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Operative Technique |

Single-Access Laparoscopic Sigmoidectomy as Definitive Surgical Management of Prior Diverticulitis in a Human Patient

Joel Leroy, MD, FRCS; Ronan A. Cahill, MD, FRCS; Misuhiro Asakuma, MD; Bernard Dallemagne, MD; Jacques Marescaux, MD, FRCS
Arch Surg. 2009;144(2):173-179. doi:10.1001/archsurg.2008.562.
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Hypothesis  Single-access laparoscopic surgery should offer minimal scarring without compromising surgical outcome. It is enhanced by both innovative port technology and technical expertise learned by developing natural orifice transluminal endoscopic surgery (NOTES).

Design  Sigmoidectomy in a human via a single laparoscopic port.

Setting  University hospital.

Patient  A 40-year-old woman with previously documented diverticular abscess.

Interventions  The multichannel single port (Triport; Advanced Surgical Concepts, Wicklow, Ireland) was placed at the umbilicus. The sigmoid was retracted by both intraluminal sigmoidoscopy and magnetic anchoring. Mesenteric dissection between the mid-descending colon and the colorectal junction was carried out close to the colon using a Ligasure Advance (Covidien, Valley lab, Norwalk Conneticut). The stapler anvil was passed retrogradely per ano to lie within the descending colon. A linear stapler effected proximal and distal sigmoidal transection. Magnetic attraction then delivered the in situ anvil pike into a colotomy placed adjacent to the proximal staple line. After its position was secured with an endoloop, the pike was mated with its stapler head positioned in the rectal stump. This allowed creation of a double-stapled colorectal anastomosis 10 cm from the anal verge. Specimen retrieval was performed via the umbilical port site.

Main Outcome Measures  Extent of scarring, occurrence of surgical complications, technical adequacy, and clinical outcome.

Results  No intraoperative complications occurred during the 90-minute procedure. A total of 40 cm of sigmoid was resected. The patient convalesced without complication and went home 4 days after surgery. At the 1-month review, she was fully recovered and her single umbilical scar was well healed.

Conclusions  With advancing surgical technology and technique, truly minimally invasive surgical procedures are feasible. Understanding of NOTES can therefore extend beyond its experimental application into contemporary surgical practice.

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Figure 1.

View of single multichannel port in situ subumbilically with the patient in a steep Trendelenburg tilt. A 10-mm camera is initially used, allowing 2 other 5-mm instruments to be inserted synchronously via the port. This camera is later changed to a 5-mm one when larger laparoscopic instruments (eg, the EndoGIA stapler; Covidien, Autosuture, Hamilton, Bermuda) are required. The insert displays the low profile of the port after placement with both its internal and external aspects being flush with the abdominal wall.

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Figure 2.

A, Initial medial mesenteric dissection using a Ligasure advance (Covidien, Valleylab, Norwalk, Conneticut). Retraction of the sigmoid is provided by a combination of a roticulated graspers manipulated synchronously via the Triport (Advanced Surgical Concepts, Wicklow, Ireland) and an intraluminal sigmoidoscope within the distal sigmoid. The line of dissection is near the bowel wall. B, After initial dissection, the metal stapler head that will be used to make the anastomosis is passed into the distal descending colon. C, This is then anchored in place in the descending colon above the line of intended proximal transection by a second magnet placed extracorporeally on the anterior abdominal wall.

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Figure 3.

A, Proximal colonic transection is performed using an EndoGIA (Covidien, Autosuture, Hamilton, Bermuda). Moving the extracorporeal magnet now will also provide a means of changing the position of the proximal intestine as it is magnetically locked to the stapler anvil. B, After further distal mesenteric dissection, a linear EndoGIA with a roticulated head can be placed across the bowel to perform the distal transection.

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Figure 4.

A, With the sigmoid now resected, a colotomy is made adjacent to the proximal staple line (in the descending colon) to deliver the anvil pike in preparation for the reanastomosis. B, Magnetic attraction then allows the pike of the anvil to be withdrawn snugly through the colotomy. During this maneuver, a roticulated grasper inserted via the transabdominal port provides downward traction on the proximal colonic segment. C, Once the pike has been snugged in the colotomy and secured in place with an endoloop, the anvil stapler is mated with the circular head of the stapler inserted per ano into the colorectal stump.

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Figure 5.

Photograph of the patient taken on the eighth postoperative day during follow-up at our clinic demonstrating her single subumbilical scar.

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