Trinity Ileal resection w narration

This video demonstrates a laparoscopic resection of a distal ileal stricture from Crohn's disease using the 5 millimeter cool seal Trinity. A 19 year old male presented with a 3 year history of medically managed Crohn's disease, but it had been having increasing abdominal pain and intermittent vomiting. An MRI showed a fixed stricture of the terminal ileum, uh, with gross proximal dilatation. This shows the patient's positioning on the table. The surgeon and the assistant were placed on the patient's left side with the monitor on the patient's right. A 12 millimeter port was placed in the umbilicus, and 25 millimeter ports were used for the dissection. Here you can see the terminal ileum being examined on the area of the fixed stricture. It turned out that there was approximately a 10 centimeter length of ileum proximal to the ileocecal valve, which remained pliable and not grossly involved. The decision was therefore made to preserve the ileocecal valve. With this setup, the 5 millimeter cool seal Trinity was used to perform the mesenteric division. Here you can see the device being placed and used to create a mesenteric window in the proximal bowel at the level of significant bowel dilatation proximal to the gross disease and stricture. Even though the mesenteric leaflet is quite thick. It can be the 5 millimeter device can still be used to dissect through the mesentery and create the mesenteric window. This will eventually be used to insert the endoGIA uh to divide the bowel both proximally and distally. Here you can see that. The mesentery is almost taken in a stepwise and layered fashion in areas where it is simply too thick. The mesentery can be taken in two separate leaflets, one proximal and one distal. Yet still contain um maintain complete hemostasis. When the mesentery is this thick, a useful technique is to make a proximal seal. On the mesenteric base and then make a more distal seal to this near the wall of the bowel and divide the tissue at this level. This ensures that there is no incomplete seal and that there is always proximal vascular control. Here you can see the mesentery is almost 2 centimeters thick, but by simply taking the anterior and posterior portion of the mesenteric leaf separately, the 5 millimeter device is more than adequate to handle this. By performing the procedure this way, we were able to limit our trocars to 25 millimeter ports and 112 millimeter port which was placed in the infra umbilical ring. This port was later used to place the endoscopic stapler and to extract the specimen. This becomes. Cosmetically superior to having to place other larger ports for a 10 millimeter sealer or a 12 millimeter stapler to take the mesenteric leaf. This portion of the video is in real time and shows the rapid progression that can be performed taking the mesenteric leaflet. This portion of the operation took approximately 20 minutes. There was no significant blood loss, and there were no unsealed vessels within the leaflet. Again, taking a proximal. Bite and sealing without dividing and then making a more distal seal on the mesenteric leaflet prevented any significant bleeding. We are almost past the gross grossly involved ileum. And passed the stricture. You can see again because the mesentery is so thick, first they. Posterior and then an anterior division will be performed. In order to make sure that all vessels are sealed adequately. Because the mesenteric leaf is less thick here, this can be done with a single seal and division. If we did encounter bleeding on the proximal end, it would be very simple to simply grasp the tissue and reseal it without dividing the tissue. Again, this is a 19-year-old male who weighs approximately. 62 kg. But this technique could be used in any size patient. There you can see the distal. 10 centimeters of ilium which are relatively non-involved. And are therefore being preserved to preserve the ileocecal valve. We've now reached a point where we're ready to place an endoscopic stapler, and so the section will be carried right up onto the mesenteric. Aspect of the bow wall. The endoGIA tan loads will be used to divide the bowel both proximally and distally. You can see that there is no heat spread from the 5 millimeter device and that because it is immediately cool, we're able to manipulate the bow and surrounding structures using the grasper function of the device. At no point did the device need to be exchanged for a different grasping tool. The endoGIA is then used to divide the bowel. First distally. And now more proximately where the bowel is grossly divided or um. Grossly dilated. And in this case, 2 loads of the endoGIA were required to completely divide the bowel. Again, using the purple load. Once the bowel is completely free, it's placed up. In the Right upper quadrant above the liver to be extracted later. The Proximal bowel and the distal ileum. That was saved are now aligned with a series of two viral sutures to allow for a side to side anastomosis. Then an enterotomy is made. On the proximal aspect of the dilated proximal ilium. As well as the proximal side of the remaining 10 centimeters of distal ileum. A 60 centimeter, sorry, 60, uh. Millimeter. Load of the NWGIA is then inserted and a side to side anastomosis is performed. Inspection of the anastomosis shows a widely patent area with no bleeding or other issues. And then the resultant enterotomy is closed with a running 20 vicral suture. The operation took approximately 90 minutes. The patient was left with an NG tube overnight, which was removed the next morning. And he was started on a clear liquid diet on the 2nd postoperative day and was discharged to home. On the 3rd postoperative day. The specimen was placed in an endoscopic bag. And brought out through the 12 millimeter umbilical trochar site with the fascia being slightly widened to allow for extraction. There was no blood loss. And the patient has done well postoperatively.