VIDEO VIGNETTE
Laparoscopic Resection Rectopexy With Preservation of the Superior Rectal Artery, Natural Orifice Specimen Extraction, and Assessment of Anastomotic Perfusion Using Indocyanine Green Imaging in Rectal Prolapse Mehmet F. Can, M.D.1 • Oktar Asoglu, M.D.2 • Emin Lapsekili, M.D.1 Sezai Demirbas, M.D.1 1 Department of Surgery, Division of Gastrointestinal Surgery, Gulhane School of Medicine, Etlik, Ankara, Turkey 2 Department of Surgery, Liv Hospital, Ulus, Besiktas, Istanbul, Turkey
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his video describes our technique of laparoscopic sigmoid resection and rectopexy in rectal prolapse in which we preserve the superior rectal artery whenever possible. The video also demonstrates the technical details of natural orifice specimen extraction and near-infrared indocyanine green imaging during surgery (see Video, Supplemental Digital Content 1, http://links. lww.com/DCR/A165). With the patient in the lithotomy position, 4 trocars are placed in the abdominal wall and dissection begins in the embryologic plane between the sigmoid mesocolon and retroperitoneal structures. Attention should be exercised to avoid damaging the hypogastric plexus. The purpose of this maneuver is to free the sigmoid mesocolon entirely and to enter the holy plane securely, and it is not intended to divide the inferior mesenteric artery and vein. Once the posterior mesorectal dissection has reached the level of the coccyx, the mesorectum is freed bilaterally in the pelvis followed by the division of the white line lateral to the sig-
Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (www.dcrjournal.com)
moid mesocolon. Next, a hole is created in the mesocolon just beneath the rectosigmoid junction indicating the point where the rectum will be transected. An isolated division of vascular structures of the sigmoid colon is undertaken starting through this hole while keeping the superior rectal artery intact. This is achieved by staying close to the bowel wall during the division of the mesocolon. The mesocolic separation is continued proximally until the optimal point to be anastomosed is reached. Traction of the potential proximal end of the anastomosis down to the promontory helps to initially determine the appropriate anastomosis line with optimal tension. Following transection, the specimen is taken out and the anvil is delivered into the abdomen through the anus. A handsewn pursestring suture is placed at the proximal colonic stump to fix the anvil head. After placement of pursestring stitches to the rectum, 1 mL of intravenous indocyanine green (2.5 mg) is administered. With the laparoscopic near-infrared camera in place (Pinpoint System, NOVADAQ, Canada), the fluorescent green becomes visible over well-perfused tissues after approximately 40 seconds. After confirmation of adequate perfusion, the anastomosis is fashioned by using a circular stapler. Fixation of the distal anastomotic stump to the promontory completes the operation.
Financial Disclosures: None reported. Correspondence: Mehmet F. Can, M.D., Gulhane School of Medicine, Department of Surgery, Division of Gastrointestinal Surgery, 06018, Etlik, Ankara, Turkey. E-mail: [email protected] Dis Colon Rectum 2014; 57: 1441 DOI: 10.1097/DCR.0000000000000214 © The ASCRS 2014 Diseases of the Colon & Rectum Volume 57: 12 (2014)
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Laparoscopic Resection Rectopexy With Preservation of the Superior Rectal Artery, Natural Orifice Specimen Extraction, and Assessment of Anastomotic Perfusion Using Indocyanine Green Imaging in Rectal Prolapse Mehmet F. Can, M.D.1 • Oktar Asoglu, M.D.2 • Emin Lapsekili, M.D.1 Sezai Demirbas, M.D.1 1 Department of Surgery, Division of Gastrointestinal Surgery, Gulhane School of Medicine, Etlik, Ankara, Turkey 2 Department of Surgery, Liv Hospital, Ulus, Besiktas, Istanbul, Turkey
T
his video describes our technique of laparoscopic sigmoid resection and rectopexy in rectal prolapse in which we preserve the superior rectal artery whenever possible. The video also demonstrates the technical details of natural orifice specimen extraction and near-infrared indocyanine green imaging during surgery (see Video, Supplemental Digital Content 1, http://links. lww.com/DCR/A165). With the patient in the lithotomy position, 4 trocars are placed in the abdominal wall and dissection begins in the embryologic plane between the sigmoid mesocolon and retroperitoneal structures. Attention should be exercised to avoid damaging the hypogastric plexus. The purpose of this maneuver is to free the sigmoid mesocolon entirely and to enter the holy plane securely, and it is not intended to divide the inferior mesenteric artery and vein. Once the posterior mesorectal dissection has reached the level of the coccyx, the mesorectum is freed bilaterally in the pelvis followed by the division of the white line lateral to the sig-
Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (www.dcrjournal.com)
moid mesocolon. Next, a hole is created in the mesocolon just beneath the rectosigmoid junction indicating the point where the rectum will be transected. An isolated division of vascular structures of the sigmoid colon is undertaken starting through this hole while keeping the superior rectal artery intact. This is achieved by staying close to the bowel wall during the division of the mesocolon. The mesocolic separation is continued proximally until the optimal point to be anastomosed is reached. Traction of the potential proximal end of the anastomosis down to the promontory helps to initially determine the appropriate anastomosis line with optimal tension. Following transection, the specimen is taken out and the anvil is delivered into the abdomen through the anus. A handsewn pursestring suture is placed at the proximal colonic stump to fix the anvil head. After placement of pursestring stitches to the rectum, 1 mL of intravenous indocyanine green (2.5 mg) is administered. With the laparoscopic near-infrared camera in place (Pinpoint System, NOVADAQ, Canada), the fluorescent green becomes visible over well-perfused tissues after approximately 40 seconds. After confirmation of adequate perfusion, the anastomosis is fashioned by using a circular stapler. Fixation of the distal anastomotic stump to the promontory completes the operation.
Financial Disclosures: None reported. Correspondence: Mehmet F. Can, M.D., Gulhane School of Medicine, Department of Surgery, Division of Gastrointestinal Surgery, 06018, Etlik, Ankara, Turkey. E-mail: [email protected] Dis Colon Rectum 2014; 57: 1441 DOI: 10.1097/DCR.0000000000000214 © The ASCRS 2014 Diseases of the Colon & Rectum Volume 57: 12 (2014)
1441
