Surgical Weekend in Umbria

Foligno, 22 settembre 2018

Palazzo Trinci

La Chirurgia della divericolite acuta: what’s new?

Attualità e prospettive

Presidente: Graziano CeccarelliStruttura Complessa di Chirurgia Multispecialistica

Ospedale San Giovanni Battista - Foligno

Francesco Ruotolo

Anatomia chirurgica e ruolo della conservazione dell’AMI

The IMA preservation during videolaparoscopic rectosigmoidectomy for benign disease

is possible to preserve the vascularization and innervation in the remaining colon and rectum,

contributing to a lower incidence of anastomotic dehiscence and anterior rectal resection syndrome (ARRS).

The procedure requires surgical skill and detailed knowledge of local anatomy

to dissect the correct layer and ligate the sigmoid branches.

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Preservazione AMI

con conservazione ACS Scheletrizzazione AMI

con sezione ACS e aa. sigmoidee

AMI - PMI

Descending colon

Transverse colon

Sigmoid colon

Radix of mesentery

Cenni di anatomia topografica e chirurgica del sigma-retto

Derotazione del mesentere terminale sec. Duval

Left parieto-colic detachment

Recesso sigmoideo di Jonnesco – Finestra arteriosa

RUOTOLO F.: Significato del recesso intersigmoideo nella chirurgia colorettale. G Chir Vol. 29 - n. 10 - pp. 393-397, 2008

HF

AMI

Uretere

PIS

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At the site of this narrowing, a more or less definite increase in the circular muscular coat of the bowel is regularly

described as the third sphincter, or the Sphincter of O'Beirne, having a special function in the act of defecation.

It is not a true sphincter, but similar in action.

Punto critico di Sudeck

Punto critico di Griffiths

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Arcata marginale paracolica di Drummond

The inferior mesenteric artery and its branches

IMV

IMA

LCA

Sigmoid aa.

SRA

Variations of the branching patterns of the left colic arterial supply after Yada The first sigmoid artery arises from the inferior mesenteric artery (IMA) (Type 1),

from the left colic artery (LCA) (Type 2), or from the angle between the LCA and IMA (Type 3).

Mondor H

Ilo del retto di Mondor

Circolazione venosa radici portali

Arco vascolare di Treitz Treitz W

“a critical zone of IMV”

Intramural network

Intramural network of rectal arteries in the submucosal layer of the wall.

Circolazione arteriosa del retto

anterior view

posterior view

Cadaveric studies focusing on the arterial supply to the rectum have shown the MRA

to be present in only 12% - 56.7% of the specimens,

and that the blood-supply derived from the hypogastric arteries was minor,

with the predominant blood-supply deriving from the SRA.

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N.B.: IMP segue IMA nell’ilo di Mondor, mentre SHP si situa posteriormente e al di fuori dell’ilo.

The inferior mesenteric plexus is derived chiefly from the aortic plexus.

It surrounds the inferior mesenteric artery and divides into a number of secondary plexuses,

the left colic and sigmoid plexuses, which supply the descending and sigmoid parts of the colon;

and the superior hemorrhoidal plexus, which supplies the rectum and joins in the pelvis

with branches from the pelvic plexuses.

Inferior mesenteric plexus - IMP

SHP

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Legge di Luschka

Anatomy of the ureters and their relations to other pelvic organs

“symptomatic uncomplicated

diverticular disease”

“segmental colitis associated

with diverticulosis”

Evolving pathophysiologic mechanisms of DDStrate et al. Am J Gastroenterol 2012; 107: 1486

Mobilization of the splenic flexure

This step is entirely determined by the length of resected colon, which should be

at least the whole sigmoid and often all or part of the distal descending colon.

Ambrosetti P

For elective resections:

All of the sigmoid colon should be removed.

Anastomosis should be made to normal rectum and must be free of tension and well vascularized.

The single most important predictor of recurrence following sigmoid resection for uncomplicateddiverticulitis is an anastomosis to the sigmoid colon rather than to the rectum.

Vascular approach

1. Section of the IMA: high ligation / low ligation

2. Preservation of the IMA: with or without preservation of the left colic artery

Not rules at all !

AMI

Disposition des vaisseaux mésentériques inférieurs et rapport de l’AMI avec le plexus nerveux hypogastrique supérieur.

AMI

VMI

PIS

Emicolectomia sinistra

AMI

VMI

L’AMI est liée et sectionnée près de son origine sur l’aorte en respectant le PIS;

la VMI est liée et sectionnée au bord inférieur du pancréas.

Posizione dei trocars

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Sigmoid colectomy

L’AMI et la VMI sont liées et sectionnées en aval de la naissance de l’ACS.

ACS

Une deuxième section de la VMI près de sa terminaison au bord inférieur du pancréas

permet de faire basculer le pédicule colique supérieur gauche vers le bas.

Approach to medial-to-lateral mobilization of sigmoid colon and identification of left ureter.

Probably Yes, for 3 reasons:

1. Better vascularization of the rectum and the splenic angle (sure)

Tocchi et al. Am J Surg 2001

Casciola L., Ceccarelli G., et al. Minerva Chirurgica 2006

Ferulano G.P., Saverio Dilillo, , et al. Ann. Ital. Chir., 2006

Trencheva et al. Ann Surg 2013/

Borchert et al. Int J Surg 2015

A. Patriti, A. Bartoli

Doryane Maria dos Reis Lima et al Gastroentero Hepatol- April 2017

2. Better postoperative functional results (probable)

Masoni et al. Surg Endosc 2013/ randomized study

Dobrowolski et al. Neurogastroenterol 2009/ Koda et al. DCR 2005

Sarli et al. World J Surg 2006/ Sato et al. Hepatogastroenterology 2003

3. Less sexual morbidity (credible)

About vascular approach: should we preserve the IMA and the left colic artery?

Scheletrizzazione AMI con sezione ACS (B) e AS(C)

Preservazione AMI con conservazione ACS

ACS

VALDONI P: Chirurgia addominale. Tecniche operatorie. Vallardi Ed., Milano, 1974

Preservazione/scheletrizzazione AMI con sezione ACS e AS

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AMIPIS

Rapporti tra AMI e tronco nervoso ortosimpatico latero-aortico sx di Delmas e Laux

The left ureter and IMA are immediately adjacent,

with the vessel lying over the ureter.

Uretere

graphic representation of the left colon nerve supply

Preservazione AMI con risparmio ACS e legatura periferica aa. sigmoidee

peripheral colonic denervation

Surg Endosc (2013) 27:199–206

AMI

ACS

AS

AS

AS

ARS

VMI

Ilo

Mondor

Preservazione AMI con risparmio ACS e legatura periferica aa. sigmoidee

The surgical approach was medial, starting by ligating the inferior mesenteric vein (IMV) near the pancreas

and identifying and detaching the trunk of the IMV from the descending colon and sigmoid.

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Surg Endosc (2013) 27:199–206

Preservation of the IMA during laparoscopic sigmoid colectomy for benign disease.

Sezionando il mesosigma a ridosso della parete intestinale,

è possibile preservare un consistente numero di fibre nervose ascendenti destinate al colon discendente,

decorrenti nella compagine del mesocolon e provenienti dal PP.

Preservazione AMI con risparmio ACS e legatura periferica aa. sigmoidee

Division of the sigmoid arteries and sparing of the superior rectal artery.

L’AMI nel tratto terminale si avvicina sempre più alla parete intestinale e va preservata nella sua integrità.

care taken not to injure the SRA

the blood flow of the terminal branches of the arc and bleeding from the colon borders to be anastomosed were verified.

Verification of adequate blood flow in the marginal arcade.

Fluorescence-guided colorectal resection

ICG-enhanced fluorescence was used during laparoscopic colorectal resection

in order to verify the adequate perfusion of the large bowel prior to anastomosis

A simple injection of few milliliters of ICG allows to have a real-time evidence of adequate perfusion of the bowel

prior to proximal transection, after division of the mesentery and before the completion of the anastomosis.

Bowel perfusion fluorescence imaging with change in transection location.

Transection line was moved more proximal in fluorescence light, as indicated by arrows

Bowel perfusion in white light with change in transection location.

Clip is placed at the planned transection line in white light

from Spinoglio

Su ciò di cui non si può parlare, si deve tacere

[Wovon man nicht sprechen kann, darüber muss man schweigen].

Ludwig Wittgenstein

Visceral fat: A key factor in diverticular disease of the colonCreeping fat, also called fibrofatty proliferation or fat wrapping, are different names for hypertrophy of the subserosal fat.

Correlation between visceral fat and chronic subclinical inflammation as visceral fat

produces elevated serum levels of several pro-inflammatory cytokines.

As it is established that visceral fat induces nitric oxide synthase,

may be the mechanism that links visceral fat to diverticula formation.