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FIGURE10-3Separationofleftmesocolonfrom
retroperitonealtissueplane.
FIGURE10-4Incisethroughmesenteryatsiteof
distalcolontransection.
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Inpatientsinwhomaprimaryanastomosisisplanned,adequate mobilizationshouldbeconfirmedvisuallybydemonstratingthatthesite plannedforproximalcolontransectionreachestothepelvisandthe distaltransectionsitewithouttensiononthemesenteryorthebowel.
Laparoscopicmobilizationofthesplenicflexuremaybenecessaryto mobilizeenoughoftheproximalbowelforthecreationofatension-free anastomosis.Thisdissectioniseasierviaalaparoscopicapproachthanin openoperationsduetotheexcellentvisualizationaffordedbythe30­degreelaparoscope.Ifathree-porttechniquehasbeenuseduptothis pointintheoperation,afourthport,placedonthepatient’sleftsidemay beadvantageousincompletingthesuperiorportionofthesplenicflexure mobilization.Theoperatingsurgeoncanmovebetweenthepatient’slegs toperformthisdissection.Withthedescendingcolonretractedina medialandcaudaldirectionbytheassistantusingtheright-sided instruments,thelateralperitonealattachmentsatthesplenicflexionare dissectedwithacombinationofbluntandsharpdissection(Fig.10-5). Caremustbetakennottoplaceexcessivetractiononthecolonor omentumduringthisdissectiontoavoidanavulsioninjurytothesplenic
capsule,whichcanresultinsignificantbleeding.Theattachmentsofthe omentumtothecolonaredividedandthedissectionproceedsfrom lateraltomedial(Fig.10-6).Oncethelessersacisentered,confirmedby visualizationoftheposteriorsurfaceofthestomach,thelienocolic ligamentisdividedandthemesenteryofthesplenicflexureisgently retractedmediallyandinferiorly.Asthisisdone,theinferiorborderof thepancreasisidentifiedandtheperitoneumofthetransverse mesocolonisdividedjustinferiortothepancreastowardthemidlineand middlecolicvessels.
FIGURE10-5Divisionoflateralperitoneal
attachmentsofsplenicflexure.
FIGURE10-6Lessersacisentered,exposingthe
pancreasandposteriorwallofthestomach.
Thenextstepinvolvesvascularligation.Withthesigmoidcolon retractedinananteriorandcaudaldirection,themesentericvesselsare identified.Adecisionismadewithrespecttoproximalanddistalcolon transectionpoints.Inthesettingofbenigndisease,theproximaland distalleveloftransectionisdoneinanareawherethebowelappears grosslyhealthy.Iftheoperationisbeingperformedformalignancy,the proximalanddistaltransectionpointsmustbedeterminedonthebasis ofsoundoncologicprinciples.Marginsarethusdeterminedbythe primaryarterialsupplyfeedingtheaffectedsegmentofthecolon. Dissectioniscarriedoutinavascularplanesoneithersideofthe mesentericvessels,whicharethensealedanddividedwithabipolar energydevice.Thelevelatwhichtheinferiormesentericarteryisdivided dependsontheclinicalscenario.Iftheoperationisbeingperformedfor malignancy,thenaneffortismadetoobtainawidelymphadenectomy, andahighligationofthevessel,nearitsorigin,isdonetofacilitate adequatelymphadenectomy.Ifperformedfordiverticulardiseaseor otherbenignconditions,thenhighligationisnotnecessary,andthe vesselscanbetakenclosertothebowelwall.Divisionofanyremaining leftcolonorsigmoidmesenteryisthenundertakenwiththebipolar vessel-sealingdevice.
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Atthispoint,transectionofthedistalportionofthespecimencanbe performed,typicallywithalinearcuttingstaple.Thestaplerispassed throughthe10-mmportandthebowelistransectedunderdirect laparoscopicvisualization(Fig.10-7).
FIGURE10-7Laparoscopicintestinalstapleris
usedtodivideatthedistalpointoftransection.
Thespecimenmaybeexteriorizedthroughawoundprotectorwith relativeease.Duringinitialportplacement,considerationshouldbe giventotheanticipatedsizeofthespecimenandpotentialextraction sites.Wecommonlyusetheumbilicalportsiteforextractionsoasnotto createanotherincision,butanyotherportsitecouldbeused.Alternately, atransversesuprapubicincisioncouldbecreatedtoallowforspecimen extraction.Thetransectedendofthespecimenissecuredwithabowel grasperinpreparationforexternalization.Insufflationisputonstandby andthecameraandcameraportareremoved.Theumbilicalincisionis thenextendedinferiorlyinthemidlinetoapproximately3–4cmintotal length,dependingonthespecimensize.Awoundprotectorisplaced, cleanoperatingroomtowelsplacedaroundthefield,andthetransected endofthebowelispresentedthroughtheprotectedwound.The specimenisgentlydeliveredoutoftheabdomenandcareistakentonot
placetractionontheproximalmesentery,whichcouldinadvertently resultinavulsionofamesentericvessel.
Proximaltransectionisthenextracorporeallyperformedwithsharp divisionofthebowel.Adequatebloodsupplyresultsinbriskbleedingat thecutsurfaceofthebowelormesentery.Alternatively,indocyanine green(ICG)perfusionassessmentmaybeemployed.Theanvilofthe circularstaplingdeviceissecuredtotheendofthebowelwitha monofilamentpursestringsuture.
Thebowelisinternalizedonceagainandthewoundprotectorisclosed. Laparoscopicinsufflationisreinitiatedandanintracorporealcolorectal anastomosisisdoneunderlaparoscopicvisualization(Fig.10-8).The specimenshouldbeinspectedtoensuretwocompleteringsoftissueafter theanastomosishasbeencreated.Oncetheanastomosisiscomplete,the pelvisshouldbeirrigatedandaleaktestperformedbysubmergingthe anastomosisunderwater,compressingtheproximalbowel,and insufflatingtherectum(Fig.10-9).Anyevidenceofbubblingduring insufflationrequiresinvestigationandrevisionoftheanastomosis.The anastomosisshouldalsoroutinelybeinterrogatedbydirect proctosigmoidoscopicvisualization.ICGmaybeutilizedtoidentify mucosalperfusion.
FIGURE10-8Completedcolorectalanastomosis.
FIGURE10-9Anastomoticleaktestisdoneby
submergingtheanastomosisunderwaterorsaline, compressingtheproximalbowelandinsufflatingthe rectum.
Withavisuallyintactandairtightcolorectalanastomosisconfirmed, fluidshouldberemovedfromtheabdomenandpelvisandathorough visualinspectionoftheabdominalandpelviccavitiesonceagain performedtoensurehemostasisandlackofinjurytootherstructures. Workingportsareremovedunderdirectlaparoscopicvisualizationto ensurehemostasisatportsites.Any10-mmorgreaterworkingportsites areclosedunderdirectvisualizationusingaportclosuredevice. Insufflationisthenstoppedandthecameraandcameraportare removed.Theoperatingteamchangesgownandglovesandaseparate closinginstrumentsetisusedtocompletetheclosureoftheabdomen.
POSTOPERATIVEMANAGEMENT
Postoperativedispositionofthepatientlargelydependsonpatient comorbiditiesandintraoperativehemodynamicandpulmonarystatus. Themajorityofpatientsmaybepostoperativelyadmittedtoamedical­surgicalwardandanenhancedrecoverypathwayisfollowed. Intraoperativelyplacednasogastricororogastrictubesareroutinely discontinuedattheconclusionoftheoperation.Oralintakeis encouragedasearlyastheeveningofpostoperativeday0,withadvance toasoftdietbypostoperativeday1inmostcases.Intheabsenceof extensivelowpelvicdissection,urinarycathetersmaybediscontinuedon themorningofpostoperativeday1.Patientsareexpectedtobe ambulatorybypostoperativeday1aswell.Whilelaparoscopiccolon resectionhasbeendemonstratedtoresultinlesspostoperativepainthan inopenprocedures,analgesiaremainsaconcernafterlaparoscopic surgery.Patientsareroutinelymaintainedonoralnarcoticaswellas non-opioidpainmedications,inadditiontoanarcoticpatient-controlled analgesiadevice.Attemptsshouldbemadetoweanpatientsfrom narcoticpainmedicationasquicklyastolerabletoavoidconstipatingside effectsofopioidanalgesics.
Otherstandardpostoperativecareprinciplesforanypatientalsoapply topatientsundergoinglaparoscopicleftcolonresection,including resumptionofallcardiac,antihypertensive,oranti-hyperglycemic medicationsasearlyaspossibleandappropriate.Glycemiccontrolis paramounttominimizetheriskofsurgicalsiteinfections,especiallyin thecolorectalsurgerypopulation.Typicallengthofstayfollowing laparoscopicleftcolonresectionis2–3days.Standardcriteriafor dischargeincludebeingafebrile,hemodynamicandrespiratorystability, returnofbowelfunction,toleranceoforalintake,abilitytospontaneously void,ambulatorystatus(barringpreadmissiondebilitation),and adequatepaincontrolonoralagents.
Werecommendavoidanceofstrenuousphysicalactivityforaperiodof 4–6weeks,butpatientsmayreturntoworkonlightduty,orwith sedentaryoccupations,within1–2weeks.

CONCLUSIONS

Laparoscopiclateral-to-medialcolondissectionshavetheadvantageof surgeonfamiliarityfrompriorexperiencewithopenleftcolonresections. Althoughinitialdescriptionsoflaparoscopicleftcolonresections involvedlateraltomedialdissection,surgeonstodayhavetheoptionto domedial-to-lateralcolondissection.Theadvantageofamedial-to­lateralapproachisthatthenaturalperitonealattachmentsoftheright andleftcolonareleftintactduringthedivisionofthevascularstructures andmesenteryneartheiroriginandthusservetokeepthecolon retractedlaterallyduringthemedialdissection.Despitethis,thelateral­to-medialdissectioncontinuestohaveutilityandprovidesthesurgeon flexibilityindeterminingtheoptimalapproachtoagivenclinical scenario.
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