Laparoscopic Segmental Colectomy for Functional Constipation

Who's speaking

• Speaker 1

Chapters

• 0:05Case Presentation and Preoperative Evaluation — Introduction of a 6-year-old with refractory functional constipation, normal rectal biopsy and anorectal manometry, 40 cm dysmotile segment on colonic manometry, and dilated distal colon on contrast enema. Initial Malone appendicostomy provided temporary improvement before recurrent impactions necessitated resection.
• 0:53Port Placement and Initial Dissection — Description of port placement avoiding the appendicostomy site, identification of dilated sigmoid funneling to normal-caliber rectum, mesenteric dissection at pelvic brim staying close to bowel, ureter identification, and rectal transection with endoGIA stapler above peritoneal reflection.
• 2:00Mobilization and Exteriorization — Cephalad division of peritoneal attachments, assessment of colonic mobility without splenic flexure takedown, exteriorization through right lower quadrant with wound protector, transection of redundant colon, and placement of EEA anvil secured with purse-string suture.
• 3:22Anastomosis and Integrity Testing — Rectal calibration, transanal passage of circular stapler with trocar deployment adjacent to rectal staple line, anvil engagement, stapler firing with confirmation of complete tissue doughnuts, and leak testing with saline and air insufflation showing no bubbling.
• 4:19Postoperative Course and Summary — Discharge on postoperative day 4 after resumption of bowel function and establishment of diet and appendicostomy flushes. Dramatically improved flush regimen with plan to transition to oral laxatives.

Key claims

• 0:05The patient is a 6-year-old girl with functional constipation refractory to medical management — Speaker 1
• 0:10Rectal biopsy and anorectal manometry were both normal — Speaker 1
• 0:18Colonic manometry identified a 40 centimeter segment of dysmotile colon — Speaker 1
• 0:23Contrast enema demonstrated a grossly dilated distal colon — Speaker 1
• 0:27The patient's findings are consistent with Group D in a previously published systematic approach to severe functional constipation — Speaker 1
• 0:37Initial Malone appendicostomy improved symptoms but after several months the patient developed impactions despite multiple colonic irrigation regimens — Speaker 1
• 0:53Preoperative bowel preparation was used to ensure decompression of the distal colon at laparoscopy — Speaker 1
• 1:01A 5 millimeter optical port is placed supraumbilically and to the left to avoid injury to the appendicostomy — Speaker 1
• 1:08Additional ports are placed under vision in the left upper quadrant and the right lower quadrant — Speaker 1
• 1:13The left colon demonstrated a grossly dilated redundant sigmoid colon which funnels into a more normal caliber rectum above the peritoneal reflection — Speaker 1
• 1:22Dissection begins at the pelvic brim using a vessel sealing device to create a mesenteric window, staying close to the bowel — Speaker 1
• 1:32The position of the ureters is established to ensure they lie away from the dissection plane — Speaker 1
• 1:41Once normal caliber colon is encountered above the peritoneal reflection, the rectum is transected using an endoGIA stapler — Speaker 1
• 1:48Several staple fires may be needed depending on the degree of dilatation — Speaker 1
• 1:52Verification is performed to ensure that the ureter has not been inadvertently caught in the staple line — Speaker 1
• 2:06In this case, taking down the splenic flexure was not required to achieve sufficient mobility of the normal caliber colon to reach the pelvis — Speaker 1
• 2:28The right lower quadrant port incision is extended to approximately 2.5 centimeters for specimen extraction — Speaker 1
• 2:40A wound protector is applied to the right lower quadrant port site during specimen extraction — Speaker 1
• 2:46The anvil component of an EEA circular stapler is secured in place using a prolene purse string suture — Speaker 1
• 3:11The colon orientation is examined to ensure there is no twist on the colon as it passes into the pelvis — Speaker 1
• 3:17The colon should lack redundancy and form a direct path into the pelvis after resection — Speaker 1
• 3:22The rectum is calibrated using scissors that come with a circular stapling device — Speaker 1
• 3:26The EEA trocar is deployed adjacent to the rectal staple line until the orange tying area is seen — Speaker 1
• 3:41A characteristic snap is felt when the anvil is properly engaged into the trocar — Speaker 1
• 3:55Two complete doughnuts of colonic tissue indicate a satisfactory anastomosis — Speaker 1
• 4:04Anastomotic integrity is tested by filling the pelvis with saline and insufflating air into the rectum, with no bubbling indicating no leak — Speaker 1
• 4:19The patient was discharged on the 4th postoperative day following resumption of bowel function and establishment of diet and appendicostomy flushes — Speaker 1
• 4:26The flush regimen was dramatically improved after resection — Speaker 1
• 4:26The plan is to attempt to transition the patient to oral laxatives — Speaker 1

Cases discussed

• 0:056-year-old girl with medically refractory functional constipation and segmentally abnormal colonic motility managed with Malone appendicostomy followed by laparoscopic segmental colonic resection