Salvadora Delgado (Gastrointestinal Surgery Consultant)
Ainitze Ibarzabal (Gastrointestinal Surgery Senior Specialist)
Hospital Clínic, Barcelona, Spain
This is a case of a total colectomy due to familial adenomatous polyposis and the video will describe the dissection of the inferior mesenteric vessels and the splenic flexure mobilization.
The patient is in a prone Trendelenburg position with legs wide open. A total of five trocars are used (one of 12mm in supra umbilical position for a 30º camera, in the right iliac fossa one of 5mm and other of 12mm, in the left flank one of 5mm and the last one at the epigastrium).
Dissection of the mesosigmoid begins after the accommodation of the small bowel, a key step during this maneuver is to perform traction of the mesosigmoid at the level of the inferior mesenteric vessels. The hook is used to open the peritoneum, the pneumo helps by dividing the embryological plains and improving visualization.
Step by step the inferior mesenteric artery is identified and sectioned with a LigaSure. A previous recognition of the left ureter must be done.
The surgery continues in a medial to lateral approach leaving under the retroperitoneal plane.
Now the inferior mesenteric vein is sectioned allowing a better mobilization of the mesocolon. Some authors describes the use of a gauze in the retroperitoneal plane to achieve better perception of the anatomy, but surgeons with experience may skip this maneuver in selected patients for saving surgical time.
Combined lateral detachment may be used to improve the colonic visualization. Now a window is opened in the mesocolon, and the most important landmark at this time is the pancreas (below) and Riolan´s arcade (above).
In the next movement, the assistant surgeon performs a traction of the transverse colon to the pelvis allowing a nice exposure of the omentum while the surgeon enters to the lesser sac.
Finally, lateral dissection continues finalizing the mobilization of the splenic flexure.