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11.3 Resection of Sigmoid Colon
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Bibliography
Bland KI, Polk HC. Radical or Extended Right Hemicolectomy for Cancer. In
Nyhus, Baker, eds. Mastery of Surgery. Boston/Toronto/London: Little,
Brown and Company; 1992.
Franklin jr. MI, Laparoscopic Surgery of the Colon and Rectum. In Arregui,
Fitzgibbons jr., Katkhouda, McKernan, Reich, eds. Principles of Laparoscopic Surgery. New York: Springer-Verlag; 1995.
Lointier PH. Laparoscopically Assisted Total Colectomy. In Steichen, Welter,
eds. Minimally Invasive Surgery. St. Louis, Missouri: Quality Medical Publishing, Inc.; 1994.
Steichen FM, Ravitch MM. Stapling in Surgery. Chicago/London: Year Book
Medical Publishers, Inc.; 1984.
Fig. 11.2.16 Step-by-step procedure:
1 Elevate right colon and mesocolon.
2, 3 Incise peritoneum in right gutter, from cecum to include hepatic flexure.
4 Transect terminal ileum and proximal transverse colon.
5 Incise root of right mesocolon and insure vessel hemostasis.
6 Incision in RUQ and removal of specimen in plastic bag.
7 Side-to-side GIA ileo-colostomy.
8 Closure of GIA entry site, excision of excess tissue and creation of
functional end-to-end anastomosis.
11.3 Resection of Sigmoid Colon
F. Köckerling, I. Gastinger
Goals and Methods
Prerequisites for this procedure include the development of the
laparoscopically useable linear stapler and the laparoscopic
pursestring suture clamp. These advances provided solutions to
the danger of peritoneal soiling and the need for oncologically
sound excisions with intracorporeal anastomosis of the open
large bowel.
The laparoscopically assisted sigmoid resection with extraabdo-
minal or extracorporeal anastomosis is still advisable as an interim solution under certain circumstances. We prefer the
completely intracorporeal procedure involving resection of the
closed sigmoid colon.
The sigmoid specimen is removed in a waterproof, impermeable sterile bag using an extractor or retrieval trocar with the appropriate diameter. To perform the resection and anastomosis
properly requires the use of linear and circular staplers in combination with a laparoscopic pursestring suture. Laparoscopic
colon surgery requires the expertise of laparoscopic surgery,
combined with an understanding of the potential technical
facilities provided by mechanical sutures and a solid base of
open colon procedures.
Indications
Benign disorders of the sigmoid colon can be managed laparoscopically. These include:
− Chronic diverticulitis without abscess formation and interloop infections.
− Endometriosis implants.
− Extensive, broad-based adenomas that cannot be removed
by an intraluminal procedure.
− Elongated sigmoid colon where laparoscopic rectopexy is indicated.
− Laparoscopic resection of sigmoid carcinomas is currently
indicated only in exceptional cases. Some carcinomas may
be suitable for this treatment if the depth of wall penetration
can be ascertained. Any other situations should be reserved
for clinical studies conducted under well defined conditions
of scientific research and ethical behavior.
Contraindications
− Extensive previous abdominal surgery with adhesions.
− Peritonitis.
− Septic complications in the presence of inflammation.
− Advanced cancer.
− General and anesthetic contraindications to laparoscopic
surgery (see chapter 2.5).
Assistant holding the laparoscope
Aspirator/
irrigator set
Surgeon
Electrocautery
unit
Assistant
Instrument table
Monitor
Insufflator
Surgeon
Patient Positioning and Position of the Operating Team
Surgical Risks and Patient Information
The patient should always be informed of possible complications of a colorectal procedure including breakdown of the
anastomosis, severe septic complications, bleeding, the possibility that colostomy might be indicated, and possible injury to
the ureter. In addition, discuss the usual risks of laparoscopic
surgery including bleeding, perforations due to placement of
trocars, and subcutaneous emphysema. The patient should be
aware that conversion to an open procedure may become necessary. Inform the patient of your specific skill and experience.
349
Special Preparations
Administer 4−5 l of a bowel preparation with GOLYTELY on the
evening before operation. Even elderly patients will tolerate
oral bowel preparation including antibiotics well in the absence
of disturbed intestinal motility. Care should be exercised in
patients with cardiac insufficiency.
Anesthesia
General anesthesia.
Patient Positioning and Position of the
Operating Team
(See Figs. 11.3.1 and 11.3.2).
Fig. 11.3.2 Resection of sigmoid
colon. Position of the operating
team and equipment.
Performing sigmoid resection re-
quires two equally experienced
surgeons, who stand on either
side of the patient. Depending on
the situation, the surgeons work
with one or both hands. Since
there is no room next to the surgeons for the assistant holding the
laparoscope, he or she stands at
the patient’s draped left shoulder.
The patient’s right arm is extended to provide vascular access
for anesthesia. A second assistant
stands next to the patient’s right
leg, and the operating room nurse
stands next to the patient’s left
leg with the instrument table. The
monitor, insufflator, and light
source are located between the
patient’s abducted legs. The elec-
trocautery unit and the aspirator/
irrigator set can be positioned
more or less as desired.
Fig. 11.3.1 Resection of sigmoid colon. Patient positioning.
For laparoscopic sigmoid resection, place the patient on an operating
table, equipped for rectal surgery, in an extreme Trendelenburg position
(inclined 30−40°). Shoulder and pelvis supports are used to maintain the
patient on the table and permit inclining the operating table in any plane
during the procedure. To minimize the risk of compartment syndrome
and compressive neuropathies, enclose the patient’s knees and calves in
thick foam rubber cushions and intermittent compression devices to
avoid venous stasis.
350
Fig. 11.3.3 Resection of sigmoid colon. Trocar placement.
T1 10/12-mm laparoscope/camera trocar: slightly superior to the
umbilicus and left of the midline
T2−5 10/12-mm instrument trocars: forming a semicircle with the la-
paroscope/camera trocar above the pelvis.
11.3 Resection of Sigmoid Colon
T1
T2
T3
T4
T5
Trocar Placement
Place the 12-mm laparoscope/camera trocar in the left upper
abdomen a few centimeters superior to the umbilicus and to the
left of the midline to maintain sufficient distance to the pelvis
and avoid insufflating the round ligament of the liver
(Fig. 11.3.3). Place two 12-mm instrument trocars each in the
left and right upper abdomen to form a semicircular pattern
with the laparoscope/camera trocar above the pelvis. To remove
the resected sigmoid segment, the right inferior 12-mm instrument trocar is replaced with a 33-mm extractor (retrieval) trocar equipped with an expansion mechanism.
Open trocar placement is an alternative.
Step-by-Step Procedure
1. Insert the trocars under laparoscopic visualization.
2. Explore the abdomen; determine the diagnosis and operative
plan. Perform intraoperative colonoscopy if necessary.
3. Incise the white line of Toldt to separate the sigmoid colon
from the lateral abdominal wall.
4. Expose the left ureter.
5. Mobilize the left colic flexure.
6. Dissect the mesosigmoid and mesocolon off Gerota’s fascia
as far medial as the aorta.
7. Using a linear stapler or clips, divide and ligate the inferior
mesenteric artery at its origin.
8. Transect the sigmoid colon and mesosigmoid en bloc proximally and distally using a linear stapler.
9. Replace one of the instrument trocars with an extractor or re-
trieval trocar. Introduce an impermeable waterproof sterile
bag into the abdomen through this trocar.
10. Place the resected sigmoid specimen (sealed at its proximal
and distal ends) into the bag.
11. Remove the resected sigmoid in the sterile bag into the extractor/retrieval trocar through the corresponding port site.
12. Place the laparoscopic pursestring suture clamp diagonally
onto the antimesenteric corner of the proximal end of the
colon.
13. Advance the straight needles and swedged on sutures into
and out of the pursestring suture clamp.
14. Resect the triangular end of the proximal colon between the
proximal row of staples and the pursestring instrument.
15. Introduce the circular stapler with anvil into the abdomen
through the extractor trocar in an airtight maneuver.
16. Holding the proximal end of the colon open, place the anvil of
the circular stapler into the colon through its pursestring end.
17. Close the pursestring suture around the central rod of the
anvil using a knot pusher.
18. Insert the circular stapler with cartridge through the anus and
penetrate the distal row of staples with the central tapered
shaft.
19. Join anvil and cartridge, close the circular stapler, and
complete the anastomosis.
Operative Technique
Fig. 11.3.4a, b Resection of sigmoid colon. Localizing the tumor via
colonoscopy.
a If the sigmoid colon lesion is neither visible nor instrumentally pal-
pable by laparoscopy, intraoperative colonoscopy is performed after
placement of the trocars and exploratory laparoscopy. If a video
colonoscope is available, the endoscopist and the surgical team can localize the focus of the disorder together. For better orientation during
the procedure, place several metal clips on both sides of a neighboring
epiploic appendix (through T3). Insert: colonoscopic view of a small
sigmoid carcinoma.
b Plane of dissection and clips marking the tumor.
1 Endoscopic view of a small sigmoid carcinoma
2 Epiploic appendix of the sigmoid colon
3 Plane of dissection in sigmoid resection
Trocar Placement
T3
a
2
351
1
Fig. 11.3.5 Resection of sigmoid colon. Mobilizing the left colic flexure.
After dividing the embryonic adhesions to the lateral abdominal wall and
mobilizing the bowel along Gerota’s fascia (as in laparoscopic abdominoperineal resection and in rectopexy), dissect the left colic flexure. To do
this, incline the operating table to the right and temporarily take the
patient out of the extreme Trendelenburg position. This exposes the left
colic flexure. Retract the flexure to the right with a swab (T2) to place ten-
sion on Lord’s ligaments to the spleen. Divide these ligaments with
hooked-electrode electrocautery (T4) or electrocautery scissors.
1 Spleen
2 Greater omentum
3 Stomach
3
b
T2
T4
2
1
3
352
T4
11.3 Resection of Sigmoid Colon
T5
T2
4
T4
a
3
1
Fig. 11.3.6 Resection of sigmoid colon. Mobilizing the left colic flexure.
After transecting the ligamentous attachments between the left colic
flexure and the spleen, gradually dissect this segment of the mesocolon
with its marginal arcade from Gerota’s fascia. Depending on the extent of
the sigmoid resection, the attachment of the mesocolon to the inferior
margin of the pancreas is also divided (see Fig. 11.3.3 for key to instrument numbers).
1 Spleen
2 Stomach
3 Pancreas
4 Marginal arcade of the left colic flexure
T4
2
b
Fig. 11.3.7a,b Resection of sigmoid colon. Transecting and ligating the
inferior mesenteric artery.
a After completely mobilizing the left colon and mesocolon along
Gerota’s fascia all the way to the aorta and exposing the ureter, continue the dissection inferior to the vascular axis in the mesosigmoid.
Dissect the adherence of the mesosigmoid off the anterior aspect of
the aorta all the way out from the inferior mesenteric artery or the superior rectal artery. Now insert a swab into this defect from the left.
Using the swab, lift the sigmoid and mesosigmoid inferior to the
vascular axis, exposing the trunk of the inferior mesenteric artery or,
respectively, its origin at the aorta. Gradually dissect the surrounding
connective tissue off the trunk of the inferior mesenteric artery. Transect and ligate the root of the inferior mesenteric artery with a linear
stapler or endoscopic clips (see Fig. 11.3.3 for key to instrument numbers).
b Tumor is marked with clips placed as required by the extent of lymph-
node dissection. The inferior mesenteric artery is ligated close to the
trunk.
컅 Fig. 11.3.8 a,b Resection of sigmoid colon. Resecting the colon and
mesentery.
a Using a linear stapler, transect the sigmoid colon and mesosigmoid en
bloc. When the proximal colon and mesocolon are divided, the inferior
mesenteric vein is also divided centrally. The linear stapler closes both
the proximal and distal ends of the bowel and the proximal and distal
ends of the resected segment. Transecting the mesentery with the stapler expedites the resection, avoids having to manipulate the
tumorous intestinal segment, and reduces bleeding. Divide the
mesentery so that the lymph nodes located around the vascular trunks
remain on the resected segment (see Fig. 11.3.3 for key to instrument
numbers).
b Plane of resection in relation to location of tumor (marked with clips).
Inferior mesenteric artery is ligated close to its origin.
a
b
T5
T3
T4
T5
Trocar Placement
353
T3
T2
Fig. 11.3.9 Resection of sigmoid colon. Introducing the sterile bag.
To extract the resected segment, replace the lower right 12-mm instrument trocar with a 33-mm extractor/retrieval trocar with an expansion
mechanism. Extend the 12-mm incision slightly and then widen it with the
expansion mechanism on the extractor trocar. After placing the extractor
trocar, introduce a watertight, impermeable sterile bag with a pursestring
suture into the abdomen. This method fulfills oncologic requirements for
safe extraction of the resected segment (see Fig. 11.3.3 for key to instrument numbers).
Fig. 11.3.11 Resection of sigmoid colon. Extracting the resected seg- 컄
ment.
A resected segment in a sterile bag that is not patterned longitudinally is
difficult to extract through a small opening. The segment is best ex-
tracted by drawing the bag into the extractor trocar, drawing the trocar
out through the abdominal wall, and opening the bag outside the abdominal cavity. Now extract the resected segment from the bag by pulling it
longitudinally by one of the rows of staples. Since the bag is waterproof
and impermeable, the danger of tumor cell spillage and seeding
metastases is eliminated, as is the risk of contaminated material escaping
and infecting the trocar incision. After withdrawing the resected segment
and the sterile bag, reinsert the extractor trocar into the abdomen (see
Fig. 11.3.3 for key to instrument numbers).
Fig. 11.3.10 Resection of sigmoid colon. Extracting the resected segment.
Using several small grasping instruments, place the resected segment
(closed proximally and distally with staples) and the attached mesentery
in the sterile bag. Then draw the pursestring suture closed and pull the
bag into the extractor trocar (see Fig. 11.3.3 for key to instrument numbers).
T5
354
11.3 Resection of Sigmoid Colon
T3
Fig. 11.3.12 Resection of sigmoid colon. Placing the pursestring suture
clamp.
To prepare the anastomosis, introduce the laparoscopic pursestring suture clamp through the extractor trocar or a 12-mm instrument trocar.
Place the laparoscopic pursestring suture clamp diagonally on the an-
timesenteric corner of the stapled proximal end of the colon. This eliminates the need for further dissection at the mesenteric attachment while
preserving optimum vascular supply to the anastomosis. The end-to-end
anastomosis compensates for the diagonal transection of the proximal
end of the colon (insert; see Fig. 11.3.3 for key to instrument numbers).
T3
Fig. 11.3.13 Resection of sigmoid colon. Placing the pursestring suture.
To place the pursestring suture, introduce the straight needle with the
needle holder into the abdomen. Holding the needle holder at an acute
angle to theshaft of thepursestring suture clamp,push theneedle into the
guide slot in the clamp. The second needle is inserted the same way. Now
pull the needles through the pursestring suture clamp. Remove the
needles from the abdominal cavity through an instrument trocar and cut
the needles from thesutures outsidethe abdomen. Thepursestring suture
is later tied with an extracorporeal knot, which is advanced into the abdomen with a knot pusher (see Fig. 11.3.3 for key to instrument numbers).
T4
T3
T2
Fig. 11.3.14 Resection of sigmoid colon. Opening the proximal end of
the bowel.
After placing the pursestring suture, resect the angle of the stapled proximal colon, peripheral to the pursestring. The length of the incision depends on the size of the anvil of the circular stapler. Use the pursestring
suture clamp to hold the colon to be excised to make the cut in the proximal bowel (see Fig. 11.3.3 for key to instrument numbers).
Complications
Intraoperative Complications
− Injury to hollow organs when establishing the pneumoperitoneum or placing the laparoscope/camera trocar.
− Injury to a major vascular structure with resulting bleeding
caused by the Veress needle or laparoscope/camera trocar.
− Thermal damage to the large or small bowel resulting from
improper use of monopolar electrocautery.
− Subcutaneous air emphysema resulting from improper
placement and maintenance of the trocars in the abdominal
wall.
− Injury to the ureter.
− Bleeding during ligation and transection of the inferior
mesenteric vessels or vascular branches in the mesentery.
− Bleeding from the spleen during mobilization of the left colic
flexure.
− Injury to the pancreas during mobilization of the left colic
flexure.
− Tissue tearing of the pursestring sutures.
− Splitting of the proximal colon as the anvil is placed.
− Improper joining of anvil and cartridge of circular stapler.
− Incomplete staple tissue rings and leakage of air or methylene blue injected to test anastomotic competency.
T5
T3
Complications
355
Fig. 11.3.15 a−c Resection of sigmoid colon. Introducing the anvil.
a Introduce a circular stapler into the abdomen through the extractor
trocar to place the anvil. Alternatively, a specially developed seating
device can be used, which can be disconnected by pressing a release
button after you have placed the anvil in the proximal end of the colon
and tied the pursestring suture. Disconnecting the circular anvil re-
T3
T5
ba c
quires a certain amount of force and can result in injury to the proximal colon (see Fig. 11.3.3 for key to instrument numbers).
b Seating device with anvil in extractor trocar (alternative to circular sta-
pler).
c Pressing the release button (b) automatically disconnects the anvil
from the seating device.
T3
T5
T2
T4
Fig. 11.3.16 Resection of sigmoid colon. Introducing the anvil.
To introduce the anvil, carefully grip the proximal end of the colon with
three graspers and hold it open. Insert the anvil into the lumen. If the
opening is the right size, you will easily be able to insert the anvil. Discon-
necting the anvil from the airtight circular stapler after tying the purse-
string suture is more difficult. Alternatively, a seating device may be used
(see Figs. 11.3.15 b and c; see Fig. 11.3.3 for key to instrument numbers).
Fig. 11.3.17 Resection of sigmoid colon. Tying the pursestring suture.
The pursestring suture is tightened with an extracorporeal surgeon’s knot
introduced into the abdomen with a knot pusher. Since monofilament suture material is used, care should be taken to introduce the knot slowly
and evenly to avoid tangling the suture tails. When the knot has been
tightened the proximal end of the bowel is ready for anastomosis using a
double stapling technique (see Fig. 11.3.3 for key to instrument numbers).
356
a
11.3 Resection of Sigmoid Colon
b
Fig. 11.3.18 a, b Resection of sigmoid colon. Anastomosis.
a Introduce the circular stapler cartridge through the anus into the rec-
tum until it lies against the row of staples that close the stump of the
rectum. Using swabs to guide it, advance the stump of the rectum
over the stapler so that when the central tapered rod is extended it
perforates the rectum at the middle of the staple suture line. Now connect the cartridge and anvil using a large grasper or a special instrument to mate tapered and hollow rods of cartridge and anvil.
b Mobilizing the left colic flexure eliminates tension on the anastomosis.
Corrective action: If one of these serious complications occurs,
immediate conversion to an open procedure is indicated. Some
of these complications can be managed laparosopically provided that the surgeon has sufficient experience in laparoscopic
suturing techniques.
Postoperative Complications
− Postoperative bleeding.
− Breakdown of the anastomosis.
− Wound infection.
− Thrombosis.
− Embolism.
− Peritonitis and abscess formation.
Corrective action: If postoperative bleeding, breakdown of the
anastomosis, and/or abscess or peritonitis occur, remedial
surgery via laparotomy is usually indicated.
Fig. 11.3.19 Resection of sigmoid colon. Completed anastomosis.
Before closing the stapler after mating anvil and cartridge, visualize and
examine the proximal and distal ends of the bowel again with the 30degree laparoscope. Apply slight tension to the ends of the bowel with
swabs to hold them against the anvil and the instrument cartridge. After
completely closing the instrument and achieving good wall-to-wall contact, fire the stapler. Exercise extreme care when withdrawing the stapler
through the anastomosis, and correct its position with swabs only. Check
the rings of tissue to verify that the anastomosis is complete. When in
doubt, we recommend intraoperative rectoscopy with air insufflation and
application of methylene blue. The procedure is completed with thorough
irrigation of the abdomen and placement of a drain at the anastomosis
site is at the surgeon’s choice.
Bibliography
Brune IB, Schönleben K. Laparoskopische Sigmaresektion. Chirurg 1992;
63:342.
Darzi A, Hill ADK, Henry MM, Luillou PJ, Monson JRT. Laparoscopic assisted
surgery of the colon. Operative technique. End. Surg. 1993; 1:13.
Franklin jr. ME, Ramos R, Rosenthal D, Schuessler W. Laparoscopic colonic
procedures. Wld. J. Surg. 1993; 17:51.
Jacobs M, Verdeja JC, Goldstein HS. Minimally invasive colon resection (la-
paroscopic colectomy). Surg. Laparosc. Endosc. 1991; 144.
Köckerling F, Gastinger I, Remmel E, Gall FP. Die laparoskopische tubuläre
Rektum- und Kolonresektion. Zbl. Chir. 1992; 117:103.
Köckerling F, Gastinger I, Schneider B, Krause W, Gall FP. Laparoskopische
kolorektale Chirurgie: Kolon- und Rekumanastomosen in Triple-Stapling-
Technique. MIC 1992; 1:44.
Köckerling F, Schneider I, Gastinger I, Schneider B, Gall FP. Laparoskopische
Tabaksbeutelnahtklemme für die minimal invasive kolorektale Chirurgie.
MIC 1993; 2:68;
O’Rourke NA, Heald RJ. Laparoscopic surgery for colorectal cancer. Brit. J.
Surg. 1993; 80:1229
Phillips EH, Franklin M, Carroll BJ, Fallas MJ, Ramos R, Rosenthal D. Laparo-
scopic Colectomy. Ann. Surg. 1992; 703.
Wexner SD, Cohen SM, Johansen OB, Nogueras JJ, Jagelman DG. Laparoscopic
colorectal surgery: a prospective assessment and current perspectives.
Brit. J. Surg. 1993; 80:1602.
Zucker KA, Pitcher DE, Martin DT, Ford RS. Laparoscopic-assisted colon re-
section. Surg. Endosc. 1994; 8:12.
11.4 Laparoscopically Assisted Left Hemicolectomy
L. U. Jung, H. Yang, S.D. Potter, M. Berry
Complications
357
Objective and Methods
As laparoscopy has become an acceptable procedure for the diagnosis and treatment of intraabdominal disease, it has been
adapted to the use in bowel surgery since the early 1990’s. The
laparoscopic approach to colon surgery has the advantage of
being less invasive than the traditional open approach. This al-
lows quicker return of bowel function, less postoperative pain
and earlier return to work.
Indications
− Diverticulitis
− Intestinal polyps
− Inflammatory bowel disease
− Colonic hemorrhage
− Tumors (benign)
− Tumors (malignant?)
Contraindications
− Severe coagulopathy
− Hemodynamically unstable patient
− Obese patient
− Malignant tumor with extended locoregional involvement.
Trocar Placement
(see Fig. 11.4.5).
The camera port is placed at the umbilicus. Two 10- to 12-mm
trocars are placed lateral to the right rectus muscle. Another
trocar either 10- to 12-mm or 5-mm is placed at the left subcostal midclavicular line. All four trocars form a semi-circle
from RLQ to LUQ.
Intraoperative Risks
− Trocar injury
− Bowels
− Solid organs
− Vascular structures
− Ureteral injury
Postoperative Risks
− Anastomotic leak
− Wound infection
− Bleeding
− Trocar site recurrence?
Postoperative Course
Special Preparation
− Standard preoperative work up as for an open procedure.
− Patiens should be informed that a small incision will be
made for delivery of the specimen and formation of the
anastomosis.
− Patients should be informed that open operation may be
needed if laparoscopic attempts fail.
Anesthesia
General endotrachal.
Instruments
− General purpose laparoscopic setup
− 4 10−12-mm trocars
− 1 GIA stapler
− 1 TA stapler
− 2 Endo Babcocks
Operative Positioning
Supine with arms tucked in on the side. The surgeon stands on
the right side of the patient and first assistant on the left. The
monitor is placed to the left of the patient at his/her feet.
An orogastric tube is used intraoperatively. Postoperatively no
nasogastric tube is needed and diet is started when bowel
sounds return. The patient is to be out of bed as soon as
possible, even on the day of the operation. The urinary catheter
is usually left for a couple of days.
Complications
Postoperative Complications
Bleeding
Corrective action: Intraluminal bleeding, usually from the
wound margins of the anastomosis can be managed endoscopically. Conventional laparotomy is indicated for intraperitoneal
hemorrhage.
Suture Breakdown in the Anastomosis
Corrective action: Laparotomy is indicated for suture breakdown
in the anastomosis; the leak is closed with sutures, larger defects and cyanotic wound margins are resected and the anastomosis reconstructed.
Peritonitis
Infection of the Abdominal Wounds
Corrective action: Open wound treatment is indicated for infections of the abdominal wall.