse-string suture is performed.
e size of the circular stapler is normally
dened using bougies. e anvil is xed by
closing the purse string.
5 Aerwards the bowel is replaced into the
abdomen. e incision should be closed separately in all dierent layers.
5 en CO2 is insuated again to continue by
laparoscopy. First the operation area is controlled to detect major or minor bleeding
spots.
5 en a mild anal dilatation is performed and
the circular stapler is inserted transanally. e
spike is extended under sight. It should
perforate the rectum in the area of the staple
line either perfectly in the middle or exactly at
a corner. e spike is then engaged into the
anvil. e ends of the bowel are joined. It must
be ensured carefully to prevent any torsion of
the proximal bowel or an interposition of collateral tissues (small bowel, vaginal wall,
appendices epiploicae, fatty tissue).
5 e device is red, opened and then extracted
carefully.
5 e donats should be checked for their com-
pleteness and will be sent to the pathologist.
It is useful to prove the tightness of the anastomosis by transanal insuation of air aer
setting the anastomosis under rinsing uid
intra-abdominally. As an alternative, the
anastomosis can be checked by a careful rectoscopy.
5 Especially if there are inflammatory altera-
tions or patients with an immunosuppression, the anastomosis can be secured by
using resorbable single stitches additionally.
5 Multilament suture material makes intracor-
poreal knotting easier. In addition it is recommendable to place a bougie intrarectally in the
area of the anastomosis while performing the
sutures.
5 Finishing the operation the abdomen is
rinsed and a drainage placed retrorectally.
All trocars are removed under sight to
exclude bleedings. en the pneumoperitoneum is released. Closure of the fascia is
performed in all incisions larger than
10mm using Vicryl sutures. The operation
is finished by wound disinfection and
applying a wound dressing. In
. Table36.1, some hints and proposals to
overcome technical diculties intraoperatively are given.
36
. Table 36.1 Pitfalls and proposals for solution
Operation step Tips and tricks
Adhesions Complete laparoscopic adhesiolysis is recommended in case of previous surgery
Hypogastric plexus 1. Use the left main branch as guideline to identify the correct layer for preparation of
the retroperitoneal space
2. Preparation and identication of the nerve can be dicult if brosis and adhesions are
existing
3. If adhesions between the hypogastric nerve and sigmoid mesentery are existing, it is
wise to free the nerve over a longer distance to prevent inadvertent injury
4. In fatty tissue, preparation should start at the right branch of the hypogastric nerve,
tracing proximally to the nerve plexus at the origin of the inferior mesenteric artery.
Then the identication of the left main bough might be easier to perform
5. Preservation of bres of the superior hypogastric plexus while dissection and ligation
of the inferior mesenteric artery
Surgical Technique andDicult Situations fromThomas Schiedeck (Laparoscopic)
. Table 36.1 (continued)
Operation step Tips and tricks
Endoretractor Using an endoretractor through the trocar in the left lower abdomen, the sigmoid
colon can be elevated to the ventral abdominal wall
Suprapubic urine
catheter
Safety for the
anastomosis
Rings of the
anastomosis
Anastomosis The anastomosis has to be tension free, closed and with good blood supply
Firing the stapler Interponated tissue between the anastomoses must be avoided
Checking tightness of
the anastomosis
Perforation of the
rectum with the
circular stapler
Extraction of the
bowel in front of the
abdomen
Spleen Careful: lesion of the capsule during mobilisation of the left exure by tension and
Pancreas Careful: lesion of the pancreas during dissection of the mesentery of the transverse
Dening and marking
of resection line
Position of the colon Careful: correct position of the proximal bowel before closing of the anastomosis,
Protective ileostomy Depending on intraoperative ndings and general state of the patient
1. Better overview in the small pelvis
2. Prevention of a postoperative urinary retention
3. Prevention of a bladder injury
By the presence of inammation or in immunosuppression, the anastomosis is
secured with additional interrupted stitches (e.g. Vicryl® 2.0)
Have to be circular, complete and intact
Have to be sent in for histopathological investigation in case of cancer
Bringing in rising uid intra-abdominally
(a) Transanal air insuation
(b) Rectoscopic control
Ideally perforation of the rectum in the area of the clamp suture
→ In the middle
→ Exactly at a corner
(a) Expanding the trocar incision in the left lower abdomen
(b) In need of additional central mobilisation
→ Using of the periumbilical incision
(c) In need of additional mobilisation of the rectum
→ Using Pfannenstiel incision
direct grasper injury
colon
Placement of clips to an appendix epiploicum or marking by ultracision or bipolar
coagulation
torsion has to be avoided
285
36
Individual Surgery for Sigmoid Diverticulitis
Contents
Chapter 37 Surgical Technique and Dicult
SusanGalandiuk
Chapter 38 Surgical Technique and Dicult
Situations from Jakob R. Izbicki – 295
JakobR.Izbicki andKaiBachmann
287
IX
289
Difficult Situations During
the Surgery for Sigmoid
Diverticulitis
SusanGalandiuk
37.1 Technical Difficulties During Primary Surgery
for Initial Disease – 290
37.2 Basic Rules for Initial Operation – 290
37.3 Technical Difficulties During Reestablishment
of Intestinal Continuity – 291
Reference – 293
37
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI 10.1007/978-3-662-49878-1_37
290
S. Galandiuk
37
Whether performed via an open or minimally
invasive approach, surgery for diverticulitis can
pose many technical challenges for the surgeon.
ese challenges can occur either during primary
surgery for initial disease or during surgery for
restoration of intestinal continuity following a
sigmoid resection, colostomy, and Hartmann procedure.
37.1 Technical Difficulties
During Primary Surgery
for Initial Disease
e philosophy in treating patients with diverticular disease is changing. With a growing tendency
toward nonoperative treatment, the advent of
computed tomography (CT)-guided drainage has
permitted drainage of pelvic and paracolic
abscesses. In many cases, this drainage avoids the
need for surgery or defers the operation until a
time when the acute inammation has subsided.
In the latter instance, this drainage greatly facilitates the surgical procedure.
37.2 Basic Rules for Initial
Operation
1. Surgical approach: If signicant inammatory disease is encountered, one should
always start dissecting in a normal plane and
work toward the abnormal plane. Approach
the pelvis from posterior to anterior, where
planes are always more “normal.” e presacral area is almost never involved with
inammation, unlike the anterior area,
which can be involved in inammation associated with diverticular disease
(. Fig. 37.1a–d). is is particularly true in
patients with complicated diverticular disease associated with colovesical or colovaginal stulas. In a patient with a signicant
inammatory process, it is always easier to
start mobilization, either (a) laparoscopically
with a medial-to-lateral approach above the
level of the disease with a high ligation
(. Fig. 37.2) and where one is starting away
from the disease or (b) in an open approach
by a lateral-to-medial mobilization, beginning at the level of the splenic exure and
proceeding downward.
2. Adequate colon mobilization: Do not hesitate
to mobilize the splenic exure mobilization
and/or divide the inferior mesenteric vein to
permit adequate mobilization.
3. Distal line resection: e distal line of resec-
tion must be within the proximal rectum.
Wolf etal. [1] showed that there was an
approximately 25 % recurrence if not all of
the sigmoid colon was removed. e proximal extent of the rectum varies greatly and
can easily be identied by the point at which
the sigmoid tenia coalesces. Failure to anastomose to the proximal rectum will result in a
high recurrence rate [1]. Conversely, proceeding down, much lower than this point,
which is commonly done, leads to an unnecessarily more dicult operation and especially reoperation. Diverticular disease does
not extend into the rectum, and there is no
need to resect it below this point, unless there
has been an abscess that has perforated into
the rectum.
4. Palpably normal proximal colon. Perform the
proximal line of resection in an area of palpably normal colon. Symptomatic diverticular disease is characterized by muscular
hypertrophy of the bowel wall (i.e., it feels
thicker than the normal colon). Many
patients have pancolonic diverticular disease, and one should not resect the entire
colon as treatment for pancolonic disease.
One needs only to feel for the area of palpably normal colon in order to determine a
suitable area for the line of proximal resection. If the operation is done through a minimally invasive approach, it is important to
exteriorize the proximal bowel through a
specimen extraction incision to enable the
operator to feel the proximal colon in order
to determine the area of appropriate bowel
transection.
5. Always test the anastomosis. Whether the
procedure is minimally invasive or open,
testing the anastomosis can easily be done
by performing a proctoscopy and insuating air into the rectum under direct visualization of the anastomosis in a pelvis lled
with water. Check to ensure the anastomosis
is airtight, while the colon just proximal to
the anastomosis is occluded either with the
surgeon’s hand or with a surgical instrument. In constructing the anastomosis, it is
cd
V. mesenterica
Difficult Situations During the Surgery for Sigmoid Diverticulitis
291
37
a
N.
hypogastricus
Sigmoid
Mesorectum
retrachiert anteriorly
Presacral space
b
Uterus
Pelvic abscess by
divertikelperforation
Sigmoid
Promontorium
ossis sacri
Uterus
Rektum
Uterus retrachiert anteriorly
Abscess by
divertikelperforation
Anterior wall of the rectum
. Fig. 37.1 a Woman with symptomatic diverticular
dise ase following robotic oophorectomy. The uterus and
tubes have become densely adherent to the proximal
sigmoid colon without a clear plane, particularly on the
patient’s right side. b Schematic representation of anat-
omy. c Same patient as approached from the presacral
space, showing clear planes without inflammation in this
area. d Further dissection revealed an abscess between
the anterior rectum, uterus, and sigmoid colon
important to assure that there are no diver-
Inferior
ticula at the proximal staple line, since this
will also result in a weakness of the anastomosis at this point and a greater tendency
for leak.
37.3 Technical Difficulties
During Reestablishment
Jejunum behind of the
M. suspensorius
duodeni
. Fig. 37.2 Medial-to-lateral mobilization in cases of
severe pelvic inflammation. Here, the inferior mesenteric
vein is shown adjacent to the ligament of Treitz prior to
beginning retroperitoneal mobilization of the colon
of Intestinal Continuity
Reestablishment of intestinal continuity in
patients with complicated diverticular disease
can be particularly challenging, especially in
those who have had pelvic sepsis and prolonged
hospital stays. is is especially true in patients
with an extremely short Hartmann stump and
signicant pelvic adhesions. In these cases, the
292
ab
S. Galandiuk
Fat pad of the bladder
Peritoneal
reflecting fold
c
Tissue to dissect
bulge under the
traction upward
. Fig. 37.3 a View of the presacral area following prior
surgery for diverticulitis by another surgeon. Note the very
short Hartmann stump. b In order to aid in identification
of the rectum, a long Babcock clamp is placed on the tissue where it is suspected that the rectal stump may be
located and superior-anterior traction is applied. c This
suspect
rectal segment
promontory of
sacrum(not more
in the picture)
Anterior superior
traction with a
Babcock clump
Peritoneal reflecting fold
d
traction causes the tissues that need to be divided to tent
upwards. These tissues are divided using the electrocautery and traction used to help identify the correct plane
posteriorly. d The posterior plane has been identified, and
superior-anterior traction is continued as the dissection
continues laterally and anteriorly
Probable stump
by Hartmann
Ongoing superior
anterior traction
anterior traction
with presentation
of avascular posterior
retrorectal surface
37
bladder and vagina tend to descend posteriorly
and cover the Hartmann stump like a cap. e
rectum can be particularly dicult to identify
and the other organs very easy to injure. e
common practice of placing polypropylene
sutures for identication of the rectal stump is of
little use. An easy aid in identifying the Hartmann
stump is to place a Babcock clamp on the tissue in
the presacral space and li upward with vertical
traction. Electrocautery is then used to score the
posterior tissue and enter the presacral space. In
this manner, the mobilization begins posteriorly
before starting the more dicult anterior mobilization (. Fig. 37.3).
In female patients whose initial surgery has
been performed by another surgeon, it is very
important to include an endoscopic examination
of the vagina in order to exclude the presence of a
vaginal stula. A pelvic abscess may sometimes
spontaneously drain through the vagina, and this
is sometimes overlooked. Conversely, in patients
with an existing colovaginal stula, this is sometimes unintentionally le in situ by the surgeon
(. Fig. 37.4). ese can still be persistent and
need to be corrected at the time of the colostomy
reversal. If more than one-half of the rectum has
been resected, in consideration of improving
postoperative functional results, it is important to
create a colonic reservoir, such as a J-pouch when
reestablishing intestinal continuity (. Fig. 37.5).
is is particularly true in elderly patients or
those with decreased mobility. Such a colonic
J-pouch is constructed with standard 5-cm limbs.
At the time of primary surgery and also secondary
Difficult Situations During the Surgery for Sigmoid Diverticulitis
Small
rectovaginal fistula
. Fig. 37.4 Woman who had undergone numerous pro-
cedures for diverticular disease, now presenting for colostomy takedown. Endoscopic examination as an outpatient
had suggested the presence of a rectovaginal fistula,
which was confirmed on a radiologic contrast study
resection at prior surgery for diverticulitis, reconstructed
with a colonic J-pouch rectal anastomosis. Shows contrast
study prior to closure of temporary loop ileostomy
293
colon-j-pouch
anastomosis
between
colon and
j-pouch
. Fig. 37.5 Elderly, frail patient with significant rectal
37
surgery, I do not hesitate to use temporary loop
ileostomy diversion. is is easy to close, particularly if hyaluronate lm is applied around the
loops of the ileum used for the stoma at the time
of its creation.
Reference
1. Benn PL, Wolff BG, Ilstrup DM. Level of anastomosis
and recurrent colonic diverticulitis. Am J Surg.
1986;151(2):269–71.
Surgical Technique
and Difficult Situations
from Jakob R. Izbicki
JakobR.Izbicki andKaiBachmann
38.1 Timing an Indication of the Operation – 296
38.2 Tactics of the Operation – 296
38.3 Loop Ileostomy – 296
38.4 Hartmann’s Procedure – 296
38.5 Laparoscopic Sigmoid Resection – 297
295
38
38.6 Loop Ileostomy – 298
38.7 Hartmann’s Procedure – 298
38.8 Open Resection of the Sigmoid Colon – 298
38.9 Open Loop Ileostomy – 299
38.10 Open Hartmann’s Procedure – 300
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI 10.1007/978-3-662-49878-1_38