Department of Obstetrics and Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut.
Department of Obstetrics and Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut.
J Minim Invasive Gynecol. 2018 Jan;25(1):19-20. doi: 10.1016/j.jmig.2017.04.015. Epub 2017 May 3.
To show a surgical video in which an incidentally found Meckel diverticulum was resected with a natural orifice-assisted laparoscopic approach during para-aortic resection of a retroperitoneal schwannoma.
Case report (Canadian Task Force classification III).
Tertiary referral center in New Haven, Connecticut.
This is a step-by-step illustration for resection of a retroperitoneal para-aortic schwannoma and of an incidentally found Meckel diverticulum. The patient was a 39-year-old white woman diagnosed with stage IV choriocarcinoma with metastasis to the lungs and left para-aortic area. She received chemotherapy in the form of etoposide, methotrexate, actinomycin-D, cyclophosphamide, oncovine (EMA-CO) and had an excellent clinical response with resolution of all metastatic disease except for the para-aortic mass. Therefore, she was taken to the operating room for laparoscopic resection of the persistent left para-aortic mass. After placement of four 5-mm abdominal ports, the pelvis and abdomen were explored and revealed an incidental Meckel diverticulum as well as the 5 cm left para-aortic mass. The peritoneum overlying the para-aortic mass was incised and the retroperitoneum explored. Given the proximity to the mass, left ureterolysis was performed. The retroperitoneal attachments were resected, and the left para-aortic mass was removed without any complications. At this point attention was turned to the Meckel diverticulum. In order not to extend the abdominal incisions, a posterior colpotomy was performed in the cul-de-sac equidistant from the uterosacral ligaments. Endo-GIA (Covidien, New Haven CT) was introduced through the 10-mm port site at the posterior colpotomy. Meckel diverticulum was resected without narrowing the lumen of the distal ileum. The specimen was removed in a contained manner through posterior colpotomy.
The procedure was performed without any complications. The patient had an uneventful postoperative course and was discharged home on postoperative day 0. Pathology revealed a retroperitoneal schwannoma with negative margins and benign Meckel diverticulum without ectopic gastric or pancreatic tissue. The patient has been disease-free since the completion of surgery.
Laparoscopic resection of the retroperitoneal schwannoma and Meckel diverticulum were successfully performed in this patient with history of stage IV choriocarcinoma. To our knowledge, this is the first report describing a natural orifice-assisted laparoscopic approach for resection of Meckel diverticulum. Natural orifice-assisted laparoscopy should be considered when the surgeon needs to remove a large specimen and/or to introduce >5-mm diameter instruments into the peritoneal cavity without having to extend the abdominal incisions.
展示一例偶然发现的 Meckel 憩室，在进行腹主动脉旁腹膜后神经鞘瘤切除时，采用经自然腔道辅助腹腔镜方法进行切除。
病例报告（加拿大任务组分类 III）。
康涅狄格州纽黑文的三级转诊中心。
这是一例腹膜后腹主动脉旁神经鞘瘤切除术和偶然发现的 Meckel 憩室切除术的分步说明。患者为 39 岁白人女性，诊断为 IV 期绒癌，肺部和左侧腹主动脉旁转移。她接受了依托泊苷、甲氨蝶呤、放线菌素-D、环磷酰胺、长春新碱（EMA-CO）化疗，临床反应极佳，除了腹主动脉旁肿块外，所有转移性疾病均得到缓解。因此，她被送往手术室进行腹腔镜切除持续性左侧腹主动脉旁肿块。在放置四个 5 毫米的腹部端口后，对骨盆和腹部进行探查，发现一个偶然的 Meckel 憩室和 5 厘米的左侧腹主动脉旁肿块。切开覆盖腹主动脉旁肿块的腹膜，探查腹膜后。由于靠近肿块，进行了左侧输尿管松解术。切除了腹膜后附着处，然后切除了左侧腹主动脉旁肿块，没有任何并发症。此时，注意力转向 Meckel 憩室。为了不延长腹部切口，在靠近子宫骶韧带的子宫直肠陷凹进行了后阴道穹窿切开术。通过后阴道穹窿切开术的 10 毫米端口部位引入 Endo-GIA（Covidien，New Haven CT）。在不缩小远端回肠腔的情况下切除 Meckel 憩室。标本通过后阴道穹窿切开术以受控的方式取出。
该手术无任何并发症。患者术后恢复顺利，术后第 0 天出院回家。病理显示为腹膜后神经鞘瘤，切缘阴性，良性 Meckel 憩室无异位胃或胰腺组织。患者自手术完成以来一直无病。
在有 IV 期绒癌病史的患者中，成功地进行了腹腔镜切除腹膜后神经鞘瘤和 Meckel 憩室。据我们所知，这是首例描述经自然腔道辅助腹腔镜方法切除 Meckel 憩室的报告。当外科医生需要切除大标本和/或将直径>5 毫米的器械引入腹腔而无需延长腹部切口时，应考虑经自然腔道辅助腹腔镜。
