A 68-year-old female with a previous history of follicular lymphoma in partial sustained remission (with no current therapy), cardiac arrhythmia (treated with beta-blockers) and osteopenia.
She was under evaluation due to repeated episodes of colitis-diverticulitis of the sigmoid colon. An abdominal CT-Scan showed a diverticulitis-like mass and a colonoscopy revealed a stenotic lumen 18cm from the anal verge (FIG1) with a normal mucosa by macroscopic and biopsy examination.
She came to the emergency room presenting with an absence of bowel movements, vomiting, abdominal pain and distension. Vital signs were stable, the abdomen was distended and tympanic. The blood test revealed normal levels of leucocytes, RCP, hemostasis and renal function. An abdominal Rx revealed a distended small bowel and the colon with no gas in the descending colon.
It was suspected that the colonic lesion had become occlusive. An abdominal CT Scan confirmed the diagnosis, showing a 10-cm stenosing lesion at the sigmoid colon that caused a retrograde distention of the colon and the small bowel (FIG2, FIG3).
An NG tube was inserted, IV fluids and analgesia were administered. The patient was proposed surgical treatment with laparoscopic intraoperative assessment.
Access to the abdominal cavity was achieved through the Hasson technique. A 30º scope was used. The small bowel and the colon were distended but there was enough surgical field to perform the dissection safely. Two 5mm ports were placed (one at each flank), a 12mm port was placed at the right iliac fossa and a single knot was made to lift the uterus and improve pelvis exposure.
The sigmoid colon and the recto-sigmoid junction were chronically swallowed and stenotic (FIG4). The first maneuver was to attempt lateral to medial mobilization and assess the possibility of resection. The mass was attached to the left fallopian tube, which could be detached. Then medial to lateral dissection was completed sectioning the inferior mesenteric artery with a mechanical suture and the inferior mesenteric vein with the energy device. The left ureter was visualized and preserved. Distal section was performed with mechanical suture below the rectosigmoid junction. A Pfannenstiel incision was built and a protective bag was placed. The colon was extracted identifying healthy colonic tissue.
The patient was stable and the tissue conditions were correct so we decided to perform a primary anastomosis. As there was a diameter mismatch between the colon and the rectum we built a latero-terminal circular mechanical anastomosis. A drainage was placed for postoperative surveillance.
Surgery was accomplished in 140 min with no intraoperative complications or conversion to open surgery. The NG tube was removed and oral intake was resumed on the second postoperative day. The patient left hospital four days after the procedure with no drainage.