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86
S. Lee-Kong and D.L. Feingold
Fig. 7.12 Isolation of the IMA pedicle
Fig. 7.13 IMA division using an energy device
IMA elevated, the retromesenteric plane is developed
cephalad as well, meeting the prior IMV dissection plane
which was developed during splenic fl exure mobilization.
By supinating the hand underneath the mesosigmoid, a mesenteric window is identifi ed on the left side of the IMA pedicle. This avascular mesentery is incised, isolating the IMA
(Fig. 7.12 ). The IMA (proximal to the left colic artery take-
off) or the main sigmoidal artery (distal to the left colic artery
takeoff) is divided with the energy device after confi rming
that the left ureter is protected (Fig. 7.13 ). The “stay-side”
(proximal) stump of the pedicle is reinforced, as needed,
with a preformed looped ligature.
An alternative to ligating the mesenteric pedicle as
described is to perform a mid-mesenteric dissection whereby
the superior hemorrhoidal artery is preserved and the actual
sigmoid branches are sequentially ligated. This may be done
for benign disease processes. This approach keeps the fi eld
of dissection off of the retroperitoneum and preserves the
IMA blood supply to the proximal rectum, which is the distal
side of the planned colorectal anastomosis. Patients with
stricturing disease or who, for whatever reason, have not had
neoplasia excluded preoperatively should undergo a cancertype operation.
Once the pedicle is ligated, the retromesenteric plane is further developed as far laterally as possible and cephalad over
Gerota’s fascia. To mobilize the sigmoid colon from its lateral
attachments at the pelvic inlet, it is helpful to retract the colon
medially using a grasper in the right-sided port and to use the
energy device placed through the hand-access port to take the
lateral attachments down. Alternatively, the lateral attachments
can be dissected out in open fashion through the hand-port
site. In order to mobilize the proximal rectum, the presacral
space is entered. This facilitates creating a colorectal anastomosis (as opposed to a colo-colonic anastomosis) and helps to
straighten the rectum to allow passage of the EEA stapler.
Bowel Division and Anastomosis
The detachable cap of the hand port is removed leaving the
self-retaining wound retractor/protector and the colon is
exteriorized. Any residual mesentery not already taken laparoscopically is taken at this point in open fashion. Open staplers (as opposed to laparoscopic devices) are used to
transect the proximal and distal colorectal margins; the specimen is delivered and oriented for the pathologist and is evaluated on a dirty back table to grossly evaluate the pathology
and the margins.
Working through the hand port in open fashion, adequate
blood supply to the end of the colon is confi rmed and the anvil
of an appropriately sized EEA stapler is seated and secured.
Care should be taken to exclude any false diverticula from the
anticipated site of the colorectal anastomosis as these can
increase the risk of leak. The remaining part of the operation
can be completed in open fashion or by resuming hand-assisted
laparoscopy. The rectal staple line is leak tested; this allows for
repair of a defect prior to creating the anastomosis. The colonic
end is brought down to the pelvis and reach is assessed.
Orientation of the colon is confi rmed by verifying that neither
the anti-mesenteric edge of the mobilized colon nor the cut
edge of the mesentery is twisted. The anus is sequentially
dilated and the EEA anastomosis is created in usual fashion.
The anastomotic donuts are evaluated and the anastomosis is
leak tested, per usual. We prefer leak testing with colonoscopic
visualization to blindly insuffl ating the rectum.
Prior to closing, hemostasis is confi rmed and the intraabdominal laparotomy pad is removed. The surgeon also
performs a manual and visual sweep to minimize the risk of
undetected retained foreign bodies and confi rms that the
small bowel is not herniated underneath the mobilized colon.
Finally, the omental pedicle is placed over the anastomosis
and under the Pfannenstiel wound.
Postoperative Care
Enteral nutrition is initiated with a clear liquid diet starting
the day of operation and the diet is advanced as patients
tolerate without waiting for fl atus or a bowel movement.
Nasogastric tubes are not utilized immediately postopera-
7 Hand-Assisted Left Colectomy
87
tively in elective colectomy cases. Progressive ambulation
is encouraged beginning the day after the operation
and incentive spirometry is uniformly implemented.
Multi-pharmacy pain control relies on the combination of
intravenous patient- controlled narcotic analgesia, intravenous ketorolac, and oral acetaminophen. Intravenous narcotics are replaced with enteral formulations once patients
tolerate a diet. Deep vein thrombosis chemoprophylaxis is
initiated prior to incision with subcutaneous unfractionated heparin or enoxaparin and continues through the hospitalization together with sequential compression devices.
Urine catheters are typically removed within 24–48 h.
Postoperative laboratory blood tests are minimized and
are typically drawn on the fi rst postoperative day only or
not at all.
Complications
As in any surgical procedure, complications from handassisted colectomy invariably occur. Intraoperative complications may include excessive bleeding, bowel injury (due to
port placement, tissue handling, or delayed thermal injury),
and ureteral injury. The incidence of technical complications
can be reduced by verifying the operative anatomy rather than
relying on pattern recognition, by minimizing the laparoscopic
use of monopolar energy, and by being mindful of potential
injuries that can occur “off screen”.
Early postoperative complications may include infection,
Pfannenstiel wound hematoma and other wound complications, prolonged ileus or early postoperative bowel obstruction, thromboembolic events, cardiac complications, as well
as the dreaded anastomotic dehiscence. The risk of many of
these complications can be reduced by adhering to sound
perioperative principles like appropriate use of perioperative
antibiotics and DVT prophylaxis, early ambulation and pulmonary toilet, timely removal of bladder catheters, and creating tension-free anastomoses with healthy bowel and
adequate blood supply (Table 7.2 ).
Table 7.2 Complications
Intraoperative
• Vascular injury
• Enterotomy
• Ureteral injury
Postoperative
• Early
– Urinary tract infection
– Respiratory infection
– Surgical site infection
– Anastomotic dehiscence
– Hemorrhage
• Late
– Anastomotic stricture
Pearls and Pitfalls
• Ureteral stenting may facilitate dissection in selected
complicated cases such as morbidly obese patients, irradiated patients, patients undergoing reoperation, and
patients whose preoperative imaging suggests abnormal
anatomy.
• One should have a low threshold for utilizing a lower
midline incision over a Pfannenstiel incision for hand
access, particularly for patients in whom you anticipate a
higher chance of conversion (extensive prior intraabdominal surgery, large tumors, fi stulizing disease, etc.).
• Surgeons unfamiliar with hand-assisted surgery can have
diffi culty “keeping the hand out of the way” and can
feel that the hand actually interferes with performing the
operation. Cupping the hand like a “C” and extending
the fi ngers so that the knuckles do not buckle improve
visualization and access to the fi eld. As surgeons progress
along the learning curve, they learn how to use the hand
more effectively and transition from using the hand only
as a grasping-type retractor to utilizing the hand and individual fi ngers for blunt dissection, maintaining exposure,
palpation of the anatomy, and keeping other structures out
of harm’s way.
• Ureter identifi cation is not always straightforward. If the
retromesenteric dissection is too deep (posterior), the left
ureter may actually be above the plane of dissection (on
the ceiling of the space). If the patient’s body habitus
and camera port placement do not allow identifi cation
of the ureter looking through the retromesenteric window under the IMA pedicle, the surgeon can incise the
mesentery cephalad to the IMA (described above) and
fi nd the ureter through that window. In cases where the
medial-to-lateral approach does not expose the left ureter, alternating to the lateral-to-medial dissection may
help identify the ureter.
• Cases with confounding anatomy and cases that are not
progressing over time should be converted to an open
approach. Conversion should not be viewed as a failure;
rather, it may be safer than persisting laparoscopically
and it is a powerful teaching tool that allows the surgeon
to understand complex anatomy and master a challenging
learning curve.
• A potential catastrophic complication of creating a
colorectal anastomosis using a circular stapler is passing
the stapler through the vagina instead of the anorectum.
This can be prevented by performing a confi rmatory vaginal exam and pulling the posterior vaginal wall away prior
to fi ring the stapler.
• Splenic bleeding from a capsular tear can usually be managed with a combination of electrocautery, absorbable
hemostatic agents, and manual compression using the
laparotomy pad.
88
S. Lee-Kong and D.L. Feingold
• The actual order in which the individual operative steps
are performed is not usually important. Part of the sophistication of the hand-assisted technique is that if the dissection does not progress due to the anatomy (tumor,
infl ammation, abdominal fat, etc.), you can switch to a
different approach (lateral-to-medial dissection, straight
laparoscopy, open dissection though the hand-port access,
etc.). Oftentimes, complicated cases can be successfully completed by alternating between these approaches
rather than by dogmatically sticking to one particular
technique.
• Extreme splenic fl exures (due to the cephalad location of
the fl exure and/or diffi cult colonic attachments) can be
challenging. Placing the patient in steeper reverse
Trendelenburg position with the right side of the table down
can facilitate the dissection by bringing the operative fi eld
closer to the surgeon. Using longer (bariatric- type) laparoscopic instruments can also be helpful in this situation.
Placing an additional 5 mm port in the right upper quadrant
can help with retraction and exposure. Approaching the
fl exure by alternating between the left paracolic gutter, the
medial-to-lateral plane, and the lesser sac helps release the
splenic fl exure by creating a knuckle that accentuates whatever attachments remain of the fl exure.
• Prior to creating the anastomosis, adequate reach of the
colon should be confi rmed. In general, the end of the
colon should stay, by itself, resting in the pelvis while
the patient is in steep Trendelenburg position. In cases
where there is insuffi cient reach, after confi rming that
all left upper quadrant attachments have been released,
sacrifi cing the left colic artery and/or taking the IMV (if
not already done) may be required. Incising the medial
aspect of the colon mesentery permits straightening of
the colon and helps with reach; when performing this
maneuver, care should be taken to preserve the blood
supply through the marginal artery. On occasion, ligating the left branch of the middle colic artery to further
release the transverse colon mesentery may be needed to
afford reach.
• If a leak is demonstrated while testing the rectal staple
line prior to creating the anastomosis, suture repair can be
performed through the hand-port access. A leak demonstrated after fi ring the circular stapler may be addressed
by suture repair, creating a new anastomosis or, in certain
circumstances, proximal diversion.
• On occasion, an anastomotic donut may be thin, incomplete, or missing. These situations, typically, do not
require a specifi c remedy as long as the endoscopic exam
is normal and the leak test is negative.
• In cases with a diffi cult retroperitoneal dissection, the
integrity of the ureters can be evaluated, to some degree,
by administering intravenous indigo carmine.
• The descending colon mesentery may restrict the reach of
the end of the colon to the pelvis. Rather than sacrifi cing
the mesentery (and potentially compromising blood fl ow
to the anastomosis), consider confi guring the anastomosis
in a side-to-end fashion (Baker anastomosis) that might
permit tension-free reach while preserving the mesentery.
• When securing the anvil of the circular stapler with the
purse-string suture, the colon may not cinch down tightly
onto the anvil leaving a gap between the colon and the
device. An alternative to tying the purse string tighter (this
often results in breaking the suture) is to place a 4-point
“U” stitch using a braided suture through the colon around
the anvil. This suture can be tied down tightly and pulls
the colon snug onto the anvil.
Conclusion
Hand-assisted left colectomy has the advantages of shorter
operative times and decreased conversion rates compared
with the “straight” laparoscopic approach; otherwise, the
two techniques have equivalent clinical outcomes. This
versatile technique restores tactile feedback to the surgeon
and facilitates dissection in cases of complicated anatomy.
In colectomy cases where diffi culties are encountered
using straight laparoscopy, conversion to a hand-assisted
procedure can potentially avoid the need for conversion to an
open approach.
References
1. Clinical Outcomes of Surgical Therapy Study Group. A comparison
of laparoscopically assisted and open colectomy for colon cancer. N
Engl J Med. 2004;350:2050–9.
2. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM,
et al. Short-term endpoints of conventional versus laparoscopicassisted surgery in patients with colorectal cancer (MRC CLASICC
trial): multicenter, randomized controlled trial. Lancet. 2005;365:
1718–26.
3. Jayne DG, Thorpe HC, Copeland J, Quirke P, Borwn JM, Guillou
PJ. Five-year follow-up of the Medical Research Council CLASICC
trial of laparoscopically assisted versus open surgery for colorectal
cancer. Br J Surg. 2010;97:1638–45.
4. Marcello PW, Fleshman JW, Milsom JW, Read TE, Arnell TD,
Birnbaum EH, Feingold DF, Lee SW, Mutch MG, Sonoda T, Yan Y,
Whelan RL. Hand-assisted laparoscopic vs. laparoscopic colorectal
surgery: a multicenter, prospective, randomized trial. Dis Colon
Rectum. 2008;51(6):818–26.
Total Abdominal Colectomy: Straight Laparoscopic Approach
Amanda V. Hayman and Eric J. Dozois
8
K e y P o i n t s
• A clear understanding of the embryonic planes when
mobilizing the colon will signifi cantly reduce the risk of
bleeding and inadvertent injury to retroperitoneal
structures.
• Appropriate port placement allows and greatly facilitates
the ability to perform optimal traction and countertraction
necessary for a straight laparoscopic approach to colonic
dissection.
• Multiple strategies are available, and should be employed,
to prevent rectal stump dehiscence in patients undergoing
subtotal colectomy for fulminant colitis.
• Exposing the lesser sac completely greatly facilitates ligation of the transverse colon mesentery.
• When extracting the entire colon through a small incision,
removing the right colon fi rst may prevent an inadvertent
perforation of the thin-walled cecum.
Background
Total abdominal colectomy (TAC) is performed for a variety
of conditions. The main surgical indications are fulminant
or toxic colitis resulting from infection (i.e., Clostridium
diffi cile ) or, more commonly, refractory ulcerative colitis, diffuse colonic Crohn’s disease, slow transit constipation, familial adenomatous polyposis, and Lynch syndrome. In some
settings, such as fulminant colitis, an end ileostomy and
Hartmann’s rectal stump are performed as an immediate anastomosis has a high risk of failure. In most other circumstances,
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
A. V. Hayman, M.D., M.P.H. • E. J. Dozois , M.D. (*)
Division of Colon & Rectal Surgery, Department of Surgery , Mayo
Clinic , 200 1st Street SW, Gonda 9-S , Rochester , MN 55905 , USA
dozois.eric@mayo.edu
e-mail:
.
10.1007/978-1-4939-1581-1_8 .
http://www.springerimages.com/videos/
an ileorectal anastomosis can be performed safely in order
to restore intestinal continuity.
Several studies have demonstrated that a minimally invasive approach to TAC is feasible, safe, and associated with
signifi cant short-term benefi ts [
invasive techniques to colectomy exist including: handassisted laparoscopy, straight laparoscopy, laparoscopicassisted laparoscopy, and single-port laparoscopy [ 3 – 5 ]. As
more experience has been gained in minimally invasive
approaches, straight laparoscopy—in which all dissection,
vessel ligation, and the manufacturing of the anastomosis are
performed intracorporeally—has become increasingly popular among surgeons. Although a straight laparoscopic
approach to TAC is associated with a longer operative times
[ 6 ], it avoids the larger incision associated with a hand-
assisted approach, which increases the risk of skin and soft
tissue infections and hernias. Moreover, if extraction of the
colon can be done through a stoma site, or a natural orifi ce
(rectal stump or vagina), instead of a formal abdominal wall
incision, even further benefi ts may be seen [ 7 ].
In this chapter, we will outline the technical steps we use
when performing a straight laparoscopic TAC followed
either by an ileorectostomy or by an end ileostomy and
Hartmann’s rectal pouch.
1 , 2 ]. A number of minimally
Preoperative Planning and Decision Making
When deciding to use a straight laparoscopic approach to
TAC, appropriate timing for surgery and proper patient selection are imperative to optimizing surgical outcomes. Patients
that need an emergency colectomy who are critically ill are
typically not suited for a straight laparoscopic approach.
Patients with severe colitis that have a dilated toxic megacolon will be a high risk for intra-abdominal bowel perforation
using a straight laparoscopic approach as this technique
requires signifi cant manipulation of the colon with bowel
graspers. In these patients we perform an open procedure,
which is fast and safe in terms of bowel manipulation.
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_8, © Springer Science+Business Media New York 2015
89
90
A.V. Hayman and E.J. Dozois
Many hospitalized patients with infl ammatory bowel disease (IBD) that surgeons are asked to see for colectomy are
nutritionally deplete, anemic, and on high-dose corticosteroids and/or immunomodulators. These patients will benefi t
from some medical optimizing if they do not need immediate
surgery. Moreover, these patients may also have a superimposed Clostridium diffi cile or cytomegalovirus infection in
addition to their underlying IBD, and a short course of antibiotic or antiviral therapy may assist in avoiding an emergency colectomy. Patients with a history of corticosteroid
use will need a steroid prep at the time of surgery, followed
by a postoperative taper.
Whenever possible, patients should meet with an enterostomal therapist preoperatively to have all potential stomal
sites identifi ed and marked and be educated about living with
a stoma. Some surgeons recommend mechanical bowel
preparation in patients undergoing laparoscopic colectomy,
not because they believe it reduces infection, but because a
large stool load in the colon makes laparoscopic manipulation of the colon diffi cult. We have not found that to be true
for most patients and only perform mechanical bowel preparation in patients undergoing TAC for slow transit constipation. However, we do perform 2 tap water enemas in the
morning of surgery in all patients to clear the lower colon
and rectum, which facilitates stapling of the ileorectal anastomosis. Ultimately, the decision of whether or not to use
mechanical bowel preparation should be individualized
based on the operating surgeon’s best judgment.
Fig. 8.1 “Asymmetric baseball diamond” laparoscopic port positioning for total abdominal colectomy ( With permission from Mayo Clinic )
Operation
Setup
Intravenous antibiotics and 5,000 units of heparin are given
within 60 min of incision. Once the patient has undergone
general anesthesia, a urinary catheter and orogastric tube are
placed. Even if planning only an end ileostomy with
Hartmann’s stump, we prefer lithotomy position so that the
operating surgeon can stand between the legs for certain
parts of the procedure and also have access to the anus and
rectum. Proctoscopy during the operation can be useful to
assess adequate closure of a diffi cult rectal stump, to evacuate all stool and mucus, and in some cases, to leave a draining rectal tube. When a rectal drainage tube is indicated, we
use a large urinary catheter with a 30 cc balloon. The catheter
is passed into the mid-rectum and the balloon is infl ated
above the level of the pelvic fl oor to keep it in place. This
obviates the need for perineal sutures to secure a tube, which
is extremely uncomfortable for patients. Both arms are
tucked and well padded with gel or foam mats to avoid
extremity nerve compression injury. Chest straps are routinely utilized to accommodate the steep medial-lateral and
caudad-cephalad bed tilts required for the procedure.
Accessing the Abdomen and Port Placement
Either an OPTIVIEW ® (Ethicon, Cincinnati, OH), Hasson, or
Veress technique can be used to secure safe access to the
abdomen. For most cases, we access the abdomen using a
5 mm OPTIVIEW port, placed just above the umbilicus. A 0°
scope is used for the OPTIVIEW access step, and then a 30°
scope is used for the rest of the operation. Our preference is
to utilize all 5 mm ports, whenever possible, as these port
sites do not require fascial closure and have a smaller risk for
postoperative hernia. Three other 5 mm ports are then placed
under direct vision in a slightly asymmetric “baseball diamond” pattern, one suprapubic, another in the right lower
quadrant (if appropriately positioned a hand’s breadth away,
the ileostomy site can be used), and the last in the left lower
quadrant slightly more cephalad than the right lower quadrant
port (Fig. 8.1 ). When intracorporeal stapling is required, one
port (usually the right lower quadrant port) will be upsized
later to a 12 mm port to accommodate the stapler. Some port
site modifi cations may be necessary based on patient anatomy. For example, in patients with a low hypogastrium, the
camera port may need to be shifted superiorly from the umbilicus. In obese patients, the left lateral port may need to be
medialized in order to reach the hepatic fl exure, and the
8 Total Abdominal Colectomy: Straight Laparoscopic Approach
91
suprapubic port placed more superior to reach the splenic
fl exure. In addition, we always have a set of extra-long bowel
graspers that come in handy when operating on tall patients
or those with high splenic and hepatic fl exures.
Operative Steps (Video 8.1 )
Right Colon
The right or left colon can be approached fi rst. We prefer to
start with the right side and use a modifi ed medial-to-lateral
approach to the colonic mobilization. The patient is placed in
steep Trendelenburg with the right-sided tilt. The small intestine is swept out of the pelvis and placed into the left upper
quadrant. The ileum, or a leaf of ileal mesentery near the
cecum, is grasped and retracted up and slightly left which
exposes the areolar plane between the distal ileal mesentery
and the retroperitoneum. Using hot scissors, the peritoneum
overlying this indentation just anterior to the iliac artery is
incised and carried proximally and medially exposing the
retroperitoneum. This dissection can be carried as far as the
ligament of Treitz, if needed. This exposes the plane between
Toldt and Gerota’s fascia and, when in this avascular plane,
blunt dissection is performed in a medial-to-lateral fashion
across to the underside of the ascending colon mesentery and
superiorly to the inferior border of the duodenum (Fig. 8.2 ).
It is critical during this dissection to stay cleanly between
Toldt and Gerota’s fascia as this avoids unnecessary bleeding
and decreases the risk of injury to retroperitoneal structures.
If signifi cant bleeding is encountered, the surgeon is likely
not in the correct plane. The ureter and gonadal vessels
should be clearly visible at this point. The dissection is then
continued inferiorly and laterally toward the cecum. The
appendix is grasped and the peritoneum incised laterally to
separate the cecal attachments from the pelvic sidewall
(Fig. 8.3 ). Care must be taken to stay just next to the bowel
to avoid injury to retroperitoneal structures. The fi nal step in
fully mobilizing the right colon is to grasp the colon and to
pull it medially so that the lateral line of Toldt is placed under
tension and can be easily incised. Very little dissection is
required at this point to join the previous medial dissection
plane. Once complete, this mobilization provides excellent
visualization of the right colon mesenteric vessels (Fig. 8.4 ).
The vessels to the right colon are taken by opening a plane
between the ileocolic and right colic arteries (Fig. 8.5 ). The
vessels can either be taken close to the colon or more proximally close to the superior mesenteric artery and vein. High
ligation of these vessels is done in IBD patients who have
dysplasia in the right colon and in patients with known
malignancy (Fig. 8.6 ). In benign cases, the vessels are taken
where easy and convenient.
Transverse Colon and Hepatic Flexure
The patient is then placed level (side-to-side) and in a slight
reverse Trendelenburg position. The omentum is addressed
fi rst. In most cases it is preserved and taken off the transverse
colon and hepatic and splenic fl exure regions by pulling
Fig. 8.2 Retroperitoneal exposure during medial-to-lateral dissection
of the right colon ( D duodenum, Ao aorta, SMA superior mesenteric
artery, Ur ureter, GV gonadal vessels) ( With permission from Mayo
Clinic )
Fig. 8.3 Dissection plane for separating the lateral attachments of right
colon from the sidewall ( With permission from Mayo Clinic )
92
A.V. Hayman and E.J. Dozois
Fig. 8.4 Posterior view of right colon after complete mobilization
( RCA right colic artery, ICA ileocolic artery, SMA superior mesenteric
artery) ( With permission from Mayo Clinic )
Fig. 8.5 Ligation of the right colon mesentery ( With permission from
Mayo Clinic )
Fig. 8.6 Plane for high ligation of mesentery near the SMA ( MCA mid-
dle colic artery, RCA right colic artery, ICA ileocolic artery, SMA supe-
rior mesenteric artery, Ca cancer) ( With permission from Mayo Clinic )
downward to the transverse colon and upward to the omentum. Caution must be taken when taking the omentum off the
splenic fl exure as it is sometimes adherent to the splenic capsule, and too much tension may result in splenic capsule
avulsion and signifi cant bleeding (Fig. 8.7 ). The hepatic fl ex-
ure can be mobilized from the left by taking down the hepatocolic ligaments, exposing the plane between Gerota's
fascia, identifi ed by its pale white appearance and the transverse mesocolon (Fig. 8.8 ). Downward traction of the colon
at the hepatic fl exure toward the pelvis greatly facilitates this
portion of the dissection as this motion puts the hepatocolic
ligaments under maximal tension. Ultimately, the avascular
plane around the fl exure is fully developed bluntly all the
way to the right abdominal side wall, forming a tunnel, and
the transverse mesocolon is separated from the gastrocolic,
duodenal, and pancreatic attachments (Fig. 8.9 ). This plane
ultimately joins the dissection done when mobilizing the
right colon earlier. At this point, the right and left branches of
the middle colic are easily exposed and can be taken
(Fig. 8.10 ). Once the left branch of the middle colic artery is
taken, we address the sigmoid and left colon.
8 Total Abdominal Colectomy: Straight Laparoscopic Approach
93
Fig. 8.7 Separation of the omentum from the distal transverse colon
mesentery during splenic fl exure mobilization ( With permission from
Mayo Clinic )
Fig. 8.9 Exposure of right retroperitoneal structures with downward
traction of hepatic fl exure after completion of mobilization ( SMA supe-
rior mesenteric artery, Ur ureter, IVC inferior vena cava) ( With permis-
sion from Mayo Clinic )
Fig. 8.8 Excision of the hepatocolic ligament during mobilization of
the proximal transverse colon at the hepatic fl exure, exposing the duodenum below ( With permission from Mayo Clinic )
Sigmoid Colon, Left Colon, and Splenic Flexure
For this portion of the operation, the patient is placed in steep
Trendelenburg with the patient’s left side tilted maximally
up. The small bowel is placed in the right upper quadrant,
exposing the left colon mesentery. The left colon is grasped
and pulled medially, putting the lateral line of Toldt under
maximal tension (Fig. 8.11 ). The sigmoid and left colon are
then fully mobilized to the midline of the abdomen in a
lateral- to-medial fashion. Again, it is critical during this
Fig. 8.10 Ligation of major colic arteries and mesentery of right colon
(R. br. MCA right branch of middle colic artery, RCA right colic artery,
ICA ileocolic artery, SMA superior mesenteric artery) ( With permission
from Mayo Clinic )
point of the dissection to stay cleanly between Toldt and
Gerota’s fascia. This exposes the retroperitoneal structures
(gonadal vessels and ureter) and avoids injury (Fig.
8.12 ).
94
A.V. Hayman and E.J. Dozois
Fig. 8.11 Dissection plane for separating the lateral attachments of left
colon from the sidewall (Ur: ureter) ( Inset : position of surgeon and
assistants around patient) ( With permission from Mayo Clinic )
The mobilization is then carried proximally to the splenic
fl exure. The splenic fl exure is taken down enough to visualize the mesentery for a safe, tension-free vessel ligation. The
splenocolic, phrenocolic, and pancreaticocolic ligaments are
identifi ed and incised for full splenic fl exure mobilization as
needed to ensure safe vessel ligation (Fig. 8.13a, b ).
Once full mobilization of the left colon and splenic fl exure is completed, the decision of where to transect the colon
must be made. If there is concern for a high-risk rectal stump,
as in the case of a patient with fulminant colitis, we transect
the sigmoid at a point that leaves enough length so it can be
brought up to the suprafascial position at the suprapubic port
site or lower part of the incision if one is made (Fig.
8.14 ). If
the stump is low risk for leak, or if ileorectostomy is going to
be performed, transection should be at the top of the rectum.
In either case, we typically preserve the superior rectal artery
to the rectal stump.
For patients who will get an ileostomy and who have a
high-risk distal bowel stump, the mid-sigmoid is transected
with the Endo GIA stapler (60 mm load) after upsizing the
right lower quadrant 5 mm port to a 12 mm port (Fig. 8.15a,
b ). Alternatively, the rectum can be transected transabdomi-
nally if a Pfannenstiel extraction port is planned. The sigmoid colon is then grasped and retracted medially and
anteriorly up toward the abdominal wall, and a vessel-sealant device is then used to ligate all remaining mesentery until
the site of the planned colon transection is reached proximally (Fig. 8.16 ).
For patients undergoing ileorectostomy, a window in the
mesentery at the level of the distal sigmoid is created by
taking the marginal artery. The mesentery is then taken
from this point inferiorly to the top of the rectum, staying
close the colon (Fig. 8.17 ). This preserves the superior rec-
tal artery blood supply to the rectal stump and signifi cantly
decreases the risk of sympathetic nerve injury. Once the
top of the rectum is adequately cleared of mesentery, the
right lower quadrant port can be upsized and the 60 mm
Endo GIA stapler is used to transect the rectum with a single fi ring (Fig. 8.18 ). The sigmoid colon is then grasped
and retracted medially and superiorly, and all the remaining mesentery proximally from this point up to the transected mesentery in the transverse colon done earlier is
taken (Fig. 8.19 ).
Fig. 8.12 Exposure of retroperitoneal structures during lateral mobilization of left colon
Specimen Extraction
Before closing the abdomen and making the ileostomy or
ileorectostomy, the entire abdomen should be inspected for
inadvertent injuries to the small bowel and for bleeding
(especially near the spleen). Options for specimen extraction fall into two main groups: through a natural orifi ce
route or through a traditional abdominal incision.
Traditional abdominal incisions can be low midline, periumbilical, Pfannenstiel, or off midline. Our preferred
approach in patients who require an ileostomy is to use the
stoma site to extract the entire colon, avoiding a formal
8 Total Abdominal Colectomy: Straight Laparoscopic Approach
Fig. 8.13 ( a ) Exposure of splenocolic ligament; ( b) Splenic fl exure recess with associated ligaments ( With permission from Mayo Clinic )
95
Fig. 8.14 Creation of a suprafascial sigmoid mucous fi stula ( With per-
mission from Mayo Clinic )
abdominal wall incision (Fig. 8.20 ). The other option for
extraction is to use a natural orifi ce. We have successfully
used the transvaginal route in our Lynch patients undergoing transvaginal hysterectomy at the time of TAC [ 7 ]. The
gynecologic surgeon performs the transvaginal hysterectomy and leaves the vaginal cuff open. We then place a
wound protector through the cuff and bring out the colon
and the terminal ileum (Fig. 8.21 ). The ileum is transected
and the EEA anvil is placed into the lumen, secured with a
purse-string suture or device, and then placed back into
the abdominal cavity. The vaginal cuff is closed transvaginally, pneumoperitoneum is restored, and the EEA stapler
is docked to the anvil using laparoscopic techniques.
Alternatively, the ileum can be brought out through one of
the port sites for anvil placement (Fig.
8.22 ).
If using a Pfannenstiel, the suprapubic port’s skin incision
is extended bilaterally, and the anterior fascia incised. The
rectus muscle is swept down bluntly, with care taken to avoid
any muscle trauma and subsequent bleeding. The peritoneum
is incised and a wound retractor placed transabdominally.
This approach also allows the passage of a small transverse
stapler, such as the TA30 or 45 to transect the rectum or midsigmoid in lieu of the Endo GIA. As the cecum is the widest
portion of the colon and has the thinnest wall, it is best to
extract the right colon fi rst when removing the whole colon
to prevent inadvertent colonic rupture when extracting
through very small incisions. One must confi rm that the
small bowel has been gathered in the left upper quadrant and
that the colon will not get caught on the small bowel mesentery upon extraction.
End Ileostomy
If creating an end ileostomy, the ostomy site is grasped with
a Kocher and a circular quarter-sized incision is made. A cylinder of subcutaneous tissue is also excised, and a cruciate
incision made in the anterior fascia above the rectus abdominis. Via a muscle-spreading technique, the peritoneum is
then exposed and incised so that two fi ngers can easily pass.
This technique is slightly more challenging than when