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(Fig.11-6).
FIGURE11-6Medial-to-lateralmobilizationof
colonfromdistalpancreas.
Vasculardivisionisthenextstepoftheprocedure.Theleftcolicartery isidentifiedandligatedatitsoriginusingthevesselsealerdeviceor vascularloadoftheEndowriststapler.Alternatively,thevesselcanbe carefullyskeletonizedandligatedwiththeclipapplierifdesired.Theleft branchofthemiddlecolicarteryisdividedinasimilarmanner.
BowelAnastomosis
Bowelanastomosiscanbeaccomplishedviaeitheranintracorporealor extracorporealanastomosis.Intracorporealanastomosisprovidesthe surgeonthefreedomofutilizinganyextractionsite—Pfannenstiel,left­sidedRocky-Davis,ormidline,forexample.Utilizationofthe Pfannenstielincisionmayconfertheaddedbenefitofareductionin ventralincisionalherniasversusmidlineextraction.
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IntracorporealTechnique
Afterappropriatemobilizationandvascularcontrolofthespecimen,the proximalanddistalbowelcanbedivided.Thepointsoftransection shouldbechosenonthebasisofoncologicfactorstoensureadequate
margins,bloodsupply,aswellasappropriatelengthforanastomosis.The colonisthendividedusingtheEndowrist45-mmblueloadstapler. Typically,two45mmstaplercartridgesarerequiredtotransecteachside ofthebowel.Thespecimenshouldthenbeplacedoutsideoftheworking fieldforlaterretrieval.Forleftcolectomy,iso-peristalticside-to-side positioningofthebowellimbsistypicallythesimplestandmost anatomicorientationforanastomosis.Thetwolimbsofthecolonare thenpositionedinaside-to-side,anti-mesentericmannerandconfirmed tobetensionfreeandappropriatelyoriented.Atleast4.5cmofoverlap betweenthetwolimbsshouldbeachievedtoensureaccommodationofat leastonefiringoftheEndowrist45-mmstapler.Appropriatevascular supplytothebowelcanbeconfirmedatthispointbyutilizing indocyaninegreenangiography.
Oncethelimbshavebeenappropriatelypositioned,maneuverstohold thebowelinthecorrectlocationandorientationmustbeundertaken. Myriadmethodshavebeendevisedtoaccomplishthis;however,thetwo mostcommonlyusedtechniquesarestaysuturesordirectgraspingofthe bowelwiththethirdarm.Staysuturescanbehelpful,butmaybetime consumingtoplaceandcanleadtotearingofthebowelifnotretracted carefully.Iftheyareutilized,theyshouldbeplacedinananti-mesenteric positionwithadequatetopreventtearing.Asimplertechniqueistograsp bothanti-mesentericsidesofthetwolimbsandbringthemtogether usingalargeatraumaticgraspersuchasthesmallgraspingforcepsorthe tip-upfenestratedgrasper.Thisaffordsthesurgeonunlimited opportunitiestorepositionaswellasalowerriskoftearingthebowel withsutures.
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Colotomiesarethencreatedineachlimbofthebowel,positionedto allowforappropriatepassageofthestaplertocreateanadequate commonchannel(Fig.11-7).Gentletensiononthebowelallowsformuch easierentryintothelumenusingelectrocauterywithoutexcessive burning.Oncethelumenhasbeenentered,placingonebladeofthe scissorsinsidethelumenandliftingupwardwithasmallamountof cauterywillfacilitateprecisecreationofasufficientlylargeapertureto accommodatethestapler(Fig.11-8).TheEndowriststapleristhengently insertedintothecolotomies.Itisusuallyeasiertoinsertthelimbsofthe stapleroneatatimeandthenadvancethebowelintotheproximal staplerafterbothcolotomieshavebeencannulated;oneortwostapler firingscanbeutilized(Fig.11-3).
FIGURE11-7Creationofcolotomy.
FIGURE11-8Insertionofstaplerandpositioning
oflimbsforintracorporealanastomosis.
Thecolotomyshouldthenbeclosedinahand-sewnmanner,inoneor twolayers,usingsuturematerialofthesurgeon’spreference.Wetypically closethedefectusingeitherarunning3-0Vicrylorarunning3-0V-Loc polydioxanonesuture.Atechnicalpearltoassistwithclosingthe colotomyistograsptheapexofthecolotomywiththethirdarmand retracttowardtheabdominalwall,thusliningupthemucosaledgesand cruciallyexposingtheinferioraspector“crotch”ofthestapleline.We
advisebeginningtheclosureatthisinferiormostaspect,whichcanbe difficulttoseewhensuturingfromsuperiortoinferior,resultingin inadequateclosureandleaks.
ExtracorporealTechnique
Oncethecolonhasbeencompletelymobilized,thespecimencanbe exteriorizedthroughawoundprotector,eitherthroughamidline periumbilicalincisionoraleft-sidedtransverseincision.Itisnot routinelypossibletoexteriorizethroughaPfannenstielincisionforleft colectomy.Itisimportanttoensurelengthofcolonhasbeenmobilized beforeattemptingtodeliverthespecimen,asexcessivetractionofthe middlecolicarteryduringexteriorizationmayleadtoavulsion.After carefullydeliveringthebowelfromtheabdomen,proximalanddistal transectionpointsarechosenandthebowelisdividedusingstaplers.The bowelcanbepositionedineitheraniso-peristalticoranti-peristaltic position,accordingtothepreferenceofthesurgeon.Itiscriticalto ensureproperorientationofthebowelinananti-mesentericmannerand ensurenotwistingispresentproximallyordistally.Theanastomosisis thenperformedintheusualmanner,asforanopenprocedure.
Chapter12
Hand-AssistedLeftColectomy
JoonghoShinandSangW.Lee

INDICATIONS

Themainlimitationoflaparoscopicsurgeryislossoftactilefeedback. Hand-assistedsurgeryprovidesmanybenefitsoflaparoscopicsurgery, whileallowingsurgeonstoretaintactilefeedback,betterretractionwitha trainedhand,andabilitytodobluntdissectionwithfingerswhenneeded. Theseadvantageshavebeenshowninrandomizedclinicaltrialsas shorteroperativetimeandlessconversionwithsimilarperioperative outcomemeasurescomparedwithstraightlaparoscopy.
Indicationsforhand-assistedleftcolectomyarethesamefor laparoscopicleftcolectomy:coloncancer,diverticulardisease,and Crohn’scolitis.Whendecidinglaparoscopicversushand-assisted approach,severalfactorsaretakenintoconsideration:bodyhabitus, location,nature,andcomplexityofpathology,andextentofplanned surgery.Inobesepatientswithheavyintraperitonealandpericolonicfat, adequateexposureandtractioncanbedifficult.Handportaccesscanbe valuableinthiscase.Ifthepatienthashistoryofcomplicated diverticulitissuchascolovesicularfistula,andpelvicinflammationand fibrosisisexpected,handaccessgivessurgeonabilitytousefingersfor bluntdissection.Inelectivesigmoidresectionfordiverticulitis,especially incomplicateddiverticulitis,hand-assistedsigmoidectomyhasbeen showntohavelowerconversionrateandshorteroperativetime,although havingequivalentoutcome.Conversionfromstraightlaparoscopicto hand-assistedlaparoscopicsurgeryratherthanlaparotomy,when intraoperativedifficultyisencountered,isanotherutilityofthis approach.
Laparoscopiccolectomyhasbeenshowntohavealonglearningcurve. Hand-assistedleftcolectomycanbeabridgebetweenopencolectomy andstraightlaparoscopiccolectomy.
PREOPERATIVEPLANNING
Thoroughhistoryandphysicalexaminationisperformedwithattention to:
pulmonarydisease(COPD)andeyediseasesuchasglaucoma.Patients withsevereCOPDarenotlikelytotoleratepneumoperitoneum.These patientsneedtobeinformedofhighlikelihoodofearlyconversionto openprocedure,ifendtidalCO2startedtoincreaseafter
pneumoperitoneumwasestablished.SteepTrendelenburgposition duringlaparoscopicprocedurehasbeenshowntoincreaseintraocular pressureintime-dependentmanner.Inpatientswithoutpreexisting eyedisease,thishasbeenshownnottoaffectvisualhealth,butin patientwithknownglaucoma,cautionshouldbetakentominimize timeinsteepTrendelenburgposition.
historyposetwotypesofchallenges.Firstisalteredanatomythatwill hinderparticularoperativesteps.Forexample,inapatientwithdistant historyofgastriccancerandBillrothIIgastrojejunostomy,takingdown splenicflexurecanbedifficult.Itisadvisabletogatherasmuchas informationpreoperativelyfromoperativereports,ifavailable,andany imagingstudy.Secondisintra-abdominaladhesions.Inapatientwith historyofmultiplelaparotomiesorpreviouscomplexoperation,itis advisabletousetheoldscartocreateverticalhandportincisionrather thanaPfannenstielincision.
Forpatientswithcomplicateddiverticulitis(e.g.,colovesicularfistula)or locallyadvancedsigmoidcoloncancer,considerbilateralureteralstent
placementatthebeginningofthecase.Itisourpreferencetousethem selectively.
Forpatientswithalargeabdominalsubcutaneousfat,itisprudentto markthestomasite,incaseunexpectedintraoperativecourse
necessitatescreationofatemporarystoma.Thisisusuallydoneinthe preopholdingareawithpatientstandingup.

SURGERY

RoomSetupandPatientPosition
TypicalroomsetupisshowninFigure12-1.
FIGURE12-1Typicalroomsetup.
Gelpadorbeanbagisusedonthetabletostabilizethepatientduring steepTrendelenburgposition.Botharmsaretucked,andhandsare
protectedbyfoampadsorbabydiapers.Inheavypatients,itiswiseto testthesecuritybyplacingthepatientsinextremepositionsbefore prepping.Ifnecessary,heavy-dutytapescanbeplacedaroundthe
patient’schestandthetable. Thepatientisplacedinmodifiedlithotomyposition,withhipextended
closeto180°relativetotorso.Thispreventstherangeofthesurgeon’s elbowfrombeingrestrictedbypatient’sflexedthigh.Careshouldbe takennottohyperextendthehip.
Flexiblesigmoidoscopyisreadyandavailablethroughoutthecase. Surgeonstandsbetweenpatient’slegs,andtheassistant(operating)
surgeonstandsonthepatient’srightsideduringlaparoscopicportion.
IncisionsandPortPlacement
APfannenstielincisioniscreatedtwofingerbreadthsabovethepubic symphysis.Ifthepatienthasanaturalskincreaseslightlyaboveorbelow, createtheincisionalongthecreaseforbettercosmesis.Thelengthofthe incisiondependsonsurgeon’shandsize,anditistypically8cmfor7½ glovesize.Theanteriorfasciaisopenedtransversely.Thefascialincision ismadewitheachendcurvedup,sothatitavoidsdividingtheinguinal ligamentinadvertently.Theanteriorfasciaisseparatedfromrectus superiorlyandinferiorly.Theposteriorfasciaisopenedlongitudinally, andperitoneumisenteredsharply.Peritoneumisenteredatsuperior aspectoftheincisiontotrytoavoidpotentialbladderinjury.Oncean adequateincisioniscreatedtopermitthesurgeon’shand,a supraumbilicaltrocarisinsertedwithhandguidance.Then,abdomenis insufflated.Threeadditional5mmtrocarsareplacedwithoptional5mm trocarinleftupperquadrantasshowninFigure12-2.
FIGURE12-2Portplacement.
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OperativeSteps
leftsideupposition.
andsweeploopsofsmallintestinesoutofthepelvisintopatient’sright sideandrightupperquadrant:inobesepatients,moistlaparotomypad ishelpfulinpackingthesmallintestinesawayfromtheoperativefield. Moistlaparotomypadcanbeusedtocleanthelensofthescopeatthe sametime.Ideallyexposuretothesacralpromontory,leftedgeofaorta, andligamentofTreitzshouldbeachievedasshowninFigure12-3.
FIGURE12-3Initialexposureofsacral
promontoryandrootofleftcolonmesentery.Arrow, referstothedirectionofperitonealincision.
pinchandholdthesigmoidcolonandmesenteryandplacethemunder anteriortension(Fig.12-4).Thismaneuverseparatestheinferior mesenteric/superiorhemorrhoidalarteryfromleftcommoniliacartery, sothatmedialtolateraldissectioncanbeachievedinthecorrectplane. Whenthereisanexperiencedassistantavailable,thesurgeonusesthe lefthandtoretract.Thesurgeon’srighthandcanuseaninstrumentsuch asabowelgrasperthroughleftlowerquadrantportforfinemaneuvers. Whentheassistantsurgeonisinexperienced,thesurgeonplacesthe righthandthroughthehandaccessdeviceandusesthelefthandtouse theenergydevicefromrightlowerquadrantportforamedialtolateral dissectionandvesselligation.
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