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80
L
aparoscopic Left Hemicolectomy
cation of the dista
l
be performed by the fl
exible endoscope into the
.
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)
M
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l
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h
-
pub
evel of the bowel transection must be done prior to
he application of the linear bowel stapler. This may
rectum while occluding the proximal colon with a
abcock clamp
he 10–12 mm port in the right lower quadrant is
xchanged with the 18 mm port using Seldinger
echnique. The 45–60 mm bowel stapler is then
introduced through this port and the bowel is tran
ected at prechosen resection margin, insuring that
o extraneous tissue is incorporated (Fig. 5 –7
ore than one application of the stapler may be
ecessary to accomplish the bowel transection.
Assess the length of mesentery to insure a tension-
ree anastomosis in the following phase. If more
ength is necessary, further scoring of the perito-
eum overlying the mesentery or transection of the
ig. 5–6
l
nferior mesenteric vein may be necessary. If it is
ivided, proximal ligation at the duodenum wit
ither clips or a stapler are preferred.
Exteriorization of the Left Colon
nce the left colon has been completely mobilized,
a trial reach to the intended level of anastomosis is
undertaken. The preoperative proximal margin can
be marked with clips to facilitate the extracorporeal
omponent of the operation. The bowel is then exte-
iorized through either the left lateral or the supra
ic midline incision and a 10–12 mm port is placed
n the left lower quadrant position (if this port has
not been placed prior to this point). A Babcock
lamp is then used to gently hold the proximal colon
n order to deliver it from the abdominal cavity. The
ncision is enlarged along the trocar length; typically
Op
erative Technique
8
7
.
-
A
-
margin is verifi
ed.
y.
-
Th
-
.
1
Fig. 5–
-cm incision is adequate for this maneuver. A
wound protector may assist in minimizing potential
contamination
Once the diseased segment has been completely
exteriorized(Fig. 5 –8), the proximal colonic resec
ion proceeds with conventional surgical techniques.
fter an adequate resection margin has been obtained,
a purse string clamp is applied on the normal proximal bowel and the diseased segment is then tran
Fig. 5 –9) After the purse string clamp is
emoved, assess the vascularity of the resection
Performing the Anastomosis
If the distal margin is in the descending colon, the
anastomosis can be extracorporeally performed
using stapling devices for a functional end to end
nastomosis or alternatively using the handsewn
technique. The bowel is then replaced into the
dominal cavit
In the much more common scenario, the distal
margin involves the rectosigmoid junction. In this
setting the anastomosis is performed intracorpore
lly. The anvil of the 29 or 33 mm circular stapler is
placed into the proximal margin of the bowel, and
the purse string suture is then secured (Fig. 5 –10)
e edge of the proximal bowel with anvil is appropriately trimmed by removing the attached appendi
ces. The proximal bowel with the anvil is then
returned into the abdominal cavity and the incision
is closed after which a pneumoperitoneum is
reestablished
The laparoscopic phase is resumed as the surgeon
moves between the legs to introduce the 29 or
3 mm circular stapling device into the rectum. A
82
L
aparoscopic Left Hemicolectomy
Fig
. 5–8
ig. 5–9
Op
erative Technique
83
0
p
ected away and the surgeon must verify that there
The stapler is then fi
red verifying that both mesen-
with transanal endoscopy with air insuffl
lled pelvis. The abdominal team then
v
fi
es that no air leaks are present.
by
utu
Fig. 5–1
abcock clamp through the right lower quadrant
port can help stabilize the distal stump of the bowel
adjacent to the staple line. With slight pressure
against the top of the stump, the spike is made to
protrude (Fig 5 –11). The anvil holder is used in
order to deliver the anvil into pelvis and then to
approximate it to the trocar and the shaft of the
circular stapler (Fig. 5 –12) Switch the position of
he camera to the right lower quadrant port so that
e team can circumferentially visualize both the
distal and proximal portion of the anastomosis. While
closing the sta
ler, any extraneous tissue must be
ring.
tery and bowel are oriented in their appropriate
natomical position. To check the integrity of the
nastomosis, a noncrushing clamp is once again
gently placed on the proximal bowel, in conjunction
ation into
eri
Closure of the Wound
After irrigation of the wounds, each wound is closed
reapproximating the fascia. The skin may be
then closed by either staples or subcuticular
s
res.
8
4
L
aparoscopic Left Hemicolectomy
ig. 5–11
Fig. 5–1
2
OSTO
E
ued for three doses unless signifi
cant fecal conta
.
NS
n
W
n
Anastomotic leak
Anastomotic stenosis
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ammatory bowel disease. Am J Surg 1996; 171:
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85
Reference
P
PERATIVE CAR
Intravenous antibiotics are postoperatively contin-
mination or an abscess is encountered during the
surgery.
Oral intake can be initiated on the day of surgery,
and then advanced to a regular diet as the patient
olerates feeding. In general the regimen begins in
e clear liquid and then advanced to solid food
COMPLICATIO
Postoperative ileus or small bowel obstructio
ound infectio
Port site herniati
REFERENCE
ucker KA. Laparoscopic left hemicolectomy and sigmoid
ectomy. In: Bruce MacFadyen BV, Jr. (ed) Laparoscopic
Surgery of t
2003: 3
ilsom JW, Bohm B. Proctosigmoidectomy. In: Laparo-
sco
ic Colorectal Surgery New York: Springer-Verlag
1995: 148–1
esimann P, Salky BA, Pfeifer J, Edye M, Jagleman DG,
Wexner SD: La
f in
1–51
oller JA, Bruce CJ. Laparoscopic sigmoid resection for
diverticular disease. In: Wexner SD (ed) La
Colorectal Surger
141–1
exner SD, Moscovitz ID. Laparoscopic colectomy in
diverticular and Cro
2000
80(4): 1299–1319
acobs M. Laparoscopic left colectomy. In: Philips EH, Rosen
thal RJ (ed) Operative Strategy in Laparoscopic Colorectal
Surgery. New Yor
e Abdomen. New York. Springer-Verlag.
9–379
aroscopic surgery in the management
aroscopic
. New York. Wiley-Liss 1999:
n’s disease. Surg Clin North Am.
: Springer-Verlag. 1995: 230–235
Low Anterior Resection for
6
Rectal Cancer
INDICATIONS
Low anterior resections are performed to treat malignant tumors of the middle and upper thirds of the
rectum, 6–14 cm from the anal verge.
PREOPERATIVE PREPARATION
Mechanical and antibiotic bowel preparation
Computed tomography (CT) of abdomen and pelvis
Endorectal ultrasonography
Other staging studies as indicated
See Chapter 1
PITFALLS AND DANGER POINTS
Anastomotic failure
Presacral hemorrhage
Trauma to rectal stump during presacral dissection
Ureteral damage
OPERATIVE STRATEGY
Prevention of Anastomotic Complications
Anastomotic complications are rare when the resection is high and the anastomosis is intraperitoneal
(see Chapter 4). Conversely, a low anterior resection
with a colorectal anastomosis below the peritoneal
refl ection is clinically and radiographically much
more prone to leak. The low colorectal anastomosis
offers additional diffi culty for several reasons.
1. Anatomic exposure is often diffi cult. This is
especially true in men, whose pelvis is narrow, and
obese patients. Diffi culty with exposure often
requires the surgeon’s hand to be held at an awkward
angle, so it is easy to make small tears in the rectum
when inserting sutures.
2. It is easy to mistake mucosa for the muscular
layer owing to the lack of serosal cover over the
retroperitoneal rectum. If sutures or staples are erroneously inserted into the mucosal instead of the submucosal and muscular layers, the anastomosis will
leak because the mucosa itself has little tensile
strength. Identify the longitudinal muscle covering
the rectum and be sure to incorporate this layer in
the suture line.
3. The diameter of the rectal ampulla fre-
quently measures in excess of 5–6 cm, and the
lumen of the proximal colon, after proper bowel
preparation, is often half this size. The anastomotic
technique used must be capable of correcting this
disparity.
4. When the surgeon has not achieved perfect
hemostasis in the pelvis, a hematoma forms in the
presacral space. It frequently becomes infected and
develops into an abscess, which may erode through
the colorectal suture line.
5. If the pelvic peritoneal fl oor is closed above
the colorectal anastomosis, deadspace may surround
the anastomosis, which is especially conducive to
leakage in the anastomosis. The peritoneal pelvic
fl oor is not resutured after the colorectal anastomosis
is completed.
6. Do not leave any empty space in the hollow of
the sacrum behind a low anastomosis. For most low
anterior resections, we free the attachments of the
splenic fl exure (see Figs. 4–4 to 4–8) so the descending colon has suffi cient redundancy that relaxed
colon fi lls the sacral space behind the anastomosis.
If this step cannot be accomplished, fi ll the empty
space in the pelvis by lengthening the omentum suffi ciently that it can be delivered to the presacral
space.
7. We have virtually eliminated leakage by
adopting the side-to-end (Baker) colorectal anastomosis. This permits the diameter of the anastomosis to be exactly equal to that of the lumen of the
86
Operative Strategy 87
commodious rectal ampulla. Healthy-sized bites of
tissue may be enclosed in the sutures with no
danger of postoperative stenosis. In effect, at the
conclusion of the anastomosis, the rectal ampulla
has been invaginated into the side of the proximal colon (see Fig. 6–23). Placing the anastomosis
within 1 cm of the closed end of the proximal colon
eliminates the danger of developing a blind-loop
syndrome.
8. Following a low anastomosis we routinely
insert a closed suction drain into the presacral space,
bringing it out through a puncture wound in the left
lower quadrant.
9. Although the use of staples for low colorectal
anastomoses has been demonstrated to be safe by
numerous studies, it is important to observe all the
precautions described below to ensure uneventful
healing.
Which Colorectal Anastomosis: Sutured, Circular Stapled, or Double Stapled?
Sutured colorectal anastomoses, described below,
have been demonstrated to be safe when performed
with delicacy of technique by a skilled surgeon on
well dissected healthy tissues. Lesions 9–10 cm from
the anal verge can generally be removed and a
sutured colorectal anastomosis performed. However,
when the surgeon resects lesions lower than 10 cm
from the anal verge, suturing the colorectal anastomosis can be diffi cult. Insertion of the circular stapler
into the rectum allows construction of a safe colorectal stapled anastomosis with greater ease for the
surgeon than is true for the sutured anastomosis.
If the cancer resection has left a rectal stump situated so low in the pelvis that even insertion of the
purse-string suture becomes diffi cult (lesions at 6–
8 cm), use the Roticulator 55 mm linear stapler (U.S.
Surgical Corp.) to close the proximal edge of the
rectal stump rather than a purse-string suture. Passing
the circular stapler into the rectum then permits
construction of a circular colorectal anastomosis
through the linear staple line closing the proximal
edge of the rectal stump. This method is especially
suitable for the lowest colorectal anastomoses.
ginal artery all the way from the middle colic artery
(Fig. 6 –1). Although this proves adequate in most
patients, there is a danger that the surgeon may not
recognize those patients whose blood supply is not
suffi cient. We believe the risk of this occurring is
greater than the benefi ts that may accrue to the
patient by routinely amputating the extra 3 cm of
inferior mesenteric artery. It is important that the
blood supply to the proximal colon undergoing anastomosis not only be adequate but be optimal before
this segment is used in a low colorectal anastomosis.
Consequently, in the usual case of rectal cancer we
transect the inferior mesenteric artery just distal to
the origin of the left colic vessel (Fig. 6 –2). Even if
only the ascending branch of the left colic artery is
preserved, there usually is vigorous arterial pulsation
in the mesentery of the descending colon. For obese
patients, transillumination of the mesentery is helpful
for identifying the junction between the inferior mesenteric and left colic arteries.
If the inferior mesenteric artery is ligated proximal
to the takeoff of the left colic artery, be sure always
to liberate the splenic fl exure and resect most of the
descending colon unless it can be proven that the
circulation through the marginal artery at a lower
level is vigorous. This can be accomplished only by
demonstrating pulsatile fl ow from a cut arterial
branch at the proposed site of the transection of the
colon. Poor blood fl ow leads to poor healing.
In the usual rectal cancer case the sigmoid colon
is removed and the descending colon is used for
anastomosis. This generally requires liberation of the
splenic fl exure, which can be accomplished in a
few minutes once the surgeon has mastered the
technique.
Indications for Complementary Colostomy or Loop Ileostomy
When there is diffi culty constructing a low colorectal
anastomosis and it is likely the surgeon has created
a less-than-perfect anastomosis, a complementary
diverting right transverse loop colostomy or loop
ileostomy should be constructed. It may be closed as
early as 2 weeks after the low anterior resection if a
barium enema shows a normal anastomosis.
Extent of Lymphovascular Dissection
Goligher (1975) advocated routine ligation of the
inferior mesenteric artery at the aorta not only for
lesions of the descending colon but also for rectal
cancer. When this is done, the entire blood supply
of the proximal colon must come through the mar-
Presacral Dissection: Prevention of Hemorrhage
Contrary to what apparently is a widely held perception, radical cancer surgery does not require stripping the tissues from the sacrum down to the
periosteum. Dissection of the perirectal tissues prox-
88
L
ow Anterior Resection for Rectal Cancer
ig. 6–1
2
-
b
.
-
p
h
v
he h
h
.
O
perative Strate
gy
89
Fig. 6–
mal to the carcinoma is necessary for removal of
tumor emboliin the lymph nodes and lymphatic
channels. If tumor has widely invaded the mesorec
um and presacral tissues, it is generally beyond cure
y radical surgery
There is a network of veins lying on the presa
cral periosteum that drain into the sacral foramina
(see Fig. 6–8b). When these veins are torn by blunt
dissection, clam
emorrhage that results often is impossible, as the
torn vessel retracts into the foramen. The massive
enous hemorrhage that follows may not be
stemmed by ligating t
intraoperative fatalities during total proctectomy
re caused by this type of presacral venous
emorrhage
ing or ligation to control the
ypogastric arteries. Most