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200
L
aparoscopic Stoma Construction and Closure
5
6
Fig. 17–
Fig. 17–
Op
erative Technique
20
7
1
Fig. 17–
202
L
aparoscopic Stoma Construction and Closure
p
p
m
la
O
d
t
(Figure 17– 8). Delivery of the sigmoid loop through
he stoma site reveals the peritoneal cavity and
neumoperitonium is then reestablished. Visual
inspection of the cavity and mesentery should be
erformed to ensure that there is no tension or
orsion of the sigmoid colon. The stoma is then
atured using standard techniques.
End Sigmoid Colostomy/Mucous
Fistu
perating Room Setup an
Trocar Placemen
The operating room set up is the same as that
epicted for loop sigmoidostomy (Figure 17–7).
ig. 17–8
Op
erative Technique
203
-
.
Identifi
cation of the Ureter
ed, the lateral attach-
-
ed and dissected
I
f
T
-
9
Pneumoperitonium is established through the umbil
cal site. The second port is placed at the stoma site
and the third port can be placed on the ipsilateral
side of the stoma. In case of extensive adhesions, the
contralateral ports may be needed to facilitate the
enterolysis
ments of the sigmoid are incised. The peritoneum is
ncised cephalad toward the direction of the origin
of the inferior mesenteric artery. The inferior mesen
eric artery and vein are swept ventrally away from
e preaortic hypogastric neural plexus which is
swept dorsally to prevent injury. The sigmoid colon
is mobilized lateral to medial and the gonadal vessels
free
of the mesentery
Figure 17–9).
ncision of the Mesocolon and Division
the Sigmoid Colon
o
he ability to mobilize the colon to the anterior
dominal wall is ensured and a window is created in
the mesentery (Figure 17–10). A laparoscopic linear
0 mm stapler is introduced and used to divide the
sigmoid colon (Figure 17–11). After division of
the sigmoid colon, a vascular stapler is used to divide
the mesentery of the sigmoid colon. This second line
stapler allows the two ends of the colon to be sepa
rated and used as an end colostomy and mucous
Fig. 17–
20
4
L
0
1
aparoscopic Stoma Construction and Closure
Fig. 17–1
Fig. 17–1
Op
erative Technique
205
fi
stula. Alternatively, a loop of sigmoid can be deliv-
.
E
d
A
eate the
fi
stula, the mesentery should be divided to
fi
stula allows inspection of the abdominal
stula can be matured though the same
lly
y
Troca
lacement
The patient is placed in the supine or modifi
ed
thot
legs and the fi
rst assistant stands to the right side of
ected stoma site.
2
ered through the stoma site and then extracorporelly
ivided after insuring appropriate orientation
xteriorizating the Proximal
Sigmoi
Babcock clamp is passed though the trocar to
deliver the proximal colon. Simultaneous withdrawal
of the trocar with a second Babcock is used to
withdraw the distal end of the colon after enlarging
e peritoneal defect
mucous
allow physical separation of the two loops of colon.
Reestablishment of the pneumoperitonium after
placement of the stoma as an end colostomy and
mucous
cavity to exclude torsion or tension. Alternatively,
Colon
Figure 17–12) To cr
stoma site, usua
at its inferior aspect.
Transverse Colostm
Operating Room Setup and
r P
li
omy position. The surgeon stands between patient’s
the patient
raised through the umbilical port where a 10 mm
trocar is placed to introduce the laparoscope; a
second 10 mm trocar is placed in the right iliac fossa
nd a third in the left iliac fossa (Figure 17–14) one
of iliac fossa ports should be placed through the
l
Figure 17–13) Pneumoperitonium is
-
Fig. 17–1
20
6
L
aparoscopic Stoma Construction and Closure
ig. 17–13
Op
erative Technique
2
4
D
ph-
.
ake Dow
p
l
The patient is placed in the modifi
w
U
w
p
07
Fig. 17–1
issecting the Omentum
The omentum is gently grasped and retracted ce
alad. The weight of the transverse colon provides
adequate countertraction, thus allowing dissection
with the harmonic scalpel. After the bowel has
been dissected, the transverse colon is gently
rasped and exteriorized through the chosen stoma
site; maturation is effected in the standard
manner
Hartmann’s T
erating Room Setup, Trocar
O
acement, and Stoma Mobilization
P
omy position. The rectum is gently irrigated using a
soft rubber catheter and warm saline solution. The
n
ed dorsal lithot-
rst
ssistant and the camera operator next to the surgeon
Figure 17–15) The monitors are placed next to
each of the patient’s knees.
The stoma is mobilized in the usual fashion, after
hich the anvil of a 29 cm, or preferably a 33 cm
stapler, is secured in place. The proximal colon and
nvil are then returned into the peritoneal cavity.
nder direct manual and visual guidance, any midline
dhesions are sharply divided after which a 10 mm
supra or infraumbilical port is placed. The stoma site
can be either completely closed or closed around a
0 mm port. Care must be taken to resect any residual proximal diverticular narrowing to ensure that
healthy, supple, compliant, well vascularized bowel
ill be used for the anastomosis. Introduction of
pneumoperitonium and placement of distal 10 mm
ort, as needed are usually in the right iliac fossa and
right upper quadrant
Figure 17–16)
208
L
aparoscopic Stoma Construction and Closure
ig. 17–15
ig. 17–16
Op
erative Technique
209
D
p
ed and dissected
-
Anastomotic landmarks are identifi
ed to insure appro-
proctographic verifi
Mobil
n
P
Th
y.
7
issecting the Rectal Stum
With the use of a rigid sigmoidoscope through the
from the surrounding structures (Figure 17–1). Adhe
sions must be lysed so that small intestinal loops can
be cleared away from the pelvis. The rectal stump is
en circumferentially mobilized for 3–5 cm from sur-
ounding pelvic tissues. Any residual sigmoid colon
should be resected to insure anastomosis of the
descending colon to the top of the rectum and not
o residual diseased sigmoid colon. A preoperative
contrast enema radiograph is helpful in this regard.
priate height, including dissipation of the appendices
uence of teniae coli as well as
cation of the 15 cm level from the
dentate line as being at the sacral promontory and
free of any diverticular openings.
ization of the Left Colo
Mobilization of the left colon is often necessary to
insure a tension free anastomosis. This mobilization
proceeds as described earlier.
erforming the Anastomosis
Before proceeding with the anastomosis, the
surgeon must establish that it can be created without
tension. A purse string suture is placed at the proximal end and a detached anvil (from an intraluminal
stapler) is inserted into the bowel
e transanal device is passed through the rectal
stump and the anastomosis is accomplished (Figure
7–19). The anastomosis is best viewed from the
right iliac fossa port; care must be taken to insure
ppropriate orientation of the bowel and its
mesenter
Figure 17–18)
Fig. 17–1