Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_788_Библиотеки_им_академика_М_И_Перельмана.pdf
328
10.6 Laparoscopic Lysis of Adhesions
Fig. 10.6.15 Lysis of adhesions. Complication: Perforation of the small
intestine with the laparoscope/camera trocar.
Although the pneumoperitoneum has been successfully established in
this patient, the surgeon has advanced the laparoscope/camera trocar
directly into an adherent intestinal loop. The laparoscope shows the typical intraluminal image of the mucosa of the small intestine (insert).
Prevention: As described in Figs. 10.6.4 and 10.6.5, hold the index finger
against the tube of the trocar when advancing the tapered tip of the trocar into the abdominal cavity. Verify the correct position of the progress
of the trocar through the laparoscope (retracted 1−2 cm into the trocar
sleeve).
Corrective action: Immediately discontinue insufflation. Further procedure
depends on the surgeon’s level of experience. In case of doubt, convert to
laparotomy. See chapter 2.3 for sutrue technique. Placement of a large
drain and antibiotic therapy are indicated in any case.
Late Complications
Mechanical Ileus
Corrective action: Laparoscopic exploration of the peritoneal
cavity and diagnosis. Perform lysis of adhesions. Therapeutic laparoscopy or laparotomy.
Note: Laparoscopy is contraindicated in the presence of severely
enlarged and distended intestinal loops with thinning of the intestinal wall.
Bibliography
Attwood SEA, Caldwell MTP, Marks P, McDermott M. Adhesions after laparo-
scopic inguinal hernia repair: a comparison of extra- versus intra-peri-
toneal placement of a polypropylene mesh in an animal model. Surg. En-
dosc. 1994; 8:777.
Bubuisson, JB, Aubriot FX, Cardone V. Laparoscopic salpingectomy for tubal
pregnancy. Fertil. Steril. 1987; 47:225.
Cuschieri A. Diagnostische Laparoskopie und laparoskopische Adhäsiolyse.
In Buess G, Cuschieri A, Périssat J. Operationslehre der endoskopischen
Chirurgie, 1/93. Berlin: Springer; 1993.
Diamond MP, Daniell JF, Feste J, Surrey MW. Adhesion reformation and de
novo adhesion formation after reproductive pelvic surgery. Fertil. Steril.
1987; 47:864.
Diamond MP, Daniell JF, Martin DC, Feste J, Vaughn WK. Tubal patency and
pelvic adhesions at early second-look laparoscopy following intraabdominal use of the carbon dioxide laser: initial report of the intraabdominal
laser study group. Fertil. Steril. 1984; 42:717.
Fayez, JA, Schneider PJ. Prevention of pelvic adhesion formation by different
modalities of treatment. Amer. J. Obstet. Gynecol. 1987; 157:1184.
Filmar S, Gomel V, McComb PF. Operative laparoscopy versus open abdomi-
nal surgery: a comparative study on postoperative adhesion formation in
the rat model. Fertil. Steril. 1987; 48:486.
François Y, Mouret P, Tomaoglu K, Vignal J. Postoperative adhesive peritoneal
disease: laparoscopic treatment. Surg. Endosc. 1994; 8:781.
Freys SM, Fuchs KH, Heimbrucher J, Thiede A. Laparoscopic adhesiolysis.
Surg. Endosc. 1994; 8:1208.
Hauy JP, Madelenat P, Bouquet de la Jolinière J, Dubuisson JB. Chirurgie per
coelioscopique des cystes ovariens. Indications et limites à propos d’une
série de 169 kystes. J. Gynecol. Obstet. Biol. Reprod. 1990; 19:209.
Jansen RP. Failure of intraperitoneal adjuncts to improve the outcome of pel-
vic operations in young women. Amer. J. Obstet. Gynecol. 1985; 153:363.
Jansen RP. Early laparoscopy after pelvic operations to prevent adhesions:
safety and efficacy. Fertil. Steril. 1988; 49:26.
Jansen RP. Failure of peritoneal irrigation with heparin during pelvic opera-
tions upon young women to reduce adhesions. Surg. Gynecol. Obstet.
1988; 166:154.
Kolecki RV, Golub RM, Sigel B, Machi J, Kitamura H, Hosokawa T, Justin J,
Schwartz J, Zaren HA. Accuracy of viscera slide detection of abdominal
wall adhesions by ultrasound. Surg. Endosc. 1994; 8:871.
Krinsky AH, Haseltine FP, DeCheney A. Peritoneal fluid accumulation with
dextran 70 instilled at time of laparoscopy. Fertil. Steril. 1984; 41.647.
Larsson B, Lalos O, Marsk L, Tronstd SE, Bygdeman M. Effect of intraperi-
toneal instillation of 32% dextran 70 on postoperative adhesion formation
after tubal surgery. Acta Obstet. Gynecol. Scand. 1985; 64:437.
Luciano AA, Maier DB, Koch EI, Nulsen JC, Whitman GF. A comparative study
of postoperative adhesions following laser surgery by laparoscopy versus
laparotomy in the rabbit model. Obstet. Gynecol. 1989; 74:220.
Mage G, Pouly JL, Bouquet de la Jolinière J, Chabrand S, Riouallon A. A pre-
operative classification to predict the intrauterine and ectopic pregnancy
rates after distal tubal microsurgery. Fertil. Steril. 1986; 46:807.
McLaughlin DS, Evaluation of adhesion reformation by early secondlook la-
paroscopy following microlaser ovarian wedge resection. Fertil. Steril.
1984; 42:531.
McLaughlin DS, Diamond MP, Daniell JF, Martin DC. Laparoscopic assess-
ment of ovarian healing following CO
gilon. Microsurg. 1987; 8:8.
Nezhat CR, Nezhat FR, Metzger DA, Luciano AA. Adhesion reformation after
reproductive surgery by videolaseroscopy. Fertil. Steril. 1990; 53:1008.
Nezhat CR, Winer WK, Nezhat FR. Laparoscopic removal of dermoid cysts.
Obstet. Gynecol. 1989; 73:278.
Riedel HH, Haag GM. Spätfolgen nach Appendektomie unter besonderer
Berücksichtigung von Unterbauchverwachsungen, chronischen Schmerzen und Sterilität. Zentralbl. Gynäkol. 1989; 111:1101.
Schieder K, Kolbl H, Dadak C, Janisch H. Die Früh-Second-Look-Laparoskopie
nach sterilitätschirurgischen Eingriffen mit dem CO
heilk. 1987; 47:721.
Trimbos KTC, Trimbos JB, van Hall EV. Adhesion formation after tubal
surgery: results of the eighth-day laparoscopy in 188 patients. Fertil.
Steril. 1985; 43:395.
Tulandi T. Adhesion reformation after reproductive surgery with and
without the carbon dioxide laser. Fertil. Steril. 1987; 47:704.
laser microsurgery: Vicryl vs. Sur-
2
. Geburtsh. Frauen-
2
10.7 Creation of a Loop Ileostomy
F. Köc kerling
329
Goals and Methods
There are two procedures for complete temporary fecal diver-
sion: the double-lumen colostomy of the right transverse colon
and the loop ileostomy of the terminal ileum. The advantages of
a temporary stoma of the ileum are a lower incidence of infection, easier rapid mobilization of an ileal loop, a stronger bowel
wall and better vascular supply, and improved healing of the
anastomosis after bowel continuity has been restored. An additional argument in favor of fecal diversion through a loop
ileostomy to protect the repair and healing of defects in the anal
and rectal region is the fact that a double-lumen transverse
colostomy often does not completely block the passage of fecal
material. In order to eliminate the risk of fecal contamination of
anal and rectal repairs by using a colostomy, the distal segment
of the colon must be closed and the ostium of the proximal segment sutured to the skin. Restoration of normal anatomy following such a procedure is more complicated and associated
with a higher rate of morbidity than is the repair of a loop
ileostomy.
A loop ileostomy performed through a small transrectal incision
in the right lower abdomen has two disadvantages: 1. It may be
difficult to identify the final loop of ileum. 2. Even with a rela-
tively small incision, creating the loop ileostomy by laparotomy
poses the problem of attaching a stoma bag in the vicinity of a
wound. For these reasons, we previously felt that a midline laparotomy and a separate circular incision in the right lower ab-
domen was necessary to safely achieve the loop ileostomy.
Creating the loop ileostomy by laparoscopy spares the patient
the midline laparatomy.
Indications
Surgical Risks and Informing the Patient
Possible complications are associated with establishing the
pneumoperitoneum, injuries to internal organs and major
vascular structures caused by insertion of the Veress needle and
blind percutaneous insertion of the optical trocar, and possible
effects of pneumoperitoneum on cardiovascular and respiratory
systems. Other complications include those resulting from
placement of the trocar in the abdominal wall, such as bleeding
from epigastric vessels, incarceration of bowel in the trocar incisions, and infection. Specific complications of laparoscopic loop
ileostomy include mesenteric bleeding resulting from the attempt to loop the intestine and injuries to the intestine from
grasping it with instruments, using electrocautery, and when
drawing the small bowel into the trocar. The patient must also
be informed of the possible need to convert to an open procedure.
Special Preparations
The most favorable location for the loop ileostomy should be
marked on the abdominal wall of the seated and standing
patient by an experienced stoma specialist or by the surgeon.
The patient should become familiar with the use of a stoma bag
in the marked position. We recommend preoperative oral administration of 4−5 l of an isotonic bowel preparation. Addition
of 50g of high-molecular-weight dextran per liter can reduce
fluid absorption to about 2 l. Even elderly patients without disturbed bowel passage usually tolerate this oral bowel preparation without complications; the standard colon preparation
previously used in patients with colorectal disorders is only required if there is an obstructing carcinoma.
An indication for the laparoscopic creation of a loop ileostomy
exists when temporary complete fecal diversion is the only in-
traabdominal procedure necessary. Possible indications include
proctologic disorders such as rectovaginal fistulas, perineal impalement injuries involving the rectum, complicated anal fistulas that do not respond to treatment, or anastomotic breakdown
following transanal full-thickness rectal wall excision. In the
presence of stenosis due to inoperable colorectal carcinoma, laparoscopic loop ileostomy is an option only if insufficiency of
the ileocecal valve has been demonstrated.
Contraindications
In the presence of a functioning ileocecal valve and stenosis due
to a colorectal disorder, a double-lumen colostomy must be
created. Adhesions are to be expected if the patient has had pre-
vious major abdominal surgery. In such cases, a conventional
procedure is indicated. If systemic cardiopulmonary risk factors
are present, establishing a pneumoperitoneum is contradicted.
Here, the surgeon should proceed with a conventional midline
laparotomy.
Anesthesia
General anesthesia.
Patient Positioning
(See Fig. 10.7.1).
Position of the Operating Team
(Fig. 10.7.2).
Trocar Placement
(Fig. 10.7.3).
330
10.7 Creation of a Loop Ileostomy
Fig. 10.7.1 Creation of a loop ileostomy. Patient positioning.
Since laparoscopic loop ileostomy is most frequently indicated in the presence of proctologic disorders, the patient is placed on an operating table
for rectal surgery. Placing the patient in an extreme reverse Trendelenburg position of up to 40° shifts the small intestine into the upper abdomen. The patient must be securely fastened to the operating table. To
eliminate the risk of compartment syndrome, venous stasis, and compressive neuropathies, place the patient’s knees and calves in thick foam
rubber cushions and venodyne boots. Position the left arm alongside the
body, and extend the right arm to provide access for anesthesia.
Monitor
Insufflator
HF-Generator
Assistant holding laparoscope
Surgeon
Aspirator/irrigator set
Assistant
Fig. 10.7.2 Creation of a loop ileostomy. Position of the operating team.
The surgeon stands on the patient’s left and looks past the ileocecal region to the monitor, which stands next to the patient’s extended right
arm. The assistant holding the laparoscope stands at the patient’s draped
Instrument table
left shoulder; the patient’s left arm is positioned alongside the body. A
second assistant stands to the right of the operating table, looking diagonally at the monitor. The electrocautery unit and the aspirator/irrigator
set can be positioned more or less as desired.
Step-by-Step Procedure
1. Insert the trocars under laparoscopic visualization.
2. Explore the abdomen; identify the terminal ileum and the
ileocecal valve.
3. Introduce a retaining tape fitted onto a straight needle,
through the 33-mm trocar.
4. Incise the peritoneum over the mesenteric attachment to the
bowel approximately 40 cm proximal to the ileocecal valve.
5. Drive the needle through the tissue at the peritoneal incision
and pull the retaining tape through the tissue.
6. Pull the intestinal loop into the 33-mm trocar.
7. Using a swab, verify that the afferent loop lies inferiorly and
the efferent loop lies superiorly.
8. Exteriorize the intestinal loop while letting down the
pneumoperitoneum and removing the trocar.
9. With the exteriorized loop supported by an elastic band, su-
ture it so as to create a penis-shaped protection.
10. Remove the trocars and close the wound in layers.
Trocar Placement
T4
331
T1
T2
T3
Operative Technique
Fig. 10.7.4 Creation of a loop ileostomy. Incising the mesentery.
Carefully expose the terminal loop of ileum and the ileocecal region using
a swab (T3). To do this, the patient must be placed in a Trendelenburg
position so that the rest of the small intestine is shifted into the upper ab-
domen to provide sufficient working space. The ileal loop is displayed so
as to provide broad exposure of the last 40 cm of ileum throughout the
procedure. The relationship of the chosen ileal loop to the ileocecal region
and the cecum must be clear in every stage of the operation to eliminate
the risk of twisting the loop when withdrawing it through the abdominal
wall. Incise the mesentery close to the intestine on both sides using a
hooked electrode or electrocautery scissors (T2).
1 Vermiform appendix
2 Cecum
3 Ileocecal valve
4 Terminal ileum
Fig. 10.7.3 Creation of a loop ileostomy. Trocar placement.
To ensure sufficient exposure of the ileocecal region and the small intestine, place the trocar for the laparoscope in the patient’s left upper abdomen (T1). Insert a 33-mm retrieval trocar at the marked optimal site of
the loop ileostomy (T4). Remove a circular patch of skin, incise the fascia,
and after establishing the pneumoperitoneum advance the 33-mm extractor trocar into the abdominal wall with the screw under laparoscopic
inspection. Place one or two additional instrument trocars (10 mm and
5 mm; T2 and T3) so that they form a semicircle around the ileocecal region with the optical trocar. Experienced surgeons may dispense with the
trocar in the left middle abdomen and perform the loop ileostomy
through only the 10-mm instrument trocar and the retrieval trocar.
Open laparoscopy is an alternative.
2
1
.
4
.
.
.
T3
3
T2
332
10.7 Creation of a Loop Ileostomy
T4
T4
T2
Fig. 10.7.5 Creation of a loop ileostomy. Mobilizing the small intestine.
Introduce a retaining tape fitted onto a straight needle into the abdomen
through the 33-mm retrieval trocar (T4). Grasp the straight needle from
the left with a needle holder (T2). Drive the needle through the
mesentery at the incision on the mesentery near the intestinal wall. Pull
the needle through the mesentery hole and around the small intestine to
loop it with the retaining tape. Then hold the needle with a grasping in-
strument and withdraw it through the retrieval trocar so that both ends of
the retaining band are now outside the abdomen.
3
.
.
1
Fig. 10.7.6 Creation of a loop ileostomy. Tightening the retaining band.
Now pull the retaining band to draw the intestinal loop into the retrieval
trocar (T4) or out through the abdominal wall. This should be possible
without placing tension on the intestine.
Note: Make sure that the afferent loop comes to rest in an inferior position
while the efferent loop remains superiorly.
1 Afferent intestinal loop
2 Efferent intestinal loop
3 Ascending colon
.
2
Fig. 10.7.7 Creation of a loop ileostomy. Exteriorizing the loop of the
small intestine.
Slowly let the pneumoperitoneum down and carefully withdraw the retrieval trocar together with the mobilized intestinal loop, drawing the
loop out of the abdomen. Replace the retaining tape with a rubber band
or an elastic bridge. Before opening and suturing the intestine, verify the
proper orientation of the afferent and efferent loops with respect to the
ileocecal region via laparoscopy. To do this, establish a reduced-pressure
(8 mm Hg) pneumoperitoneum. Once the components are properly positioned, incise the exteriorized loop transversely and superiorly. Next,
evert the afferent loop with clamps and suture it so as to create a nippleshaped cone. Secure this cone with interrupted sutures that do not penetrate the mucosa; sutures should encompass the seromuscular tissue of
the afferent loop to secure the everted segment in this position. A stoma
bag may be used with the loop ileostomy immediately.
1 Afferent loop of the small intestine
2 Efferent loop of the small intestine
3 Ascending colon
Bibliography
333
Complications
Intraoperative Complications
In addition to the typical complications associated with establishing the pneumoperitoneum and placing the trocars, specific
intraoperative difficulties can occur. Attempting to pull on the
intestinal loop with the rubber band can produce bleeding in
the mesentery and cause injury to the ileum. If the bleeding is
minor and injuries do not compromise the integrity of the in-
testinal lumen, they can usually be repaired after moving the
loop through the abdominal wall. Major bleeding and serious
injury that compromises the wall of the intestine require imme-
diate laparotomy. If the intestine is positioned improperly and
the mesentery is twisted, ischemia of the exteriorized loop can
occur.
Corrective action: After re-establishing the pneumoperitoneum
and repositioning the intestinal loop, verify that the blood
supply to the loop has been restored and compression of the
mesentery eliminated. If the afferent loop lies in a lower posi-
tion, the efferent one in a superior position, and ischemia still
persists, then the marginal vascular supply may be compromised.
Corrective action: Remove and reposition the rubber band.
Postoperative Complications
The laparoscopic approach reduces the incidence of late complications. Preservation of the integrity of the abdominal wall,
elimination of an additional incision, and a loop ileostomy performed with optimum visualization tend to prevent adhesions.
In this setting there should be a lower incidence of late complications.
Bibliography
Fasth S, Hulten L. Loop ileostomy; a superior diverting stoma in colorectal
surgery. Wld. J. Surg. 1984; 8:401.
Göhring U, Lehner B, Schlag P. Ileostomie versus Colostomie als passageres
Deviationsstoma unter dem Aspekt der Stomarückverlagerung. Chirurg
1988; 59:842.
Post S, Schürmann G, Herfarth C. Das Enterostoma bei Morbus Crohn.
Chirurg 1991; 62:306.
Reck T, Bin Dayna K, Schneider C, Gastinger I, Köckerling F. Die la-
paroskopische Anlage einer Loop-Ileostomie. MIC 1992; 1:118.
Schmidt CD, Hempel K. Maßnahmen zur Reduktion der Komplikationen bei
der Anus praeternaturalis-Rückverlagerung. Chirurg 1987; 58:252.
Wedell J, Meier zu Eissen J, Störmer J, Meier zu Eissen P. Die Morbidität und
Letalität des intraperitonealen Verschlusses der doppelläufigen Transversumfistel. Langenbecks Arch. Chir. 1982; 356:17.
Williams NS, Nasmyth DG, Jones D, Smith AH. De-functioning stomas: a pro-
spective controlled trial comparing loop ileostomy with loop transverse
colostomy. Brit. J. Surg. 1986; 73:566.
Winkler R. Stomatherapie. Stuttgart: Thieme; 1983.
Necrosis and retraction of the stoma represent serious compli-
cations. This usually is due to compression of the marginal
vascular supply with the retaining band, an excessively narrow
abdominal incision, or to suturing the loop under tension. It is
important to support the stoma on a flexible bridge. Any re-
operation should be performed via laparotomy.
Late Complications
− Prolapse.
− Stenosis.
− Retraction.
− Peristomal dermatitis.
− Peristomal hernia.
− Peristomal infection.
− Mechanical ileus due to internal impingement, adhesions, or
volvulus.
− Problems due to improper surgical technique.
334
11 . Laparoscopically-Assisted Large Bo w el Procedures
11.1 Creation of an Intestinal Stoma
G. Götz, A. Pier
Goals and Methods
A stoma is created to permit the discharge of bowel contents
and intestinal gas and to preserve or restore intestinal passage
and emptying. A stoma can be permanent or temporary.
The following procedures are available in conventional open
operations:
− Terminal colostomy (single-lumen), for example sigmoidostomy following excision of the rectum or temporary
colostomy of the descending colon in Hartmann’s operation
following sigmoidectomy for complicated diverticulitis.
− Temporary double-lumen colostomy (loop colostomy), for
example as a permanent stoma in the presence of an inoperable rectal carcinoma, or as a temporary transverse
colostomy in the course of a two or three stage sigmoidectomy.
− Terminal nipple ileostomy.
− Double-lumen permanent ileostomy.
− Double-lumen protective temporary ileostomy and as
special forms:
− Multiple enterostomies.
− Cecostomy.
− Appendicostomy.
− So-called continent stomas.
The following procedures are of interest in laparoscopic
surgery;
− Sigmoid colostomy.
− Transverse colostomy.
− Ileostomy (see chapter 10.7).
Of these procedures, the sigmoid colostomy and ileostomy lend
themselves best to laparoscopic procedures.
Surgical Risks and Patient Information
Complications are relatively rare when creating a stoma laparoscopically. In spite of this, the patient should be informed of
the possible need to convert to an open procedure.
Special Preparations
− The location of the stoma should be determined preoperatively with the patient standing, seated, and lying down.
The patient should practice the use of a stoma bag.
− Antibiotics.
− Gastric tube.
− Urinary catheter.
Anatomy
(See Figs. 11.1.1 and 11.1.2).
Anesthesia
General anesthesia.
Patient Positioning
(See Fig. 11.1.3).
Position of Operating Team
Indications
− Palliative procedures in the presence of incomplete mechanical ileus of the colon (large-bowel obstruction).
− Terminal sigmoid stoma following laparoscopically assisted
abdominoperineal excision or amputation of the rectum.
− Stoma of the ileum following laparoscopic proctocolectomy
and repair of anal and rectal injuries and of rectal-vaginal
fistulas.
Contraindications
− Anesthetic risks.
− Coagulation disorders that do not respond to treatment.
− Previous abdominal operations.
Two surgeons are required to create a stoma laparoscopically.
The first assistant guides the laparoscope and stands opposite
the surgeon. The surgeon stands opposite the respective section
of the bowel selected for the stoma. The operating room nurse
stands at the foot of the operating table with the instrument
tray.
The monitor should always be positioned in the surgeon’s field
of vision. A second monitor opposite the assistant is recommended. The light source and video documentation unit are
housed in the cabinet carrying the monitor. The electric generator, aspirator/irrigator set, and insufflator are on the patient’s
right. The position of the monitor can be varied according to
where the surgeon stands.
Side supports on the operating table are important. They permit
placing the patient in extreme lateral positions.
Position of Operating Team
335
1
2
3
Fig. 11.1.1 Creation of a double-lumen colostomy.
Schematic diagram of the sections of colon and tenia relationships used in
the various locations of stomas of the colon.
1 Cecum
2 Ascending colon
3 Right colic flexure or hepatic flexure
4 Transverse colon
5 Left colic flexure or splenic flexure
6 Descending colon
7 Sigmoid colon
8 Rectum
9 Free tenia
10 Omental tenia
11 Mesocolic tenia
Fig. 11.1.3 Creation of a double-lumen colostomy. Patient positioning.
Supine in Trendelenburg position. Lateral and shoulder supports on the
operating table may be of help.
4
5
Fig. 11.1.2 Creation of a double-lumen colostomy.
Schematic diagram of the transverse colon.
1 Transverse mesocolon
2 Mesocolic tenia
3 Omental tenia
4 Free tenia
5 Greater omentum
336
11.1 Creation of an Intestinal Stoma
Monitor
Assistant
Fig. 11.1.4 Creation of a
double-lumen colostomy. Positioning of the operating team
and equipment.
Electrocautery
unit
Aspirator/
irrigator set
Surgeon
Insufflator
Instrument
table
OR nurse
Trocar Placement
337
Trocar Placement
(Fig. 11.1.5).
Fig. 11.1.5 Creation of a double-lumen colostomy. Trocar placement.
The number and placement of the trocars depend on the expected findings. After insertion of the laparoscope/camera trocar and exploratory laparoscopy, the surgeon inserts the remaining trocars under laparoscopic
visualization. The location of the 20-mm instrument trocar depends on
the selected location of the colostomy. Here the mobilized segment of
the colon is grasped and exteriorized (see Fig. 11.1.9).
T1 10.5-mm laparoscope/camera trocar
T2 20-mm instrument trocar
T3 5.5-mm instrument trocar
Open trocar placement is an alternative.
T1
T2
T3
Step-by-Step Procedure
I Technical preparations
1. Adjust the electrocautery unit to a medium setting.
2. Connect the aspirator/irrigator set.
3. Start the recording unit.
II Establishing the pneumoperitoneum
1. Select pressure plateau according to patient’s size, age, and
weight (6−8 mm Hg for children; 10−14 mm Hg for adults).
2. Connect all equipment required for operation.
3. Make a skin incision about two finger breadth superior to the
umbilicus for the Veress needle and laparoscope/camera trocar.
4. Insert the Veress needle.
5. Perform safety tests: injection, aspiration, “slurp”, manometer,
and rotation tests.
6. Perform insufflation procedure.
III Laparoscopy
1. Insert laparoscope/camera trocar with tapered stylet using
Semm’s technique.
2. Explore the peritoneal cavity visually.
3. Insert the instrument trocars under laparoscopic visualization.
4. Determine the diagnosis and operative plan.
A Double-lumen colostomy
1. Assess the mobility of the sigmoid colon.
2. Separate the sigmoid colon from the lateral gutter.
3. Open a window in the mesosigmoid.
4. Elevate the sigmoid colon on a rubber band and withdraw the
band through the 20-mm trocar.
5. Exteriorize the intestinal loop after removing the 20-mm trocar
over the rubber band and enlarging the incision if necessary.
6. Create the stoma.
B Terminal colostomy (e. g., incontinence resection)
1. Assess the mobility of the sigmoid colon.
2. Continue with the intraabdominal steps of an abdominoperineal excision/amputation of the rectum (see chapter 12.5).
3. Transect the rectum using a GIA stapler.
4. Aspirate the rectosacral pouch.
5. Create a terminal stoma.