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_898_Библиотеки_им_академика_М_И_Перельмана.pdf
76
T. Sonoda
Alternatively, the IMV can be isolated and divided independently of the IMA. In diffi cult cases, it is actually helpful
to isolate and divide the IMV before the IMA. The IMV is
identifi ed adjacent to the ligament of Treitz in a location
superior to the IMA, and in this location, it is isolated and
divided. This provides an excellent entry point to the correct
dissection plane between the left colon mesentery and retroperitoneal fascia and can aid in the mobilization of the
splenic fl exure.
Pearls and Pitfalls
D i f fi culty in Identifying the Left Ureter
The left ureter may be diffi cult to fi nd when one is not dissecting in the correct plane. As mentioned previously, the tendency is to dissect deep to the retroperitoneal fascia, into the
retroperitoneum itself, and keep the left ureter and gonadal
vessels still attached to the sigmoid mesentery. An attempt
should be made to reestablish the proper dissection plane
anterior to the retroperitoneal fascia (Figs. 6.8 and 6.9 ). The
retroperitoneal structures tend to stain purple in color, and
the mantra of “purple goes down” should be remembered.
If this is not effective, a medial mesenteric dissection is
started in an easier area, lateral to the inferior mesenteric vessels. Find the left colic vessel, make mesenteric windows iso-
lating the vessel, and divide it close to its origin. The cut left
colic vessel is lifted and the retroperitoneal fascia is identifi ed
and bluntly swept in a dorsal direction separating the retroperitoneum from the mesentery. Then, the cut medial edge of
the mesenteric window attached to the inferior mesenteric
vessels is lifted, and this plane is bluntly dissected toward the
midline. When the inferior mesenteric vessels are freed from
the retroperitoneal structures from a lateral direction, just to
the left of the IMV should be the left ureter. Once the ureter
is found in this location, it is traced more inferiorly.
If this step is not successful, a lateral mobilization of the
sigmoid colon should be carried out in order to identify the
left ureter more distally. In this location, the most reproducible location is as the ureter crosses the bifurcation of the
common iliac artery. If the left ureter is not identifi ed by any
of the aforementioned methods, then the operation should be
converted to open surgery. Even in this case, however, one
should fi rst mobilize the splenic fl exure before the conversion so the open incision could be kept small in size.
Retromesenteric Dissection
The divided medial edge of the mesentery is grasped, exposing a wide mesenteric window. The retroperitoneum is further swept in a dorsal direction, separating it from the left
colon mesentery in a medial-to-lateral direction (Fig. 6.10 ).
Since the mesentery is congenitally adhered to the retroperitoneum, the tendency is to dissect in a plane that is too deep.
Instead, it is important to repeatedly identify the true line
Fig. 6.8 Congenital fusion of the sigmoid mesentery to the retroperitoneal fascia makes it easy to dissect in the wrong plane. The left ureter
and gonadal vessels in this case will be anterior to the dissection
Fig. 6.9 The proper dissection plane requires the conscious separation
of the mesentery and retroperitoneal fascia
Fig. 6.10 The dissection of the retromesenteric plane from a medialto- lateral direction
6 Laparoscopic Sigmoidectomy/Left Colectomy
77
of fusion between the mesentery and retroperitoneum.
The retromesenteric plane is extended laterally to the abdominal wall, superiorly toward the upper half of the left kidney,
and inferiorly past the left psoas muscle.
Lateral Dissection
The sigmoid colon is retracted in a medial direction, and its
lateral attachments are dissected from laterally. It is important to identify the left ureter and gonadal vessels again to
avoid injury to them. After initial dissection, the prior dissection plane from the medial side should be encountered. If the
medial dissection had been carried out lateral enough to the
abdominal wall, what is left of the lateral attachment should
be a thin peritoneal layer. This lateral mobilization is taken in
a superior direction toward the splenic fl exure (Fig.
6.11 ).
Splenic Flexure Mobilization
Unless the sigmoid colon is redundant, splenic fl exure mobilization will be necessary for many of the sigmoid and left
colon resections. This step can be very tedious, especially in
obese patients. One must understand the anatomic attachments of the splenic fl exure, which include splenocolic,
renocolic, and gastrocolic ligaments.
A systematic approach to splenic fl exure takedown should
be utilized. The splenic fl exure takedown is greatly facilitated by a generous posterior retromesenteric dissection, and
thus, the posterior renocolic attachments are fi rst mobilized.
Fig. 6.12 Splenic fl exure: the splenic fl exure is mobilized from the
descending colon in a cephalad direction
Then, the prior lateral dissection along the white line of Toldt
is further taken in a cephalad direction and around the splenic
fl exure from left to right (division of the splenocolic ligament) (Fig. 6.12 ). The assistant helps with retraction of the
omentum and the surgeon retracts the descending colon in a
caudal and medial direction. One must be careful not to use
excessive traction in either medial or inferior direction since
the splenic capsule could easily tear. The key to expeditious
fl exure takedown is to remain close to the colon as the omentum is dissected from the splenic fl exure. It is helpful to look
for the most distal point of omental attachment to the splenic
fl exure and begin separating the omentum from the colon
and epiploic appendages here. Attention should be paid to
the dorsal attachments of the fl exure to the tail of the pancreas. The lesser sac is entered, and the omentum is dissected
off of the distal transverse colon until the splenic fl exure
mobilization is complete. As soon as the lesser sac is entered,
one should try to identify the stomach, because it can adhere
close to the colon leading to inadvertent injury.
Fig. 6.11 The lateral dissection of the sigmoid colon and descending
colon is facilitated by a robust medial mobilization
Pearls and Pitfalls
D i f fi cult Splenic Flexure
This could be from obesity, complex omental adhesions, or
close proximity of the splenic fl exure to the spleen. One
should fi rst refer back to the general guidelines for splenic
fl exure takedown. Has an adequate posterior dissection been
performed? Has the splenic fl exure mobilization been performed close to the colon wall? Is the patient positioning
78
T. Sonoda
Fig. 6.13 Splenic fl exure: the splenic fl exure is mobilized from the
transverse colon side, taking down the omental attachments
Fig. 6.14 The mesorectum is cleared off
adequate, i.e., out of the steep Trendelenburg position? If the
patient is large and the assistant’s right lower quadrant port is
useless due to lack of reach, consider placing an additional
5-mm right epigastric port.
The next step in a diffi cult splenic fl exure mobilization is
to start a medial dissection (i.e., from the transverse colon
side) (Fig. 6.13 ). The omentum is dissected off of the distal
transverse colon, again staying close to the colonic wall and
entering the lesser sac. This dissection is extended to the left
to the splenic fl exure. Dissecting on both the right and left
sides of the splenic fl exure, the mobilization is completed.
Bowel Division, Exteriorization, and Anastomosis
The site of distal transection is identifi ed. The distal bowel
division is performed intracorporeally. In cancer, the site of
distal resection is 5–10 cm distal to the tumor, and in diverticulitis it is the top of the rectum. The mesentery is scored at
this point close to the bowel wall. With care not to injure the
bowel wall, the mesorectum is divided at this location including the superior hemorrhoidal vessels using a dissecting
energy device (Fig. 6.14 ).
Using an endoscopic linear 60-mm stapler placed through
the 12-mm right lower abdominal port, the bowel is divided
(45-mm stapler for smaller patients) (Fig.
should be made to make a transection perpendicular to the
bowel wall with one fi ring, but if two fi rings are necessary,
the spike of the circular end-to-end stapler should be brought
out at the confl uence of the two fi rings. Next, the site of proximal transection is assessed intracorporeally; this location
should allow for a tension-free anastomosis with good blood
6.15 ). Attempt
Fig. 6.15 Distal bowel transection using an endoscopic 60-mm
stapler
fl ow. The sigmoid mesentery located cephalad to the cut
inferior mesenteric vessels is then dissected toward this point
of proximal transection. This site should be identifi able when
it is exteriorized, and it is helpful to mark an epiploic appendage in this area with cautery or clips. A laparoscopic grasper
is then used to grasp the end of the colon to be exteriorized.
6 Laparoscopic Sigmoidectomy/Left Colectomy
79
Fig. 6.17 The water level should be brought lower, to about mid rectum so that the anastomosis is underwater
Fig. 6.16 Circular double-stapled end-to-end anastomosis
A minilaparotomy is created for exteriorization. The reasonable sites are the umbilicus, left lower quadrant port site,
and suprapubic position. The wound is enlarged to 3–5 cm or
larger depending on the size of the pathology. A wound
retractor is placed. The stapled end of the colon is found and
the bowel is exteriorized, and the marked area of proximal
transection is located. The marginal vessel is divided at this
level, and the bowel is divided. Good blood fl ow from the
marginal vessel and to the end of the colon must be confi rmed. A purse-string suture is placed into the open mouth
of the colon and tied around the anvil of a circular stapler.
The author’s preference is to use a 28-mm stapler in most
cases unless the rectum is capacious. Especially in
diverticulitis, the upper rectum is often contracted, and you
may be unable to pass a circular stapler of larger diameter. In
cases of extensive diverticulosis where the proximal bowel
still contains multiple diverticula, one should consider bringing the anvil out from the antimesenteric colon more proximally and performing a side-to-end anastomosis.
The bowel is returned back inside the abdomen, and the
minilaparotomy is closed with facial sutures. Under laparoscopic visualization, the circular stapling device is inserted
into the rectum and through the end of the rectal stump. After
confi rmation that the mesentery is not twisted, a stapled endto- end circular anastomosis is performed (Fig.
6.16 ).
The pelvis should then be fi lled with saline using a laparoscopic irrigation device, and a leak test performed. The
bowel is occluded with a laparoscopic grasper proximal to
the anastomosis, and the anastomosis is immersed in saline
while the rectal lumen is insuffl ated with air or carbon dioxide (Fig. 6.17 ). Care is taken to be sure there is no migration
of small bowel loops underneath the cut mesenteric edge.
Alternatively, an extracorporeal anastomosis can be performed. In this case, rather than perform an intracorporeal
distal bowel division, a low midline or Pfannenstiel incision
is created and the distal transection is performed using open
techniques. It is still helpful at times to divide the mesorectum intracorporeally even in this case. After distal transection, the bowel is further exteriorized and the proximal
division, anastomosis, and leak test are all performed through
the small incision.
Pearls and Pitfalls
Positive Leak Test
One must fi rst clearly identify the area of leak. This is best
done with continuous CO 2 insuffl ation through a fl exible sigmoidoscope. Carbon dioxide is absorbed from the lumen of
the bowel much faster than air, limiting distension that can
obscure the surgical fi eld. If there is a single defect, the
defect is small and can clearly be visualized laparoscopically, interrupted intracorporeal sutures can be used to
close the defect. The subsequent leak test must be negative.
For all other defects, the defective anastomosis should probably be resected and a new one created. This can still be
accomplished laparoscopically if the rectum is cleaned off
distal to the prior anastomosis and the rectum is divided
using a laparoscopic linear stapler. The anastomosis is then
80
T. Sonoda
exteriorized through the prior minilaparotomy wound and is
resected, and a new anvil placed into the bowel. If this intracorporeal revision is technically challenging, it can be completed through a Pfannenstiel or a low midline incision.
According to one study of colorectal anastomoses, a positive leak test occurred in 7.9 % of tested anastomoses. Higher
rates of clinical leak occurred in those with positive air leak
tests compared with negative ones (7.7 % vs. 3.8 %). When a
leak test was positive, the subsequent clinical leak rates were
0 % with reanastomosis versus 12 % with suture repair [
1 ].
Conclusion
A straight laparoscopic approach to the sigmoid and left
colon can be successfully utilized as the surgical procedure
of choice for a number of colorectal conditions. While this
approach can be technically demanding and requires
advanced laparoscopic skills, in most cases, your patient will
reap the benefi ts from a minimally invasive approach.
Undoubtedly, there are many technical approaches to this
procedure, and while the basic steps remain the same, the
approach for each surgeon should be individualized.
Reference
1. Ricciardi R, Roberts PL, Marcello PW, Hall JF, Read TE, Schoetz
DJ. Anastomotic leak testing after colorectal resection: what are the
data? Arch Surg. 2009;144:407–11.
Hand-Assisted Left Colectomy
Steven Lee-Kong and Daniel L. Feingold
7
K e y P o i n t s
• The hand-assisted approach to colectomy is a versatile
technique that facilitates dissection in diffi cult clinical
circumstances.
• During standard “straight” laparoscopic colectomy, the
surgeon must rely on the experience and skill set of the
assistant. In hand-assisted surgery, the surgeon is able to
perform much of the dissection and uses the assistant
essentially as a camera holder.
• The surgeon can advance through the learning curve by
dividing the operation into individual steps and focusing on
what needs to be accomplished in each step; in this fashion,
the operation becomes a standardized, reproducible method.
• Laparoscopic colectomy is a challenging operation; oncologic adequacy should not be compromised for the sake of
performing a less invasive procedure.
• A major benefi t of the hand-assisted approach to colectomy is that the surgeon can approach the dissection from
all directions (medial, lateral, cephalad) and, in complex
cases, can easily change from one approach to another in
order to complete the dissection.
Background
The most common indications for elective left colectomy
include sigmoid adenocarcinoma, diverticular disease, and
adenomatous polyps not amenable to endoscopic removal.
Open colectomy has largely been supplanted by minimal
Electronic supplementary material: Supplementary material is avail-
able in the online version of this chapter at
Videos can also be accessed at
978-1-4939-1580-4
S. Lee-Kong , M.D. • D. L. Feingold , M.D. (*)
Department of Surgery, New York Presbyterian Hospital ,
Columbia University , 161 Fort Washington Avenue , New York ,
NY 10032 , USA
sal116@cumc.columbia.edu; df347@cumc.columbia.edu
e-mail:
.
10.1007/978-1-4939-1581-1_7 .
http://www.springerimages.com/videos/
access surgery; the benefi ts of laparoscopic-assisted
colectomy over open surgery include accelerated postoperative recovery, earlier return to baseline level of functioning, decreased length of stay, decreased pain and narcotic
use, and decreased operative blood loss [
laparoscopic approach results in longer average operative
times and can be particularly challenging in obese patients,
re- operative patients, and patients with advanced disease.
A variation of the standard laparoscopic approach, handassisted colectomy, shortens operative times, decreases
conversion rates, and restores tactile feedback that aids in
dissecting otherwise diffi cult anatomy without compromising the benefi ts of a minimally invasive approach [ 4 ]. Hand-
assisted laparoscopy is a versatile approach to colectomy
that allows for dissection of complicated anatomy, palpation
to facilitate intraoperative tumor localization, and dissection
through the hand-port access in open fashion or by using
straight laparoscopy.
1 – 3 ]. The straight
Preoperative Planning
A relevant history and physical examination, assessment of
prior abdominal surgery and the location of abdominal scars,
and review of the available cross-sectional imaging and colonoscopy report are important as these can infl uence the operative plan. With the exception of patients with selected very
large tumors, tumors requiring complex en bloc resection,
and patients known to have severe adhesions, nearly all
patients contemplating left colectomy are candidates for
hand-assisted surgery.
Pearls: Potential alterations in bowel function should be
discussed preoperatively as patients can be frustrated by
unexpected changes in bowel habits. The possible need for
a defunctioning stoma should also be discussed in advance
of left colectomy; however, diversion is rarely required.
Ideally, a complete colon evaluation should be performed
prior to colectomy to exclude synchronous pathology.
H.M. Ross et al. (eds.), Minimally Invasive Approaches to Colon and Rectal Disease: Technique and Best Practices,
DOI 10.1007/978-1-4939-1581-1_7, © Springer Science+Business Media New York 2015
81
82
Procedure
Setup
Lower extremity sequential compression devices are placed
and activated and general anesthesia is induced. The patient
is placed in either modifi ed lithotomy position with adjustable stirrups or in split-leg position with a bariatric-type
table (Fig.
minimize the risk of neuropraxia or pressure-related skin
breakdown. This positioning allows the surgeon to stand
between the legs during mobilization of the splenic fl exure
and permits access to the anus for colonoscopy or insertion
of the circular stapler. If stirrups are used, the thighs should
be kept parallel to the fl oor, as greater than 10° of fl exion of
the hip can often limit the ability to access the upper abdomen through lower abdominal ports. The right arm is padded
and tucked in neutral position to allow the surgeon and assistant to stand on the right side of the table. A strap is placed
across the chest to secure the patient to the operating table to
facilitate extreme positioning during portions of the operation that require gravity to aid exposure. A bladder catheter is
placed and the abdomen is prepared and draped, per usual.
Deep venous chemoprophylaxis should be administered
prior to the procedure, and appropriate intravenous antibiotics should be given within 1 h of the skin incision. To further
reduce surgical site infection, patients are oxygenated with
0.8 FiO 2 during the case. Core body temperature should be
maintained according to individual institutional protocols.
7.1 ). It is important to adequately pad patients to
S. Lee-Kong and D.L. Feingold
The surgeon should confi rm that all equipment is either in
the room or is readily available (Table 7.1 ). A 30° angled
laparoscope is used to look over the horizon of the operative
fi eld; this scope is more versatile than a standard 0° scope.
Additional suggested equipment includes a colonoscope
insuffl ation is preferred over ambient air) and lighted
(CO
2
handheld deep pelvic retractors that facilitate pelvic dissection through the hand-port access. In general, disposable
devices (hand port, energy device, and suction irrigator) are
not opened until the surgeon enters the abdomen and confi rms the feasibility of a hand-assisted approach.
Procedure Steps
Hand-Assisted Left Colectomy (Videos 7.1 , 7.2 , and 7.3 )
Port Placement
Hand-port placement: A Pfannenstiel incision placed two fi ngerbreadths above the symphysis pubis is used for the majority of patients. In patients with prior lower midline incisions
and in patients considered at higher risk of conversion, a
lower midline incision is typically used. When dissecting
through the subcutaneous fat down to the fascia through a
Pfannenstiel incision, avoid skiving towards the symphysis
pubis as placing the port too close to the pubis may restrict
access through the port and may cause the hand port not to sit
well. Adequate fl aps must be created between the anterior
rectus sheath and the rectus muscle to ensure suffi cient space
for the operating surgeon’s hand. Once the abdomen is
Fig. 7.1 Positioning of the
patient on a split-leg table
7 Hand-Assisted Left Colectomy
83
Table 7.1 Equipment
• 5 mm 30° laparoscope
• Trocars (5 mm × 4), hand-access port
• Laparoscopic blunt atraumatic graspers and scissors
• 5 mm blunt tip LigaSure™ (Covidien, Mansfi eld, MA) or other
energy device, per surgeon preference
• Bowel stapler with appropriate loads
• End-to-end stapling device (appropriate sizes available)
• Colonoscope with carbon dioxide insuffl ation device
• Standard laparoscopic instrumentation (i.e., atraumatic graspers,
Maryland dissector, etc.)
be preferable to place upper quadrant ports to evaluate the
adhesions and to potentially perform adhesiolysis to allow
hand- port placement.
A laparotomy pad (with an attached radiopaque ring) is
placed within the abdomen prior to securing the hand-port
device. The pad facilitates exposure by keeping the small
bowel out of the fi eld, keeping the operative fi eld dry, and
allowing the surgeon to clean the scope without actually
removing the scope from the abdomen. In order to reduce the
risk of a retained foreign body, a hemostat is placed on the
surgeon’s surgical gown as a reminder that a laparotomy pad
is within the abdomen. When the pad is removed and handed
back to the scrub nurse, the hemostat is handed back as well.
Left Colon Dissection
Mobilization of the splenic fl exure: In the majority of cases,
the splenic fl exure will need to be mobilized to ensure a
tension- free colorectal anastomosis. In order to decrease the
risk of splenic injury, care should be taken to avoid undue
traction on splenic attachments during the mobilization.
Manipulation of the splenic fl exure mesentery must also be
done carefully, as injury to the marginal artery may compromise the vascular supply to the bowel being used for the
anastomosis. There are several ways to approach taking
down the splenic fl exure (medial at the inferior mesenteric
vein (IMV), lateral up the left paracolic gutter, entering the
lesser sac at the midline). Typically, and especially in cases
with an extreme splenic fl exure, a combination of all three
approaches is utilized to mobilize the fl exure all the way to
the ligament of Treitz.
Fig. 7.2 Hand-assisted device and port site placement for a left
colectomy
entered, inspection of the fi eld and palpation through the
wound allows the surgeon to determine whether or not to
proceed in hand-assisted fashion. If confi rmed, a reusable
5 mm camera port is then placed near the umbilicus with the
surgeon’s hand within the abdomen protecting the viscera,
and the abdomen is insuffl ated. Two additional 5 mm working ports are placed under direct laparoscopic visualization in
the left lower quadrant and right lower quadrant lateral to the
inferior epigastric vessels (Fig.
7.2 ). Once the ports are
placed, and before the dissection is begun, the abdomen is
surveyed and thoroughly explored for any abnormalities
(metastases, adhesions, injury due to port placement, etc.).
In patients likely to have adhesions from prior surgery
that might interfere with hand-assisted colectomy, it may
Medial-to-Lateral Approach at the IMV
This is the preferred approach to the fl exure because it allows
relatively easy mobilization of the colon and mesocolon up
off of the retroperitoneum, while the lateral-to-medial
approach requires the surgeon to dissect in a plane while
looking up over the horizon. Placing the patient in reverse
Trendelenburg position with the table tilted right side down
allows the small bowel to be placed in the right side of the
abdomen and aids in exposing the anatomy. The assistant
stands on the right side of the patient holding the camera and
using a grasper through the right-sided port to retract the
greater omentum and transverse colon cephalad over the liver
exposing the paraduodenal fossa with the left colon mesentery and ligament of Treitz (Fig. 7.3 ). The surgeon, standing
between the legs with the left hand in the abdomen and the
energy device in the left-sided port, should appreciate the
location of the aorta, the 4th portion of the duodenum, and
the IMV. The intra-abdominal laparotomy pad helps to keep
the small bowel out of the fi eld of dissection. The peritoneum
overlying the paraduodenal space is incised and a retromesenteric plane is developed in medial-to-lateral fashion
7.4 ). This peritoneum should be taken sharply to avoid
(Fig.
84
S. Lee-Kong and D.L. Feingold
Fig. 7.3 Paraduodenal fossa at the ligament of Treitz demonstrating
the inferior mesenteric vein (IMV)
Fig. 7.5 Entering the lesser sac near the midline
Fig. 7.4 Medial-to-lateral dissection at the IMV in the avascular plane
using energy so close to the duodenum. The retroperitoneum
including the ureter, the gonadal bundle, and Gerota’s fascia
are pushed dorsally and the mesocolon is swept ventrally. If
the correct plane is entered, this dissection is relatively avascular. This dissection is carried as far laterally to the abdominal wall as possible and cephalad to the inferior border of the
pancreas. Care should be taken to avoid dissecting behind the
pancreas or into the retroperitoneum as this can jeopardize
the retroperitoneal structures. Once this dissection is completed, the IMV can be divided using the energy device.
The greater omentum is retracted anteriorly and cephalad
by the assistant and the transverse colon is retracted caudally
by the surgeon. This retraction facilitates exposure to enter
the avascular plane that separates the greater omentum from
the transverse colon and mesocolon (Fig.
7.5 ). This dissec-
tion, most easily started near the midline at the falciform
ligament, enters the lesser sac and is carried laterally towards
the splenic fl exure (Fig. 7.6 ), fully releasing the omentum,
Fig. 7.6 The lesser sac is entered—notice the back wall of the
stomach
which can now serve as an omental pedicle fl ap. During the
dissection, the surgeon’s left hand protects the colon and the
stomach from collateral damage from the energy device. As
the dissection progresses along the left transverse colon, it is
important to use tissue triangulation to actually see the colon
as it courses cephalad into the left upper quadrant at the
splenic fl exure; this helps prevent injury to the colon.
While the left colon is gently retracted by the assistant
grasping an epiploica, the surgeon’s left hand is placed into
the retromesenteric space and is used to demonstrate the
plane of dissection. Using the energy device through the leftsided port, the colon is released from its lateral attachments
(commonly referred to as the white line of Toldt), and the
retromesenteric dissection plane that had been mobilized
previously in medial-to-lateral fashion is entered. The dissection is carried cephalad towards the splenic fl exure
7.7 ). The mesocolon is dissected free from the inferior
(Fig.
border of the pancreas, completely releasing the splenic fl exure. Once the left colon is mobilized, the surgeon performs a
sweep with his hand to confi rm the colon is completely
mobilized from the retroperitoneum, the omentum, and the
7 Hand-Assisted Left Colectomy
85
Fig. 7.7 Taking down the remaining lateral colonic attachments while
working cephalad towards the splenic fl exure
Fig. 7.9 Grasping the inferior mesenteric artery pedicle
Fig. 7.8 Exposure of the sigmoid mesocolon. The aortic bifurcation
and common iliac vessels can be seen. In addition, the right ureter is
often seen crossing over the iliac in this view
spleen, as persistent attachments can jeopardize reach to the
pelvis and the ability to exteriorize the specimen.
Sigmoid Colon Mobilization
This mobilization is typically performed using a medial-tolateral approach. Occasionally, in cases with complicated
anatomy like severe infl ammation or signifi cant redundancy
of the colon, the lateral-to-medial approach may be technically easier.
Medial-to-Lateral Dissection of the IMA
With the patient in steep Trendelenburg position, the assistant stands at the right shoulder holding the camera and the
surgeon stands at the right hip with the right hand in the
abdomen and the energy device in the right-sided port. The
mesosigmoid is exposed by retracting the small bowel out of
the pelvis and towards the right upper quadrant. The laparotomy pad again helps keep the small bowel out of the way.
The surgeon should appreciate the aorta and the aortic bifurcation, the common iliac arteries, and the right ureter
(Fig. 7.8 ). The sacral promontory is an important landmark
as it is a midline structure and helps keep the surgeon
Fig. 7.10 Identifi cation of the left ureter
Fig. 7.11 Developing the left retromesocolic plane
oriented. Using the hand, the IMA pedicle is elevated
and retracted towards the patient’s left side (Fig. 7.9 ).
The peritoneum just dorsal to the pedicle is scored with
the energy device and the retromesenteric plane is entered.
The window into the retromesenteric space is extended caudal past the sacral promontory to allow wide exposure of the
retroperitoneum. This plane is developed bluntly by pushing
the retroperitoneal structures (hypogastric nerves, left ureter
(Fig. 7.10 ), left gonadal vessels) dorsally while dissect-
ing laterally towards the left sidewall (Fig. 7.11 ). With the