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358
11.4 Laparoscopically Assisted Left Hemicolectomy
Step-by-Step Procedure
(Figs. 11.4.8 to 11.4.11)
1. The patient is placed on the operating table in the supine
position. The surgeon and the camera operator stand at the
right side of the table and the first assistant stands at the left.
The TV monitor is caudad to the patient’s left hip.
2. A 2-cm vertical skin incision is made at the infraumbilical area.
A vertical incision is then made at the linea alba and the peritoneal cavitiy is entered. A 10-mm blunt trocar is placed and
secured.
3. A pneumoperitoneum using CO
peritoneal cavity is then explored and other trocars are placed
under the direct vision as in Figure 11.4.1.
4. The operating table is placed in Trendelenburg position and
tilted to the right to shift the small bowel medially and out of
the pelvis.
5. Using an Endo Babcock, the left colon is retracted medially
and is mobilized using scissors and electrocoagulation along
the white line in the left paracolic gutter (Fig. 11.4.2a, b).
insufflation is created. The
2
6. The patient is placed in reverse Trendelenburg position and
the splenic flexure is pulled inferomedially to take down the
splenic flexure (Fig. 11.4.2a, b).
7. The mesocolic vessels and mesocolon are clipped or divided
with the Endo GIA stapler (Fig. 11.4.2b).
8. The segment of colon to be resected is exteriorized through
an oblique muscle-splitting incision in the left lower abdomen
(Fig. 11.4.3).
9. The specimen is held with a bowel clamp peripheral to the
projected anastomotic site and an extraabdominal side-to-
side anastomosis is made with the GIA stapler at the appro-
priate level of cranial and caudad bowel transection
(Fig. 11.4.4).
10. The bowel limbs are closed with a single application of the
TA 90 stapler in healthy tissue, including the GIA introduction
site with the specimen. The specimen is then transected using
the TA stapler as a guide (Fig. 11.4.5).
11. After inspecition of the anastomosis (Fig. 11.4.6), the left
lower quadrant incision is closed and the pneumoperitoneum
is re-established and the final inspection of the abdominal
cavity is performed (Fig. 11.4.7).
12. The pneumoperitoneum and the trocars are removed and the
trocar sites closed in a standard fashion.
Operative Technique
Fig. 11.4.1 The patient is placed in a supine position and prepped. The
pneumoperitonium is created using CO
cal port. Normally four trocars are used for a left hemicolectomy. A 10-
mm trocar is placed at the umbilicus. The peritoneal cavity is then visually
explored. The other trocars are placed under the direct vision. A 10- to 12mm trocar is placed lateral to the left rectus muscle and slightly above the
umbilicus (this can be a 5-mm trocar for grasping forceps and scissors),
followed by a 10- to 12-mm trocar lateral to the right rectus muscle and
just below the umbilicus, and another 10- to 12-mm trocar in the right
lower quadrant for Endo GIA, Endo Babcock and other instruments.
insufflation through the umbili-
2
Complications
359
Fig. 11.4.2a, b The operating table is rotated toward the right side, in
the Trendelenburg position to shift the small bowel medially and out of
the pelvis. Using an Endo Babcock the left colon is retracted medially and
is mobilized along the line of Toldt in the left paracolic gutter, with scis-
sors and electrocoagulation. To take the splenic flexure down, the patient
a b
is placed in a reverse Trendelenburg position and special care is taken
during the dissection to avoid splenic injury. The mesocolic vessels and
mesocolon are clipped or divided with the Endo GIA stapler. Every attempt is made to identify the ureter and minimum coagulation is used
around the ureter.
Fig. 11.4.3 After satisfactory mobilization of the colon, a small oblique
incision is made into the left abdomen and the segment of colon to be re-
sected is exteriorized. Release of pneumoperitonium helps the colon to
be more easily delivered through the incision.
Fig. 11.4.4 The specimen is held with a bowel clamp distal to the projected anastomotic site and an extraabdominal side-to-side anastomosis
is made with the GIA stapler at the appropriate level of cranial and caudad
bowel transection.
360
11.4 Laparoscopically Assisted Left Hemicolectomy
Fig. 11.4.5 Following this anastomosis, both bowel limbs are closed with
a single application of the TA 90 stapler in healthy tissue, including the
GIA introduction site with the specimen. The specimen is transected using
TA stapler as a guide. By using this stapling technique, the stapler is fired
only twice (once for the anastomosis and another one for closure and
transection of the specimen), rather than four times (twice for dividing
proximal and distal bowel, once for anastomosis, and once for closure of
anastomosis).
Fig. 11.4.6 Overview of the functional end-to-end stapled anastomosis.
2
1
2
4
3
Fig. 11.4.7 The left lower quadrant incision site is closed and the
pneumoperitonium is reestablished and final inspection of the abdominal
cavity is performed. Then the pneumoperitonium and the trocars are removed and trocar sites closed in a standard fashion.
Fig. 11.4.8 Step-by-step procedure:
1 Elevate left and sigmoid colon from left gutter.
2 Incise white line of Toldt and splenocolic ligament and elevate left colon
and mesocolon to its midline root.
3 Secure all vessels at their respective origins with clips or vascular endo-GIA.
4 Oblique, muscle splitting LLQ incision.
Bibliography
8
6
7
6
7
5
361
9
5
Fig. 11.4.9 Step-by-step procedure:
5 Exteriorize segment of colon to be excised.
6 Clamp both bowel limbs peripheral to projected anastomotic site.
7 Perform side-to-side anastomosis, central to bowel clamp, with GI stapler.
10
7
8
9
6
Fig. 11.4.10 Step-by-step procedure:
5 Colon segment to be excised.
6 Clamp across both bowel segments.
7 Partially exteriorized side-to-side anastomosis.
8 Closure of both limbs of colon with transverse TA 90 linear staple line, cen-
tral to GIA introduction site.
9 Transection of specimen, using linear stapler as a guide.
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.
Caballero MG, Thorbeck CV. Indications, Advantages, and Techniques of La-
paroscopically Assisted Segmental Resection for Carcinoma of the Left
Colon. In Steichen, Welter, eds. Minimally Invasive Surgery. St. Louis, Missouri: Quality Medical Publishing, Inc.; 1994.
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. 11.4.11 Step-by-step procedure:
6 Specimen, including GIA introduction site.
7, 8 Anatomical side-to-side anastomosis will function as well as an end-to-
end anastomosis.
9 Closure of incision after repositioning bowel.
10 Pneumoperitoneum is reestablished and operative site is inspected.
362
11.5 Combined Endoluminal and Open Colon Procedure
11.5 Combined Endoluminal and Open Colon Procedure
S. D. Potter , H. Rajdeo, K. Bhuta, L. R. M. Del Guercio
Objectives and Methods
Endoluminal endoscopy is widely used for the preoperative
assessment of gastrointestinal disease, to identify location and
nature of the disease process. This useful technique of intraluminal evaluation has not been widely utilized as an intraoperative
tool. There are many occasions when the fiberoptic gastrointestinal endoscope or colonoscope could guide the open or laparoscopic dissection of severely scarred or matted intestine,
facilitate the localization of fistulae, and help in the definition of
anastomotic variations used after previous resections of the
stomach, small and large bowel, especially in the absence of re-
liable records.
This chapter discusses a situation in which a complicated
abdominal procedure was enhanced by the use of intraoperative fiberoptic endoscopy (ILE).
Indications
쐌 Complicated fistulae not clearly identified radioscopically or
clinically.
쐌 History of multiple operations with or without intestinal re-
sections; no clear description is available.
쐌 Primary gastric or esophageal resections, to aid in the inter-
nal definition of landmarks and margins.
쐌 Pedunculated colon lesions.
Position of Surgeon and Equipment
The surgeon is positioned in the usual place required for the
procedure to be performed. The endoscopist is either at the
head for upper endoscopy or between abducted legs (lithotomy
position) for colonoscopy. The monitors can be placed either on
the right and the left side of the patient, near the shoulders. For
the combined endoluminal and intracavitary videoendoscopic
procedures, one monitor is dedicated to each one of the procedures.
Complications
Operative Complications
The same risks present during endoluminal endoscopy are present during intraoperative endoscopy. These risks include perforation and bleeding. Given the complicated nature of the
operation that requires intraoperative endoluminal endoscopy,
the occurrence of these complications tends to be higher unless
extreme care is taken. The patient should be made aware of the
risks, however, he or she should also be aware that the complications can usually be managed satisfactorily if noted intraoperatively. While the risk of injury can be higher, the overall
operative risk and successful outcome may be improved with
the use of intraoperative endoluminal endoscopy.
Contraindications
쐌 Active intraluminal bleeding can interfere with visualization
and slow the operative procedure when expeditious action is
most needed.
쐌 Severe, acute inflammation which can lead to perforation.
Instruments
쐌 Fiberoptic gastroscope and colonoscope.
쐌 Various videoendoscopic or traditional instruments.
Position
The patient is generally in the supine position for abdominal
procedures, but this may vary depending on the operation.
Postoperative Complications
The most serious postoperative complication is a missed intraoperative bowel injury. Although bowel injury is sometimes
difficult to avoid, immediate identification and repair will usually prevent postoperative difficulties and limit operative morbidity. If an injury is not noted during the operation however,
poor recovery, fistulae, severe sepsis, and even death may
ensue. To prevent this disastrous outcome, meticulous dissection and examination of the bowel intraoperatively are mandatory.
Operative Procedure
Figures 11.5.1 to 11.5.3 illustrate reoperation in a man with a
history of a right hemicolectomy with ileotransverse colostomy
for Crohn’s disease. He had developed a retroperitoneal abscess
and enterocutaneous fistula postoperatively. At reexploration,
the patient was placed in the lithotomy position to facilitate
colonoscopy. The colonoscopy demonstrated a fistula at the site
of the ileotransverse colon anastomosis. A retroperitoneal abscess communicated with the bowel at the same site. Drains
were placed in the retroperitoneum, and the fistula was closed
with staples. An omental patch was fashioned to cover the
fistula repair. The entire colon and distal small bowel were
clearly visualized with the colonoscope. This simplified therapeutic measures that could have been treacherous without
this combined approach.
Step-by-Step Procedure
1. The patient is placed on the operating table in the supine position if gastroscopy is planned, whereas the lithotomy position
is best for colonoscopy.
2. The endoscope is advanced into the esophagus and stomach or
rectum and colon under visualization either via the eyepiece or
on the video monitor. The pathology or anatomy in question is
identified, and the endoscopist communicates this information
to the surgeon. Both share in decision making.
Bibliography
Bowden jr. TA. Intraoperative endoscopy of the gastrointestinal tract. In Dent
TL, Strodel WE, Turcotte jr. JG (eds.). Surgical Endoscopy, p. 167−188. Chicago: Year Book; 1985.
Grisendi A, Lonardo A, Della Casa G et al. Combined endoscopic and surgical
management of Diealfoy vascular malformation. J. Amer. Coll. Surg. 1994;
179:183−186.
Rajdeo H, Bhuta K. Intraoperative endoscopy for complex problems in
gastrointestinal surgery. Compl. In Surg. Nov. 19; 199:37−41.
Smedh K, Olaison G, Nyström O, Sjödahl R. Intraoperative endoscopy on
Crohn’s disease. Br. J. Surg. 1993; 80:897−900.
Bibliography
Fig. 11.5.1 A previous right hemicolectomy for Crohn’s disease had been
complicated by retroperitoneal abscess and enterocutaneous fistula.
Colonoscopy at the time of reoperation showed the fistula to originate
from the ileotransverse colon anastomosis and to communicate with the
skin and the retroperitoneal abscess. The abscess was drained.
363
Fig. 11.5.2 The fistula was closed in healthy bowel with the linear stapler,
under intraluminal, endoscopic surveillance.
Fig. 11.5.3 The linear staple closure was covered with an omental flap.
The lumina of large and small bowel were examined again by endoscopy,
to insure complete repair of the fistula and rule out any other endoluminal
pathology.
364
12. Laparoscopically-Guided/Assisted Colo-Rectal Procedures
12.1 Repair of Perforations of the Colon and Rectum
F. Köc kerling
Goals and Methods
“Rare events are rare, but they do occur.” This maxim also applies to instrumental, i. e., iatrogenic, unintentional perforation
of the wall of the large bowel and the rectum.
Thirty-seven percent of endoscopic perforations of the large
bowel occur in the sigmoid colon, 26% in the rectum, 9% in the
descending colon, 14% in the transverse colon, and 6% in the ascending colon. Mortality from endoscopic perforations of the
large bowel rises with the time elapsed until operation—from
17% at up to eight hours to over 50% at 24−48 hours. If abdomi-
nal symptoms occur following diagnostic or therapeutic colonoscopy with evidence of air in the abdominal cavity or the contrast enema reveals a defect, immediate surgical repair is indicated. If this condition is accompanied by other pathological
findings, such as sigmoid diverticulitis or sigmoid carcinoma,
the objective of surgical intervention will be to repair the iatrogenic perforation and resect the pathological process. When diagnostic colonoscopy has produced no pathological findings or
when a polyp has already been removed endoscopically, surgical intervention is indicated to suture the defect or resect the affected segment. Conditions are best when the diagnosis is made
early and colonoscopy has been preceded by intestinal lavage.
Escape of fecal material can usually be avoided if the diagnosis
is reached promptly. The conditions for laparoscopic repair of
an endoscopic colorectal perforation may be favorable in such
cases.
Surgical Risks and Patient Information
The patient should be informed about the opportunities that laparoscopic colorectal surgery offers, specifically as regards repair of an isolated iatrogenic colorectal perforation. The surgeon
should mention that this was not previously an established surgical procedure. Since this complication is rare, the surgeon will
not generally have much experience in correcting it. Accordingly, the surgeon should refer to other laparoscopic colorectal
procedures in assessing the risks when informing the patient,
and he or she should mention possible complications in laparoscopic colorectal surgery. This includes the risk of repair failure
or infection.
Special Preparations
Preoperative bowel preparation should precede colonoscopy,
and not too much time should have elapsed between the bowel
preparation and the diagnosis. Presence of intraabdominal air
on the plain upright chest X-ray and a contrast enema can confirm the diagnosis of endoscopic perforation. Further preparations include placement of a nasogastric tube and urinary
catheter.
Anesthesia
Indications
Iatrogenic or accidental colorectal perforations following diagnostic or therapeutic colonoscopy, in the absence of pathological colon findings and established peritonitis, may lend them-
selves well to laparoscopic repair if the bowel has been pre-
pared for endoluminal endoscopy prior to the injury.
Contraindications
If a colorectal lesion requiring separate operative treatment is
present in addition to the endoscopic perforation, conventional
operation is indicated to treat both conditions simultaneously.
If the interval between perforation and operation is excessive
and there is clinical evidence of peritonitis, the lesions should
be approached by laparotomy. Conventional operation is also
indicated to repair extensive tears in the wall of the colon in the
absence of any preexisting lesions.
General anesthesia.
Patient Positioning
(Fig. 12.1.1).
Position of the Operating Team
(Fig. 12.1.2).
Trocar Placement
(Fig. 12.1.3).
Fig. 12.1.1 Repair of iatrogenic perforations of the colon and rectum.
Patient positioning.
For laparoscopic repair of iatrogenic perforations of the sigmoid colon,
rectum, ascending colon, and distal segment of the descending colon,
place the patient on an operating table for rectal surgery in an extreme
Trendelenburg position (inclined 30−40°). Shoulder and pelvis supports
should be used to restrain the patient and permit inclining the operating
table in any plane during the procedure. To reduce the risk of compartment syndrome and compressive neuropathies, enclose the patient’s
knees and calves in thick foam rubber cushions and venodyne boots.
Complications
365
Fig. 12.1.2 Repair of
iatrogenic perforations of
the colon and rectum.
Position of the operating
team and equipment.
Repair of iatrogenic per-
forations of the sigmoid
colon, rectum, ascending
colon, and the distal segment of the descending
colon requires two equally
experienced surgeons,
who stand on either side
of the patient. Depending
on the situation, the sur-
geons work with one or
both hands. The assistant
holding the laparoscope
stands at the patient’s
draped left shoulder. The
patient’s right arm is ex-
tended to provide 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 ab-
ducted legs. The electro-
cautery unit and the
aspirator/irrigator set can
be positioned more or less
as desired.
Assistant holding the laparoscope
Aspirator/
irrigator set
Surgeon
Electrocautery
unit
Assistant
Instrument table
Complications
Intraoperative Complications
− Bleeding from the trocar incisions.
− Damage to major intraabdominal or retroperitoneal vascular
structures when establishing the pneumoperitoneum or
placing the trocars.
− Perforation of hollow organs caused by insertion of the
Veress needle and placement of the trocars.
Monitor
Insufflator
− Subcutaneous emphysema.
− Lesions to the colon from grasping instruments.
− Bleeding when the colon is mobilized.
− Thermal injury to intraabdominal organs.
− Enlargement of the defect caused by a technically deficient
attempt at closure.
Corrective action: Most of the intraoperative complications
listed here should be managed by conversion to laparotomy.
366
T3
12.1 Repair of Perforations of the Colon and Rectum
T1
T2
T4
T5
Postoperative Complications
− Postoperative bleeding.
− Repair insufficiency accompanied by abscess or peritonitis.
− Abscess.
Corrective action: These complications regularly require correction by laparotomy.
Step-by-Step Procedure
1. Insert the trocars under laparoscopic visualization.
2. Explore the abdomen visually; determine diagnosis and operative plan.
3. If sufficient assessment of the perforation cannot be obtained,
perform intraoperative colonoscopy.
4. If necessary, mobilize the affected segment of the colon.
5. Close the defect transversely with linear staplers.
6. Depending on the size of the lesion, laparoscopic sutures may
be used to repair the defect.
Bibliography
Fig. 12.1.3 Repair of iatrogenic perforations of the colon and rectum.
Trocar placement.
T1 10/12-mm laparoscope/camera trocar: slightly superior to the
umbilicus and left of and lateral to the midline.
T2−5 10/12-mm instrument trocars: forming a semicircle with the la-
paroscope/camera trocar around the pelvis.
Open trocar placement is an alternative.
Operative Technique
Beger HG. Instrumentelle Rektum- und Kolonperforation. In Beger HG, Kern
E. Akutes Abdomen, p. 276. Stuttgart: Thieme; 1987.
Frümorgen P. Art, Häufigkeit, Verhütung und Behandlung von Komplika-
tionen. In Frümorgen P. Diagnostische und therapeutische Endoskopie in
der Gastroenterologie, p. 42. Berlin: Springer; 1991.
Hohenberger W, Mewes R, Köckerling F, Gall FP. Perforationen an Dünn- und
Dickdarm. Chirurg 1987; 58:561.
Köckerling F, Gastinger I, Schneider B, Krause W, Gall FP. Die laparoskopische
Versorgung iatrogener kolorektaler Perforationen. MIC 1992; 1:60.
Fig. 12.1.4 Repair of iatrogenic perforations of the colon and rectum. Intraluminal diagnosis.
If laparoscopic examination cannot localize the lesion because the perforation site is covered by the mesenteric attachments or is in the fixed
part of the colon, intraoperative colonoscopy performed under laparoscopic control may be helpful. Visually, the endoscopic perforation may
appear as a localized puncture, a long tear in the wall of the colon, or anything in between. If there is an extended tear in the wall of the colon, it
can only be managed by resecting the affected segment of the colon.
Whether such damage can be treated laparoscopically depends on location of the lesion and the surgeon’s skill and experience. Laparoscopic repair of a torn colon by segmental resection is possible in principle (see laparoscopic sigmoid colon resection and laparoscopic hemicolectomy,
right).
Note: This represents another example of combined endoluminal and intracavitary endoscopy (or open operation if needed).
T2
Goals and Methods
367
T5
T3
Fig. 12.1.5 Repair of iatrogenic perforations of the colon and rectum.
Closing the lesion with staples.
Often the damage consists of a puncture or localized laceration of the intestinal wall. Repairing the lesion laparoscopically will also require mobil-
izing the affected segment of the colon along Gerota’s fascia to permit
closing the defect without creating tension. The sigmoid, descending,
and ascending colon are mobilized and exposed in the same manner as in
laparoscopic sigmoid resection or laparoscopic hemicolectomy. After mobilizing the bowel, grasp the defect with two 5-mm graspers (T2 and T5).
Place transverse tension on the colon, everting and opposing the edges of
the defect. Now close the defect with a linear stapler (30 mm or 60 mm;
T3) and excise the excess tissue beyond the stapler with the instrument
used as guide for this excision.
T3
T2
T5
Fig. 12.1.6 Repair of iatrogenic perforations of the colon and rectum.
Closing the lesion with sutures.
If the lesion is a localized puncture or an extended seromuscular defect
that does not compromise the mucosa, the perforation may be closed
with interrupted sutures. Laparoscopic sutures with intracorporeal or extracorporeal knot-tying may be used. If the entire thickness of the colon is
perforated, the defect may also be closed with a transverse suture. If the
seromuscular coat has been peeled off the colon over a large area without
compromising the mucosa, anatomic reconstruction of the seromuscular
coat is possible (see Fig. 12.1.3 for key to instrument numbers).
12.2 Repair of Rectal Prolapse
F. Köckerling, I. Gastinger
Goals and Methods
In a prolapse of the rectum, the proximal wall of the rectum is
invaginated into the rectal lumen and b eyond into or through
the anal canal. The prolapse generally begins with the anterior
rectal wall, rarely with the posterior wall, and often involves the
entire circumference. We refer to an inner prolapse or an intus-
susception when the invaginated rectal wall stops short of the
closed anal canal or enters it without projecting beyond it. In a
complete rectal wall prolapse, the entire invaginated rectal wall
protrudes through the anus.
Patients with a prolapse of the rectum may present with normal
continence or varying degrees of incontinence. In the absence of
neurological disorders or traumatic sphincter damage, the in-
continence will most probably be due to impaired stool sensa-
tion, possibly as a result of irritation of the stretch receptors, re-
duced sensitivity of the anal canal, and/or overstretching the
continence organ with increased secretion of fluid, mucus, and
blood from the prolapsed mucous membrane. Fifty percent of
the patients relate a history of constipation. Occasionally, this is
regarded as the cause of the prolapse of the rectum.
There are well over one hundred surgical procedures for treat-
ing prolapse of the rectum. We differentiate between:
1. extraabdominal, anal, perineal, or perianal surgical procedures and
2. intraabdominal surgical procedures with bowel resection or
bowel conservation and suspending-anchoring the rectosigmoid and mesorectum-sigmoid to the presacral fascia and
left lower abdominal gutter.
Criteria for assessing the quality of various procedures are the
incidence of recurrence and improvement in continence and
colon function.
The extraabdominal, anal, and perineal corrective procedures
may be performed under spinal or epidural anesthesia.
However, these methods have a high rate of recurrence and thus
should only be used in elderly patients with serious systemic
complications. In the absence of increased surgical or anesthetic
risk factors, the surgeon should use the abdominal procedures
for correcting prolapse of the rectum.
A low rate of morbidity and recurrence indicate Well’s rectopexy as the procedure of choice. Statistical surveys have revealed a mortality rate of 1.2% and a rate of recurrence of 3% for