Malrotation and Volvulus with Trinity

This video demonstrates a laparoscopic reduction of a midgut volvulus with lad's procedure using the Coolseal Trinity 5 device. A 12 year old female presented with a three month history of intermittent pain and weight loss with an acute worsening of her symptoms. A CT scan showed evidence of a mid gut volvulus. She was taken emergently to the OR and positioned in a, Dorsal lithotomy position. The surgeon was positioned between the patient's legs, and here you see the port placement. 35 millimeter ports were used for the procedure. Upon entering the abdomen. It could be seen that there was a clear disorientation of the bowel. Initial attempts to run the bowel to determine the extent of the volvulus. We're done with 25 millimeter bowel clamps. But in early on, it became evident that there was an internal hernia and a complete twist of the bowel. Using the cool seal device, these lads bands can easily be taken. While manipulating the bowel, the ability to dissect grasp tissue and then seal and divide the tissue safely in close proximity to the bowel wall is key to the success of this operation. Here you can see some of the initial bands being taken down as we try to determine the anatomy. And Figure out the cause of the complete obstruction. Again, because we were able to manipulate the tissues as well as grasp them and then seal and divide them, we are able to limit our instrument instrumentation changes and do not lose exposure. Here you can see an overlying band, which is partially obstructing the small bowel. The ability to have the Trinity device activated while laying on the bow wall without any injury is key to the success of this procedure. Here we can see one of the large obstructing bands as we try to release the colon and move it to the left side of the abdomen. The anatomy in this case is quite confusing because of the. 360 degree twist of the bowel as well as the internal hernia. The key to this operation is to. Operate in front of the camera and eventually run the bowel in front of the camera instead of chasing the bowel around the abdomen. This prevents disorientation and allows the surgeon to keep a clear view of the. Affected area Now we can start to see the superior mesenteric vessels as they're released, and they're quite engorged because they've been twisted. Here are some further bands overlying the terminal ileum and near the area of the right colon. Gradually, all of this tissue is released, which allows us to place the colon. In the left side of the abdomen. As we run the bowel, we find further adhesive bands which continue to be partially obstructing. It is critical that the bow be completely run from. The duodeno jujunal junction all the way to the ileocecal valve to ensure that all of these bands have been released. Again, you can see the engorged vessels of the mesentery because of the twist. With the majority of the bands taken down, we now run the bowel from proximal to distal, trying to ensure that there are no further obstructive bands. As we get more distal, we do find bands extending from the colon and overlying the proximal small bowel or duodenum. These are taken with the cool seal as well. Does it continue to be large, uh, Adhesive bands which obstruct different portions of the proximal small bowel and by releasing these we are eventually able to relocate the colon to the left side of the abdomen. This is the last of the bands causing the internal hernia around which the twist was formed. Here, you can see the superior mesenteric vessel as it becomes freed. And this is followed up towards the base of the mesentery. The key to this operation is making sure that the mesentery has been broadly widened to prevent a twist in the future. One should be able to see the superior mesenteric artery and vein coming straight down into the middle of the abdomen with no twists or obstruction. These are the final bands which were obstructing the duodenum proximally. With all of this complete, we now run the bowel again from proximal to distal. Here you can see the duodenum as it has been straightened out. Coming from the first portion of the duodenum down to the communication with the jejunum. The ballots then run from proximal to distal to make sure that no bands have been missed. Also, this places all the small bowel on the patient's right and the colon on the patient's left. Again, the key to this is running the bowel in front of the camera, not chasing it around the abdomen. The final portion of the procedure is to take out the appendix. Here the appendiceal mesentery is taken using the cool seal, and then the appendix is divided with a single application of the 5 millimeter stapler. This allows us to keep all our ports at 5 millimeters and not upsize to a 12 millimeter port for a larger stapler. This is then brought out through the umbilical trochar site. The operation took approximately 90 minutes, and the patient did well.