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Incising the
peritoneum
with scissors
1
Avascular
fatty tissue
2
Duodeum
Kidney
Psoas muscle
3
Lesion
4
Duodenum
Ureter
Middle
colic artery
Right
colic artery
Line of incision
Ileocolic artery
143
Terminal ileum
PLATE
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63
DETAILS OF PROCEDURE e end of the colon is closed
by a continuous absorbable suture on an atraumatic needle and whipped
loosely over a Pace-Potts or similar noncrushing clamp (figure 5). Interrupted silk sutures placed beneath the clamp may be used. e clamp
is then opened and removed. If a continuous suture is used, it is pulled up
snugly and tied. A single layer of silk Halsted mattress sutures is placed
about or cm from the original suture line, care being taken that no fat
is included. As these sutures are tied, the original suture line is invaginated
so that serosa meets serosa (figure 6). e surgeon must determine before
closing the ends of the colon whether an end-to-end, end-to-side, side-toend, or lateral anastomosis is to be carried out (figures 14, 16, 17, and 18).
e end-to-side approximation is physiologic, simple, and safe to perform. e small intestine, still held in its clamp, is brought up adjacent to
the anterior taenia of the colon (figure 7). e small intestine should retain
a good color and give evidence of adequate blood supply before the anastomosis is attempted. If its color indicates an inadequate blood supply, the
surgeon should not hesitate to resect a su cient length until its viability is
unquestionable. Next, the omentum, if not previously excised, is retracted
upward, and the anterior taenia of the transverse colon is grasped with Babcock forceps at the site chosen for anastomosis (figure 7). Following this,
the edge of the mesentery of the small intestine should be approximated
to the edge of that of the large intestine, so that herniation of the small
intestine cannot occur beneath the anastomosis into the right gutter
(figure 14). is opening is closed before the anastomosis is started, since
on rare occasions the blood supply may be injured by the procedure and the
viability of the anastomosis jeopardized. A small, straight crushing clamp
is applied to the anterior taenia, including a small bite of the bowel wall
(figure 8). Following this, the clamps on the terminal ileum, as well as on
the anterior taenia of the transverse colon, are so arranged that a serosal layer of
interrupted mattress or nonabsorbable synthetic sutures can be placed,
anchoring the terminal ileum to the transverse colon (figure 9). e two
angle sutures are not cut and serve as traction sutures (figure 9). An opening is made into the large intestine by excising the protruding contents of
the crushing clamp that has been applied to the anterior taenia (figure 10).
An enterostomy clamp is then applied behind each of the crushing clamps.
e crushing clamps are removed, and the terminal ileum is opened; likewise, the crushed contents of the transverse colon are separated. Sometimes
it is necessary to enlarge the opening in the mucosa of the colon, since
the previous excision of the contents of the crushing clamp did not provide a su ciently large stoma for satisfactory anastomosis. e mucosa
is then approximated with a continuous locked nonabsorbable suture on
atraumatic needles, which is started in the midline posteriorly. e sutures,
A and B, are continued as a Connell inverting suture around the angles
and anteriorly to ensure inversion of the mucosa (figures 11 and 12).
C, R
Interrupted ne silk sutures are preferred by some for closing the
mucosal layer. An anterior row of mattress sutures completes the anastomosis. Several additional mattress sutures may be placed to reinforce the
angles (figure 13). e patency of the stoma is tested. It should permit
introduction of the index nger. If the tension is not too great, the raw surface over the iliopsoas muscle may be covered by approximating the peritoneum of the lateral abdominal wall to the mesentery.
e second method shown is a direct end-to-end anastomosis (figures 15
and 16). e discrepancy in the size of the terminal ileum and the transverse colon can be overcome safely by attending to certain technical details.
Added luminal circumference can be provided by exaggerating the oblique
division of the terminal ileum. During the anastomosis, slightly larger bites
are taken in the colonic side to compensate for the discrepancy between the
two sides of the anastomosis. Following completion of the anastomosis, any
remaining gap between the mesenteries is approximated. e patency of
the lumen is determined by palpation.
If a side-to-end anastomosis is preferred by the surgeon, the stump of
the small intestine is closed as previously described for the large intestine.
e small intestine is then brought up to the open end of the large intestine
(figure 17), the posterior row of serosal sutures is placed, the small intestine is opened, and the continuous mucosal suture or the inverting sutures
are placed as well as, nally, the anterior serosal sutures of interrupted
silk or nonabsorbable synthetic material. Whenever this type of procedure
is carried out, care should be taken that only a very small portion of small
intestine protrudes beyond the suture line, since blind ends of bowel that
are in the peristaltic line form a stagnant pouch against which peristalsis
tends to work, increasing the chance of eventual breakdown.
In the fourth method, the ends of the large and small intestines are
closed, and a lateral anastomosis is carried out. Only a small portion of
small intestine should protrude beyond the suture line. e small intestine
should be anchored to the colon with interrupted sutures of silk or nonabsorbable synthetic material, including both angles of the stoma as well as
the closed end of small bowel (figure 18). e stapled equivalent of each of
the variations can be found in earlier chapters illustrating the use of various
stapling instruments in small bowel anastomoses.
CLOSURE Drains are undesirable unless gross infection has been encoun-
tered. e site of anastomosis is covered with omentum. e abdominal
wall is closed in routine fashion, and a sterile dressing is applied.
POSTOPERATIVE CARE e patient should be in a comfortable position.
Diarrhea or frequent bowel movements may be satisfactorily controlled by
medication and diet. e need for continued steroid therapy, particularly
in patients with regional ileitis, should not be overlooked in the immediate
postoperative period. ■
144
5
Inferior
taenia
Omentum
Transverse colon
Duodenum
Kidney
Ureter
Site of stoma
7
Anterior
taenia
8
Transverse colon
Posterior
serosal suture
9
Ileum
6
11
Mucosal
suture A
14
Mesocolon
Iliopsoas
muscle
Suture B
Completed anastomosis
Spermatic
vessels
Suture A
12
Alternate Methods
Ileum
15
Traction suture
10
Anterior
serosal sutures
13
Suture B
End - to - End Anastomosis
Colon
16
Branches
of right
colic
artery
Side - to - End
Ileum
17
Stoma
Colon
Lateral
18
Colon
Stoma
Anchoring
sutures
145
PLATE
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64
INDICATIONS Laparoscopic resection of the colon is most commonly
indicated for benign colon conditions such as chronic diverticulitis and
large polyps that are not amendable to removal during colonoscopy. e
laparoscopic approach is being used with increasing frequency for carcinoma. In general this approach is not recommended in patients with emergency conditions such as obstruction, perforation, or massive bleeding.
PREOPERATIVE PREPARATION For patients having surgery for polyps
and occult neoplasms, it is essential to have the lesion tattooed during
colonoscopy or localized by a preoperative barium enema. Identi cation of
the tumor during laparoscopy is usually di cult. e use of intraoperative
colonoscopy is di cult during laparoscopic procedures; hence, accurate
preoperative localization is necessary. e patient should receive a standard
mechanical bowel preparation, and prophylactic antibiotics are administered within one hour of the incision and are to be discontinued within
hours of surgery. Subcutaneous heparin is administered and sequential
compression devices are placed for prevention of venous thromboembolism.
ANESTHESIA General anesthesia is required. An orogastric or nasogastric
tube is inserted.
POSITION e patient is positioned in the modi ed lithotomy position
with the legs supported on stirrups. Padding is used to protect all pressure
points. e le arm is tucked. e patient should be secured to the operating table with tape, as repositioning of the table may be needed to enhance
exposure during the operation. e operating room setup is shown in
figure 1A. e surgeon and camera operator stand to the patient’s le .
e assistant stands between the patient’s legs. Two video monitors are used
as shown.
OPERATIVE PREPARATION e skin is prepared in the routine manner
and a sterile plastic drape applied.
INCISION AND EXPOSURE Access to the peritoneal cavity is achieved
by an open or Hasson technique. An infraumbilical incision is made
and a - to -mm Hasson port inserted. e abdomen is insu ated to
mm Hg. A -degree-angled scope is employed. A er the Hasson port is
inserted, there are three commonly used port placements (figure 1B). e
rst con guration is shown in figure 1b has a - mm trocar to the le
of the midline in the le lower quadrant with mm ports in the le upper
quadrant and the right lower quadrant. Using this method, the extraction
incision is made as a vertical midline either at the level of the umbilicus or
in the suprapubic area. e second con guration is a - to -mm port
in the le lower quadrant and -mm ports in the suprapubic midline and
a right upper quadrant in the subcostal location in the midclavicular line.
e upper -mm port on the right side may allow better mobilization of
the hepatic exure in some patients. With this con guration, the extraction
incision is either midline as described above or in the transverse direction
at the site of the -mm right-upper-quadrant port or a transverse rightlower-quadrant incision. e third con guration uses a hand port in the
midline, a - to -mm port if the le lower quadrant, and -mm ports at
the subxiphoid midline location and the right subcostal area. A hand port
is used to extract the specimen.
DETAILS OF PROCEDURE Mobilization of the right colon is shown by a
lateral to medial approach. A medial to lateral approach may be used but
is not described here. In the lateral medial approach, mobilization begins
at the cecum. e patient is placed in the Trendelenburg position and tilted
degrees to the le . e cecum is grasped with an atraumatic instrument
and retracted medially and anteriorly (figure 2). Using a monopolar cautery endoscissors or an ultrasonic device, an incision is made in the peritoneal re ection close to the lateral wall of the bowel at the tip of the cecum
(figure 2). e assistant then grasps the ascending colon and retracts it
medial and cephalad, permitting the incision to be extended upward to the
region of the hepatic exure using a traction counter-traction technique
(figure 3). As the dissection begins, care should be taken to avoid ureteral
injury (figure 3). As one approaches the hepatic exure, the duodenum
may be visualized and protected (figure 3). For mobilization of the hepatic
C, R L
exure, the patient should be placed in the reverse Trendelenburg position.
If there is a - to -mm trocar in the right lower quadrant, repositioning
the laparoscope to this sight may provide better visualization. e hepatic
exure is then retracted medially and inferiorly. An ultrasonic device
is used to divide the peritoneal attachments (figure 3). Care is taken to
avoid injury to the underlying duodenum during hepatic exure mobilization. For mobilization of the hepatic exure the patient should be placed in
the reverse Trendelenburg. If there is a - mm trocar in the right lower
quadrant reposition the laparoscope to this site may provide better visualization. e hepatic exure is then retracted medially and inferiorly. An
ultrasonic device is used to divide the peritoneal attachments (figure 4).
Next the proximal transverse colon is mobilized by dividing the omental
attachments along the line of dissection in figure 2. e assistant grasps
the omentum and holds this upward. e surgeon grasps the mesenteric
side of the transverse colon to put tension on the omental attachments. e
omental attachments are divided with ultrasonic shears or electrocautery
taking care not to injure the colon. Division of the gastro colic ligament is
frequently necessary to completely mobilize the hepatic exure from the
liver. e extent of omental detachment may vary depending on the location of the lesion and the degree of reach needed.
e mesentery is divided in the next series of steps. e ileocolic vessels
are grasped and retracted toward the anterior abdominal wall. e peritoneum overlying the mesentery is incised at a point beneath the ileocolic
vessels with electrocautery endoscissors and a window created. For malignancy, this should be near the root of the mesentery. e cecum is grasped
and retracted laterally to elevate the ileocolic vessels. e vessels are skeletonized and then divided with the linear laparoscopic stapler with .-mm
staples or clips (figure 4a and 4b). e dissection is carried toward the
hepatic exure and the stapling process repeated until the mesentery is
divided. e dissection is continued to and including the right branch of
the middle colic artery.
In figure 4a, the right colic artery is being dissected. figure 4b shows
the ligated ileocolic artery, right colic artery, and the right branch of the
middle colic. e line of resection is shown in figure 5. A er complete
mobilization the bowel is externalized through a - to -cm incision by
extending the right-lower-quadrant incision or the umbilical incision. A
plastic wound protector is used. e terminal ileum and colon are exteriorized through this opening. e proximal and distal margins of the specimen are then divided using a linear stapler (. mm staples). Larger staples
may be needed depending on the thickness of the bowel wall. A side-toside hand-sewn or stapled anastomosis may be performed. To perform a
side-to-side stapled anastomosis, stay sutures are placed to secure the two
antimesenteric walls of the ileum and the colon. An enterotomy for the
introduction of the stapling device is created by excising a small portion
of the staple lines along the ileum and transverse colon with curved Mayo
scissors (figure 6a). e linear stapler is then introduced and closed
(figure 6a). e posterior aspect of the bowel is examined to be certain
that no mesentery is included in the closed stapler. Once this is ensured,
the stapler is discharged and the anastomosis created. rough the enterotomies, the staple line is inspected for bleeding. Small bleeding points are
sutured with silk gure-of-eight sutures. e enterotomy is closed
with a stapler (figure 6b). e nal appearance is shown in figure 6b.
e mesenteric defect is closed and the bowel returned to the peritoneal
cavity.
CLOSURE e incision used to exteriorize the bowel and complete the
extracorporeal anastomosis is closed with interrupted or running sutures.
e port sites greater than mm are closed with sutures as well.
POSTOPERATIVE CARE e orogastric or nasogastric tube is removed in
the postoperative care unit. Intravenous uids are administered and vital
signs and urine output monitored every hours. Prophylactic antibiotics
are discontinued within hours of the surgery. e bladder catheter is
removed on postoperative day or . An initial postoperative diet consisting of clear liquids is started on postoperative day if there is no distention
or indications of complications and this is advanced as tolerated. ■
146
147
PLATE
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65
INDICATIONS e operation is performed chie y for tumor of the le
colon or a complication of diverticulitis.
PREOPERATIVE PREPARATION Tumors of the le colon are frequently of
the stenosing type. Patients with this condition o en come to the surgeon
with symptoms of impending intestinal obstruction.
When obstruction is not complete, the bowel can best be prepared over
a period of days by oral administration of the appropriate cathartics and
a clear liquid diet for the last hours. e frequency with which cathartics and cleansing agents are administered will vary depending upon the
amount of obstruction. e level and nature of the obstruction may be con rmed by barium enema; however, colonoscopy allows biopsy for pathologic identi cation, identi cation and removal of additional lesions such as
polyps, and potential evaluation of the proximal colon. In the presence of
total obstruction, a nasogastric tube is passed for decompression and the
colon is emptied from below with enemas. Evaluation of the distal colon
with colonoscopy is valuable and a virtual colonoscopy may be obtained
with special CT imaging to evaluate the proximal colon. A baseline carcinoembryonic antigen (CEA) blood test is obtained. If this and enzymatic
liver function tests are elevated, CT or imaging scans of the abdomen and
liver may be obtained to evaluate metastatic spread. Perioperative antibiotics are given. A Foley catheter is inserted a er induction of anesthesia.
ANESTHESIA General anesthesia is preferred.
POSITION e patient is placed in a comfortable supine position and
rotated slightly toward the operator. A slight Trendelenburg position may
be used, although it can rarely lead to lower extremity compartment syndrome. If the colon tumor or process is in the lower le colon or sigmoid
region, most surgeons will position the patient in a modi ed lithotomy
manner using Allen stirrups supporting the knees and ankles. is will
allow for prepping and draping of the rectal region for potential passage
of an EEA stapling device. e legs are spread and the knees elevated suf ciently to provide this access to the rectum but not so high or wide as to
interfere with the abdominal portion of the operation. If there is any doubt
as to the locations, lithotomy position is recommended.
OPERATIVE PREPARATION e skin is prepared in the routine manner.
INCISION AND EXPOSURE e operator stands on the patient’s le side.
A liberal midline incision is made centered below the level of the umbilicus.
e liver as well as other possible sites for metastasis are explored. e small
intestines are then packed away medially with warm, moist packs. A pack is
placed toward the pelvis and another along the lateral wall up to the spleen.
DETAILS OF PROCEDURE Precautions against possible spread of the tumor
should include limited manipulation of the growth. As soon as possible, the
tumor should be covered with gauze and its major blood supply clamped.
With the bowel at the point of the lesion held in the le hand, the lateral
peritoneal re ection of the mesocolon is incised close to the bowel except
in the region of the tumor over as wide an area as seems essential for its
free mobilization (figure 1). Following this, the bowel is retracted toward
the midline and the mesentery is freed from the posterior abdominal wall
by blunt gauze dissection. Troublesome bleeding may occur if the le spermatic or ovarian vein is torn and not ligated. e le ureter is identi ed
because it must not be drawn up with the mesentery of the intestine and
accidentally divided. A fan-shaped incision of su cient size is made so that
the entire le colic artery and vein down to their origins can be removed in
order to maximize removal of regional lymph nodes (figure 2). Some sur-
C, L E--E A
geons perform this division as soon as possible to minimize angiolymphatic
spread of tumor from manipulation and traction of the specimen. In this
technique, originally called “no touch,” it is essential that the surgeons have
already identi ed the le ureter as well as the inferior mesenteric and sigmoid vessels (see Anatomy Plate , Vessels and ). At least cm of margin from the gross border on either side of the lesion should be allowed. e
contents of the clamps applied to the mesentery are tied. e mesenteric
border of the bowel at the proposed site of resection is cleared of mesenteric
fat in preparation for the anastomosis (figure 3).
In most patients, the splenic exure of the colon is mobilized to avoid
an anastomosis under tension. is maneuver is easier and safer to accomplish if the midline incision is extended up to the xyphoid. is technique
is shown in figures 15, 16, and 17. Alternatively, the omentum may be
removed in its relatively avascular junction along the le colon until the
splenocolic region is reached. e descending le colon is then mobilized
superiorly along the extension of the lateral line of Toldt. By approaching
both ends toward the middle, the sometimes di cult splenocolic omental
attachments are safely visualized and divided with minimal risk of splenic
injury.
Most surgeons would currently use a stapled closure for a le hemicolectomy or sigmoidectomy, as described in Plate . In either case, care
must be taken to divide distally below the rectosigmoid junction both to
avoid leaving sigmoid diverticula and because it allows better mobility of
the rectum and easier advancement of the EEA stapler. In cases where the
surgeon does not have access to staplers, the following hand-sewn method
is included. Paired crushing clamps of the Stone or similar type are placed
obliquely across the bowel above the lesion within cm of the limits of
the prepared mesentery (figure 4). e eld is walled o with gauze, and
the bowel is divided. A pair of noncrushing clamps is then applied to the
prepared area below the lesion, and the bowel is divided in a similar fashion. e ends of the large intestine are brought end to end to determine
whether the anastomosis can be carried out without tension. e clamps
are approximated and manipulated so that the posterior serosal surface of
the intestine is presented, to facilitate placement of a layer of interrupted
mattress silk sutures (figure 5). e mesenteric border should be free
of fat to achieve accurate approximation of the serosa. e sutures at the
angles are not cut and are utilized for traction (figure 6).
Enterostomy clamps are placed several centimeters from the crushing
clamps, and the crushing clamps are removed (figure 6). e portions
of excessive bowel that were beyond the clamps may be excised. e eld
is completely walled o with moist, sterile gauze packs, and a direct open
anastomosis is carried out. e mucosa is approximated with a continuous
lock suture on an atraumatic needle starting in the middle of the posterior
layer (figure 7). At the angle, the lock suture is changed to one of the Connell type to ensure inversion of the angle and the anterior mucosa (figures 8
and 9). A second continuous suture is started adjacent to the rst one and
is carried out in a similar fashion (figure 10). A er the mucosa has been
accurately approximated, the two continuous sutures, A and B, are tied with
the knot on the inside (figure 11). A layer of interrupted silk sutures
or nonabsorbable sutures is utilized to approximate the anterior serosal
layer. Particular attention is given to either angle to ensure accurate and
secure approximation.
Alternative techniques for colon anastomoses include the use of single
layer of delayed absorbable interrupted sutures with knots within the lumen
and the use of stapling instruments. e latter technique is shown in Plate ,
Colon Anastomoses, Stapled.
CONTINUES
148
Tumor
3
1
Incision in
parietal peritoneum
Incision
Tumor
2
Involved nodes
Left
colic artery
Sigmoid artery
Posterior
serosal sutures
5
4
A
7
Posterior
mucosal suture
10
6
Angle suture
Crushed margin
Scudder clamp
9
8
B
Anterior
11
A
B
mucosal suture
A
B
149
PLATE
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66
DETAILS OF PROCEDURE Following the approximation of the
mucosal layer, all contaminated instruments are discarded. e eld is covered
with fresh moist gauze sponges and towels. It is desirable for the members of
the surgical team to change gloves. e anastomosis is further reinforced by an
anterior serosal layer of interrupted silk sutures (figure 12). It is sometimes advisable to reinforce the mesenteric angle with one or two additional
mattress sutures. Any remaining opening of the mesentery is then closed
with interrupted sutures of ne silk. If there is a great deal of fat in the mesentery, which tends to hide the location of blood vessels, it is unwise to pass
a needle blindly through it lest a hematoma form between the leaves of the
mesentery. It is safer to grasp the peritoneal margins of the mesentery with
small, pointed clamps and e ect a closure by simple ligation of their contents.
Finally, adequacy of the blood supply to the site of the anastomosis should be
inspected. Active, pulsating vessels should be present adjacent to the anastomosis on both sides (figure 13). If the blood supply appears to be interfered
with and the color of the bowel is altered, it is better to resect the anastomosis
rather than risk leakage and potentially fatal peritonitis. e patency of the
stoma is carefully tested by compression between the thumb and index nger
(figure 14). It is usually possible to obtain a two- nger stoma.
To ensure easy approximation of the open ends of the large bowel, especially if the lesion is located near the splenic exure, it is necessary to free
the intestine from adjacent structures. e abdominal incision may have
to be extended up to the costal margin, since exposure of the uppermost
portion of the splenic exure may be di cult. A er the relatively avascular peritoneal attachments to the descending colon have been divided, it
is necessary to free the splenic exure from the diaphragm, spleen, and
stomach. e splenocolic ligament is divided between curved clamps, and
the contents are ligated to avoid possible injury to the spleen, with troublesome hemorrhage (figure 15). Following this, a pair of curved clamps
is applied to the gastrocolic ligament for the necessary distance required
to mobilize the bowel or remove su cient intestine beyond the growth.
Sometimes, in the presence of growths in this area, it is necessary to carry
C, L E--E A
the division adjacent to the greater curvature of the stomach. e surgeon
should not hesitate to remove a portion of the le gastroepiploic artery, if
indicated, since the stomach has such a good collateral blood supply. In
some instances, a true phrenocolic ligament can be developed, which must
be divided to free the splenic exure (figure 16).
If it is necessary to free a portion of the transverse colon, the omentum
may be freed from the bowel by incising its avascular attachments adjacent
to the colon (figure 17; see also Plate ). In some instances, omentum
may be involved with the growth, and it may be desirable to remove all or
part of it. e splenic exure is re ected medially following the division of
its attachments, and care is taken to avoid the kidney and the underlying
ureter. It is usually necessary to divide a portion of the transverse mesocolon (figure 18). is should be done carefully, taking into consideration
possible injury to the underlying jejunum in the region of the ligament
of Treitz. e large inferior mesenteric vein will also require division and
double ligation as it dips down under the inferior margin of the body of the
pancreas to join the splenic vein. e bowel is freed of all fatty attachments
at the site selected for anastomosis. Noncrushing clamps are applied, and
the bowel is divided (figure 19). Arterial pulsations in the mesentery on
both sides should be veri ed. e anastomosis is carried out as previously
described. If it becomes necessary to ligate the middle colic artery, the entire
transverse colon, including the hepatic and splenic exures, may need to be
resected to ensure an adequate blood supply at the site of anastomosis. In
this situation the viability of the colon depends upon the right colic artery
on one side and the le colic artery on the other.
CLOSURE e closure is made in the usual manner.
POSTOPERATIVE CARE e patient is encouraged to cough, sit up, and
ambulate as soon as possible. e nasogastric tube provides decompression
until bowel activity returns, usually on the rst or second day a er surgery.
Oral intake of clear liquids is begun and advanced as tolerated, whereupon
intravenous hydration and electrolytes are discontinued. ■
150
12
Anterior
serosal sutures
Resection for High Lesion
13
14
Testing patency
of stoma
Approximatd mesentery
15
Splenocolic
ligament
Lesion
16
Edge of
peritoneum
Phrenocolic
ligament
Omentum
19
Stomach
17
Spleen
Inferior
taenia
Transverse
mesocolon
Branch of middle
colic artery
Omentum
18
Branch of middle
colic artery
151
PLATE
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67
INDICATIONS Laparoscopic resection of the colon is most commonly indi-
cated for benign colon conditions such as chronic diverticulitis and large
polyps that are not amendable to removal during colonoscopy. e laparoscopic approach is being used with increasing frequency for carcinoma. In
general this approach is not recommended in patients with emergency conditions such as obstruction, perforation, or massive bleeding.
PREOPERATIVE PREPARATION For patients having surgery for pol-
yps and occult neoplasms it is essential to have the lesion tattooed during
colonoscopy or localized by a preoperative barium enema. Identi cation
of the tumor during laparoscopy is usually di cult. e use of intraoperative colonoscopy is di cult during laparoscopic procedures hence accurate
preoperative localization is necessary. e patient should receive a standard
mechanical bowel preparation and prophylactic antibiotics are administered
within one hour of the incision and are to be discontinued within hours
of surgery. Subcutaneous heparin is administered and sequential compression devices are placed for prevention of venous thromoembolism.
INCISION AND EXPOSURE e setup is similar to the laparoscopic right
colectomy. However, the surgeon and camera operator stand on the patient’s
right and the rst assistant on the patient’s le (figure 1). e surgeon
and camera operator may switch places during the procedure to facilitate
exposure and operating angles. e surgeon moves between the legs during
portions of the operation, in particular during the creation of the colorectal
anastomosis. e port placement is the same as the right colectomy except
C, L L
that the upper abdominal -mm trocar is the right upper quadrant in the
midclavicular line (figure 2a and 2b). is port may facilitate mobilization of the splenic exure (figure 3). figure 2b shows an alternative port
placement.
DETAILS OF PROCEDURE For the initial mobilization of the sigmoid
colon, the patient is rotated to the right. e sigmoid colon is grasped with
an atraumatic forceps and retracted medially. e peritoneal attachments
are then divided using the ultrasonic shears and blunt dissection (figure 3).
Care is taken to identify the ureter and avoid ureteral injury. e peritoneal attachment is divided up to the splenic exure. is is facilitated by
the rst assistant or surgeon providing counter-traction of the colon. As
the dissection nears the splenic exure, it is best to stay underneath the
omentum and develop a plan between the omentum and the splenic exure (figure 4). Dissection between the omentum and spleen can lead to
splenic injury. e omentum is separated for a variable distance along the
transverse colon depending on the amount of colon to be removed and
the amount of mobility that will be necessary to complete a tension-free
anastomosis. Mobilization of the splenic exure and the transverse colon
may be facilitated by a reverse Trendelenburg position. e proximal rectum is mobilized (figure 5). In figure 5, the orientation of the dissection is rotated so the head is to the reader’s le and the foot to the right.
e line of mesenteric incision is shown. e surgeon needs to know the
anticipated position of the le and right ureter.
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