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Laparoscopic anterior resection of rectum

Laparoscopic anterior resection of rectum
D-r Puchkov D.K. (CMS) is performing an operation (2018).

In this video the technique of performing the anterior rectal resection for chronic diverticular disease of the sigmoid colon is presented. A 58 year-old female patient was treated, having the diagnosis: Diverticular disease of the sigmoid colon, relapsing diverticular without complications. Within the last 5 months a patient thrice was hospitalized for acute complications of diverticular disease. During preoperation investigation according to fibrocolonoscopy, had found multiple diverticula with the symptoms of inflammation in the sigmoid colon, and in rectum on the border of middle ampullar and upper ampullar parts and proximally thickening and rigidity of rectal wall had been found out. RCT of abdominal cavity had shown multiple diverticula in the sigmoid colon, some indirect symptoms of presence of “chronic” abscess in Douglas cul-de-sac.
“Classical” scheme of positioning of troacars had been used: in the right iliac area, the right and left mesogastric area. The operation was started from rectum, identification of interfascial layer with help of Harmonic scalpel (”Ethicon”) device. In case, if it is not possible clearly visualize the layer between Toldt’s fascia and fascia Gerotae distally to the inferior mesenteric artery, the layer could be visualized under the inferior mesenteric vein. Transection of the inferior mesenteric artery was done near at the origin with LigaSure instrument (“Medtronic”). The next stage was exposure of the inferior mesenteric vein, identification of embryologic layer of the large colon, we use from media-to-lateral direction towards splenic flexure. For safe mobilization of the splenic flexure of the colon was dissected in inframesocolic way. Preliminarily dissection of pancreas should be done, then opening of omentum sac, after that the abdomen of the left lateral canal was incised, then mobilization of the descending part of colon and of splenic flexure of the colon took place. Then exposure of rectum along the posterior wall with the identification of the left ureter took place. Exposure of rectum is up to the infiltrate level along the posterior wall, then – along the right and left half - curcumference, and only after at the end-along the anterior wall. Transection of the large colon in the distal part was done with EcheloFlex-60 (a blue cassette) device (“Ethicon”). Then minilaparotomy was performed (about 5 cm), a latex ring “Dextrus” was placed in the wound to restrict tissues of the anterior abdominal wall from the colon. The colon was exteriorized, resection of specimen was done, the head of CDH-29 device (“Ethicon”) was inserted into the proximal end, it was fixed by purse-string suture, “Vicryl” 2-0 thread was used, then, it was immersed into the abdominal cavity. CDH-29 device was introduced transanally, created an anastomosis. Operation was finished by draining the small pelvis. The duration of operation was 130 minutes.

Laparoscopic resection of the sigmoid colon for acute diverticulitis

Laparoscopic resection of the sigmoid colon for acute diverticulitis
Professor Puchkov K.V. is performing an operation (2017).

In this film the technique of laparoscopic resection of sigmoid colon with end colostomy exteriorization is presented. A 64 year-old female patient was treated with the diagnosis: Diverticular disease of sigmoid colon with phlegmonous peridiverticulitis. The patient was admitted in hospital in 4 days after the beginning of the disease with the clinical presentation of acute diverticulitis of the sigmoid colon. During preoperation investigation according to RCT of the abdominal cavity, shown multiple diverticula, having the sizes 0.4—2 cm had been found out in her sigmoid colon, in the middle one-third of sigmoid colon, infiltrate (d~6 cm) had been found out, in mesentery of the sigmoid colon fluid formation with 2 cm in diameter with non-homogenous contents had been found out. Within the period from 2012 to 2016 twice a year the patient had attacks of acute diverticulitis, accompanied by temperature increase up to 39 degrees, abrupt pain in the lower abdomen; it required admitting to the surgical department of hospital. During the last 12 months the patient was thrice delivered to hospital for exacerbation of diverticular disease.
Then it was decided to perform an urgent operation. The “classic” scheme of positioning of troacars had been used: in the right and left iliac area, in the left mesogastric area. The operation was started with adhesiolysis, opening of the small pelvic on the right side of rectum, exposure of rectum along the posterior wall within the boundaries of mesorectal fascia with the identification of the left ureter with “Harmonic” scalpel (“Ethicon”) device. The next stage is separation of inflammated wall of the sigmoid colon from the lateral wall of pelvis in a “blunt” way, opening the left lateral canal, mobilization of sigmoid and descending colon within the boundaries of mesocolic fascia with “LigaSure” instrument (“Medtronic Covidien”). After transection of mesentery of descending colon transection of the large colon in its distal part was done with “EndoGIA-60” device (a blue cassette) (“Medtronic Covidien”). Specimen was removed throught the minilaparotomic access. In the left mesogastric area stoma was created. Operation was finished by draining the small pelvis. The duration of operation was 145 minutes.
Histologic conclusion: Diverticular disease of the large colon with perforation of one of diverticula with formation of mesenteric abscess. In postoperation period complex antibacterial, anti-inflammatory therapy was done. The patient had been discharged from hospital on the 6 days after operation.

Laparoscopic elective resection of the sigmoid colon for divertucular disease

Laparoscopic elective resection of the sigmoid colon for divertucular disease.
Professor Puchkov K.V. is performing an operation (2017).

In this video the technique of performing laparoscopic resection of the sigmoid colon with formation of circular stapler anastomosis is presented. A 62 year-old male patient was treated, having the diagnosis: Diverticular disease of the sigmoid colon. Chronic diverticulitis with relapses. The patient was admitted to hospital in 3 months after the ending of his therapeutic conservative course of treatment for acute diverticulitis of the sigmoid colon. During the last 16 months the patient 4 times was taken to hospital because of exacerbation of his diverticular disease. It was decided that a patient should be operated. Preoperation investigations have been done. According to FCS values and investigations with contrast enhancement multiple diverticula, having the sizes 0.4-1.2 cm, have been found out in his sigmoid colon.
The “classic” scheme of positioning of troacars had been used: in the right and left iliac area, and on the left in the mesogastric area. The operation was started with the dissection of peritoneum of the left lateral canal, mobilization of the sigmoid colon and descending colon within trauma of the mesocolic fascia with the “LigaSure” instrument (MEDTRONIC COVIDIEN). The next stage - opening of the peritoneum in the right of rectum, dissecting of rectum along the posterior wall within damaging of mesorectal fascia with the identification of the left ureter. The mandatory condition of performing the “correct” operation, according to our point of view, is preserving of the superior rectal artery and the left colic artery. Transection of the large colon in the distal part was done with EndoGIA-60 device (a violet cassette) (MEDTRONIC COVIDIEN).
Specimen was removed throught the minilaparotomic access Circular apparatus was introduced transanally and anastomosis was created. The second layer of single interrupted suture was placed in the anastomosis line. Operation was finished by placing transabdominal drainage. Duration of operation was 120 minutes.

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