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96
A.V. Hayman and E.J. Dozois
Fig. 8.15 ( a ) Ligation of marginal artery in sigmoid colon mesentery; ( b ) Intracorporeal transection of sigmoid colon with laparoscopic stapler
to create a rectal stump (inset: position of surgeon and assistants around patient) ( With permission from Mayo Clinic )
Fig. 8.16 Ligation of proximal sigmoid mesentery with vessel sealer
after transection ( With permission from Mayo Clinic )
approached open, as minimal counter tension can be applied
intra-abdominally. If using a Pfannenstiel, the laparoscopy
camera cable can be disconnected and used as a “fl ashlight”
Fig. 8.17 Ligation of sigmoid mesentery prior to transection (inf. rectal a.: inferior rectal artery) ( With permission from Mayo Clinic )
to identify the ileal stump (if not already grasped with a locking bowel grasper) to be delivered to the ileostomy site. It is
of paramount importance at this point to make sure that the
ileum and ileal mesentery are not twisted or rotated. When in
proper orientation for a right-sided end ileostomy, the cut
loops are seen in the right upper quadrant to prevent internal
herniation. A Brooke ileostomy is then made after closing all
port sites (Fig. 8.23 ).
edge of the ileal mesentery should be seen going directly to
the head of the pancreas and splayed out fl at. Moreover, all
of the small bowel should be placed in the left side of the
abdomen and pulled out from under the ileal mesentery if
Ileorectostomy
If performing an ileorectal anastomosis (end-to-end), the
ileal stump is delivered through the extraction site, and a run-
8 Total Abdominal Colectomy: Straight Laparoscopic Approach
97
Fig. 8.18 Open transection of sigmoid colon to create rectal stump
(inf. rectal a.: inferior rectal artery) ( With permission from Mayo Clinic )
Fig. 8.19 Transection of remaining proximal colon mesentery after
sigmoid colon transection ( With permission from Mayo Clinic )
Fig. 8.20 Specimen extraction via planned ileostomy site ( With per-
mission from Mayo Clinic )
Fig. 8.21 ( a ) Transvaginal extraction of specimen and transection of
the ileum with a GIA stapler; ( b ) Transvaginal insertion of anvil into the
ileum for planned ileorectal anastomosis with an EEA stapler ( With
permission from Mayo Clinic )
ning purse string is created with 2.0 PDS suture. The anvil
from the 28 mm EEA is inserted intraluminally and secured
with the purse-string suture. The EEA stapler is carefully
maneuvered transanally to the end of the rectal stump after
using rectal sizers to dilate the sphincter. The pin is advanced
through the rectal stump, usually just superior to the rectal
staple line, and the anvil secured with a click, after ensuring
the colon mesentery is not twisted. Generally, the splayed
taeniae will be positioned anteriorly. The stapler is closed
completely and fi red. If desired, interrupted sutures can be
98
A.V. Hayman and E.J. Dozois
placed at the crossing staple lines to better secure the “dogeared” areas (Fig.
8.24a, b ). An alternative anastomotic
approach is the side (the ileum) to end (the rectum) ileorectal
anastomosis. The end of the ileum is stapled and oversewn
with interrupted 3.0 Lambert silk sutures. An enterotomy to
place the anvil must be made on the antimesenteric side of
the ileum 3–4 cm proximal to the transected end of the ileum
to avoid an ischemic segment between the circular staple line
and the transected end of the ileum. A purse-string stitch is
used to secure the anvil. Finally, a proctoscope is introduced
into the distal rectum to insuffl ate the anastomosis under a
water bath after occlusion of the ileum above the anastomosis. In the event of a “positive leak test,” we generally revise
the anastomosis instead of suture repairing it, but ultimately
this decision is made on a case-by-case basis. If technically
satisfi ed with the operation, and if there is no tension and an
excellent blood supply, we do not perform a defunctioning
loop ileostomy. In very rare cases where patient factors and
tissue quality are not ideal, a diverting loop ileostomy is done.
Fig. 8.22 ( a ) Insertion of anvil into the ileum via laparoscopic port site
extraction after intracorporeal transection and transvaginal extraction in
setting of shortened mesentery; ( b ) Creation of ileorectal anastomosis
using an EEA stapler after vaginotomy repair ( With permission from
Mayo Clinic )
Fig. 8.23 Creation of a Brooke
ileostomy ( With permission from
Mayo Clinic )
Fig. 8.24 ( a ) Creation of ileorectal anastomosis using an EEA stapler;
( b ) Sutures used to secure lateral “dog ears” on rectal side of ileorectal
anastomosis ( With permission from Mayo Clinic )
8 Total Abdominal Colectomy: Straight Laparoscopic Approach
Postoperative Care
At our institution, almost all patients are enrolled in an
enhanced recovery pathway that has been reported previously [ 8 ]. Key components of the pathway include:
– Absence of mechanical bowel preparation
– Preoperative intrathecal injection (when appropriate)
– Intraoperative fl uid restriction
– General diet (apart from fresh fruits and vegetables) start-
ing the night of surgery
– Routine pre- and postoperative oral NSAIDs and acet-
aminophen administration
– Avoidance of intravenous opioids
– Early ambulation
– Removal of urinary catheter on the fi rst postoperative day
– Cessation of intravenous fl uids on the fi rst postoperative day
We check electrolytes and a complete blood count on the
fi rst postoperative day and then only when indicated afterward. For patients who have an ileostomy, postoperative
stoma teaching is essential. Patients with stomas are not discharged until the stoma output is between 500 and 1,500 ml
per day. In the ileorectostomy patients, a bowel movement
prior to discharge is required.
Complications
Intraoperative
First and foremost, conversion to an open procedure should
never be viewed as a failure, but instead, as the appropriate
measure to take to avoid major complications. In some cases,
we have converted from straight to hand-assisted laparoscopy
if for technical reasons a hand inside will make the operation
safe and still provide the benefi ts of minimally invasive surgery. Intraoperative complications during straight TAC are
similar to that of minimally invasive colectomy and include:
trochar or cautery injury to hollow or solid organs or vessels,
inadvertent ligation of the ureter, vascular pedicle bleeding,
and delayed thermal injury to the small bowel from cautery.
Thermal injuries when noticed are treated with intracorporeal
Lembert sutures of the bowel to seal the site of injury.
Care must be used when using vessel-sealant devices in
patients with severe atherosclerotic diseases, as these devices
will not be as effective or reliable when sealing large calcifi ed vessels. When mobilizing the splenic fl exure, injudicious retraction can lead to splenic capsular bleeding and,
occasionally, the need for emergent splenectomy [ 9 ].
Another important safety issue is to ensure that the patient
is properly secured to the table. Given the extreme changes in
table angulation during this case, it is important to confi rm that
99
the patient is both properly padded and secured, using chest
and/or shoulder straps. One tip is to have the anesthetist simulate extreme Trendelenburg and lateral positions prior to prepping and draping to confi rm no excessive patient movement.
Delay in diagnosis of an intraoperative injury usually
results in greater morbidity for the patient than when recognized at the time of operation. It is essential to be prepared
for the unexpected and to be vigilant about exploring the
abdomen at the end of the procedure to search out potential
problems. We have found that most intraoperative injuries
can be avoided by ensuring that the surgeon stays in the correct plane of dissection at all times, avoids excessive and
blind retraction, and always visualizes the critical anatomy.
Postoperative
Ileorectostomy is notorious for an increased risk of postoperative complications when compared to other anastomoses,
both for anastomotic leaks [ 10 , 11 ] and postoperative bowel
obstructions [ 12 ]. Reasons are manifold but likely include
diffi culty with size mismatch, ischemia, or excessive mobility of the small intestine mesentery leading to volvulus.
For all straight laparoscopic TAC cases, there are risks of
an unrecognized enterotomy, small bowel thermal injury
(leading to a delayed enterotomy), and ureterotomy.
Postoperative bleeding can result from poorly sealed or tied
mesenteric vessels, from splenic capsular bleeding, or from
the abdominal wall where ports have been placed. Ports
placed through the inferior epigastric vessels that bleed in the
postoperative period can lead to life-threatening bleeding
when the tamponade effect of the trocar is gone. Other postoperative complications specifi c to a subtotal colectomy also
include mesenteric or portal vein thrombosis [ 13 ] or, most
frequently, early small bowel obstruction from adhesions,
mesenteric volvulus, or at the site of the ileostomy (either
from edema or too small of a fascial aperture). Postoperative
bowel obstruction requiring reoperation has been reported in
up to 8 % of patients [ 14 ]. In cases of fulminant colitis (i.e.,
ulcerative colitis or Clostridium diffi cile ), rupture of a high-
risk rectal stump can occur, resulting in abdominal sepsis. If a
high-risk sigmoid stump was tacked in the suprafascial position, it may later rupture, resulting in a wound infection. The
wound can be opened, and controlled mucus fi stula can be
managed with a stoma appliance. As mentioned previously,
one may consider leaving a urinary catheter with infl ated balloon or red rubber catheter in the rectum for a day or so to
promote drainage of bloody stool and mucus and release of
air in order to decrease subsequent risk of “stump blow out.”
Meticulous technique is essential as postoperative bleeding or
anastomotic leaks can result in pelvic hematomas or subsequent abscesses, which may compromise future surgery.
100
Outcomes
Studies confl ict over the absolute benefi ts of laparoscopy
versus open approach to TAC in regard to postoperative complications [ 15 – 18 ]. One of the purported, but not proven,
benefi ts of laparoscopic TAC is the prevention of adhesions,
which is especially relevant if a future ileoanal pouch is
planned [
17 , 19 ]. Multiple studies have shown that laparo-
scopic TAC is safe and feasible in experienced hands and
results in shorter lengths of stay and a decrease in wound
infections compared to open approaches [ 17 ].
Pearls and Pitfalls
Perhaps the most important consideration for surgeons to
recognize is that a laparoscopic TAC is a technically challenging procedure, necessitating the ligation of multiple vessels and working in multiple quadrants of the abdomen.
Moreover, straight laparoscopy requires advanced knowledge of embryologic planes and regional anatomy to avoid
collateral damage. An experienced laparoscopic camera
operator and frequent table adjustments are required to maximize visualization. Surgeons at the beginning of their learning curve may want to consider getting more experience with
straight laparoscopic segmental colectomy and hand-assisted
TAC early in their career prior to undertaking a straight laparoscopic approach to the entire colon when independent
operating experience is limited. Having a senior colleague
that can mentor can greatly facilitate the learning curve.
For the most challenging cases (obese, adhesions from
prior surgery), adding more ports can greatly facilitate successful completion of the operation [
7 ]. Traction and coun-
tertraction are critical to make the straight laparoscopic
approach successful, and one should not hesitate adding
ports to facilitate this. Patient selection (less obese patients,
no previous surgery) and staying consistent with a standardized technical approach will improve effi ciency as the surgeon’s experience grows.
Conclusion
A straight laparoscopic approach to TAC with either end
ileostomy or restorative ileorectal anastomosis can be utilized as the surgical procedure of choice for a number of
colorectal conditions. This approach is highly technical and
requires advanced laparoscopic skills. In most cases, the
operation is associated with shorter length of stay and fewer
wound complications and may prove to decrease adhesion
burden, giving the patient a greater chance to benefi t
from laparoscopic procedures in the future. There are many
A.V. Hayman and E.J. Dozois
technical approaches to straight laparoscopic TAC, and the
best approach for each surgeon is individualized. This chapter serves as a guide to what we believe to be a safe, effi cient,
and effective approach. For the surgeon early in the learning
curve for advanced laparoscopy, we hope that the systematic
approach we have outlined here will facilitate further learning leading to confi dence in performing a straight laparoscopic TAC.
References
1. Holubar SD, Larson DW, Dozois EJ, Pattana-Arun J, Pemberton
JH, Cima RR. Minimally invasive subtotal colectomy and ileal
pouch-anal anastomosis for fulminant ulcerative colitis: a reasonable approach? Dis Colon Rectum. 2009;52(2):187–92.
2. Fichera A, Zoccali M, Gullo R. Single incision (“scarless”)
laparoscopic total abdominal colectomy with end ileostomy for
ulcerative colitis. J Gastrointest Surg. 2011;15(7):1247–51
[Comparative Study].
3. Paranjape C, Ojo OJ, Carne D, Guyton D. Single-incision laparoscopic total colectomy. JSLS. 2012;16(1):27–32 [Case Reports
Review].
4. Cahill RA, Lindsey I, Jones O, Guy R, Mortensen N, Cunningham
C. Single-port laparoscopic total colectomy for medically uncontrolled colitis. Dis Colon Rectum. 2010;53(8):1143–7 [Comparative
Study Research Support, Non-U.S. Gov’t].
5. Ozturk E, Kiran RP, Remzi F, Geisler D, Fazio V. Hand-assisted
laparoscopic surgery may be a useful tool for surgeons early in the
learning curve performing total abdominal colectomy. Colorectal
Dis. 2010;12(3):199–205 [Comparative Study].
6. Boushey RP, Marcello PW, Martel G, Rusin LC, Roberts PL,
Schoetz Jr DJ. Laparoscopic total colectomy: an evolutionary experience. Dis Colon Rectum. 2007;50(10):1512–9.
7. Dozois EJ, Larson DW, Dowdy SC, Poola VP, Holubar SD, Cima
RR. Transvaginal colonic extraction following combined hysterectomy and laparoscopic total colectomy: a natural orifi ce approach.
Tech Coloproctol. 2008;12(3):251–4 [Case Reports].
8. Lovely JK, Maxson PM, Jacob AK, Cima RR, Horlocker TT, Hebl
JR, et al. Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery. Br J Surg.
2012;99(1):120–6.
9. Merchea A, Dozois EJ, Wang JK, Larson DW. Anatomic mechanisms for splenic injury during colorectal surgery. Clin Anat.
2012;25(2):212–7.
10. Hyman N, Manchester TL, Osler T, Burns B, Cataldo
PA. Anastomotic leaks after intestinal anastomosis: it’s later than
you think. Ann Surg. 2007;245(2):254–8.
11. Alves A, Panis Y, Trancart D, Regimbeau JM, Pocard M, Valleur
P. Factors associated with clinically signifi cant anastomotic leakage
after large bowel resection: multivariate analysis of 707 patients.
World J Surg. 2002;26(4):499–502.
12. Pemberton JH, Rath DM, Ilstrup DM. Evaluation and surgical
treatment of severe chronic constipation. Ann Surg. 1991;
214(4):403–11. [Research Support, U.S. Gov’t, P.H.S.]; discussion
11–3.
13. Broucek JR, Francescatti AB, Swanson GR, Keshavarzian A,
Brand MI, Saclarides TJ. Unusual thrombotic complications. Am
Surg. 2012;78(6):728–9 [Case Reports].
14. Alves A, Panis Y, Bouhnik Y, Maylin V, Lavergne-Slove A, Valleur
P. Subtotal colectomy for severe acute colitis: a 20-year experience
of a tertiary care center with an aggressive and early surgical policy.
J Am Coll Surg. 2003;197(3):379–85.
8 Total Abdominal Colectomy: Straight Laparoscopic Approach
101
15. Parnaby C, Ramsay G, Macleod C, Hope N, Jansen J, McAdam
T. Complications after laparoscopic and open subtotal colectomy
for infl ammatory colitis: a case-matched comparison. Colorectal
Dis. 2013;15(11):1399–405.
16. Frid NL, Bulut O, Pachler J. Acceptable short-term outcome of
laparoscopic subtotal colectomy for infl ammatory bowel disease.
Dan Med J. 2013;60(6):A4645.
17. Tilney HS, Lovegrove RE, Purkayastha S, Heriot AG, Darzi AW,
Tekkis PP. Laparoscopic vs open subtotal colectomy for
benign and malignant disease. Colorectal Dis. 2006;8(5):441–50
[Meta-Analysis].
18. Seshadri PA, Poulin EC, Schlachta CM, Cadeddu MO, Mamazza
J. Does a laparoscopic approach to total abdominal colectomy and
proctocolectomy offer advantages? Surg Endosc. 2001;15(8):837–
42 [Comparative Study].
19. Fowkes L, Krishna K, Menon A, Greenslade GL, Dixon
AR. Laparoscopic emergency and elective surgery for ulcerative
colitis. Colorectal Dis. 2008;10(4):373–8.
Total Abdominal Colectomy: Hand- Assisted Approach
Kiyokazu Nakajima , Tsunekazu Mizushima ,
and Riichiro Nezu
9
Key Points
• Don’t make the minilaparotomy wound too small.
• Select a hand-access device and energy device carefully
to suit your needs.
• Don’t do everything under HALS. Use straight laparoscopic as well as both “open” and “HALS” techniques
effectively.
• Consider “lateral-to-medial” rather than “medial-tolateral” approach for infl ammatory conditions. The mesentery can bleed easily.
• Don’t use your hand randomly. The “palm-up” and
“palm-down” are different techniques. Be comfortable
with both and use them effectively.
• Communicate with your surgical crew consciously. You
are the only person with tactile feedback, so ensure they
are aware of what you are doing and your next steps.
Introduction
Total abdominal colectomy (TAC) is one of the most complex
and extensive operations. It requires a full mobilization of the
entire abdominal colon, division of the mesentery with safe
ligature of all major colonic vessels, colonic resection, and
anastomosis (or ileostomy) while exposing all necessary
Electronic supplementary material: Supplementary material is avail-
able in the online version of this chapter at
. Videos can also be accessed at http://www.springerimages.com/
1_9
videos/978-1-4939-1580-4
K. Nakajima , M.D., F.A.C.S. (*) • T. Mizushima , M.D.
Department of Gastroenterological Surgery , Osaka University
Graduate School of Medicine , 2-2, E-2, Yamadaoka ,
Suita, Osaka 565-0871 , Japan
knakajima@gesurg.med.osaka-u.ac.jp
e-mail:
R. Nezu , M.D., Ph.D.
Department of Surgery , Nishinomiya Municipal Central Hospital ,
8-24, Hayashida-cho , Nishinomiya, Hyogo , Japan
.
10.1007/978-1-4939-1581-
anatomical structures effectively in each of the abdominal
quadrant [
lenging when using laparoscopy, since TAC is mostly indicated for patients with infl ammatory conditions such as
ulcerative colitis (UC) and Crohn’s disease, where anatomy is
often distorted with adhesions, abscesses, and fi stulae [ 2 , 3 ].
proposed as a practical alternative to both open and straight
laparoscopic surgery. With HALS, surgeons regain their tactile sensation and gentle handling of the bowel, which may
enhance effi cacy and safety of complex colorectal operations
such as laparoscopic TAC and total proctocolectomy [ 1 , 2 , 4 ].
In this chapter we describe our recent technique of HALS
TAC and discuss its potential advantages over straight laparoscopic TAC.
1 , 2 ]. These steps become further technically chal-
Hand-assisted laparoscopic surgery (HALS) has been
Indications
The indications for HALS TAC are basically similar to open
or laparoscopic TAC, such as UC and Crohn’s extensive colitis. In fulminant UC, TAC with end ileostomy is indicated as
fi rst-stage operation. In Crohn’s colitis, ileorectal anastomosis can be considered when the perianal disease is absent or
well controlled with local therapy [ 2 ]. HALS can be consid-
ered even in “semi-emergent” settings in patients with
infl ammatory bowel disease when the hemodynamic status
remains stable. However, open TAC should be selected when
safe pneumoperitoneum is not physiologically achievable.
Currently the authors do not use HALS for cases with megacolon, since laparoscopic exposure is not optimal due to distended colonic segments.
Other indications involve slow transit constipation resistant to medical treatment, familial adenomatous polyposis
with rectal sparing, and hereditary non-polyposis colorectal
cancer. TAC is not usually indicated for colorectal cancers,
expect for limited cases with synchronous multiple lesions
located in two or more separated colonic segments.
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_9, © Springer Science+Business Media New York 2015
103
104
Patient Positioning
Under general anesthesia, the patient is placed in the modifi ed lithotomy position with the legs positioned in padded
stirrups. The trunk should remain fi xed adequately on an
operating table even in a steep Trendelenburg position. The
operating surgeon stands between the patient’s legs. The
assisting surgeon(s) stands on the both sides of the patient.
The surgeon fi rst stands on the patient’s right side and then
moves to the left side, as the procedure proceeds from the left
colon to the right colon (Fig.
9.1 ).
Hand-Access Device Placement
A 7–8 cm minilaparotomy is made. We exclusively use
muscle- splitting Pfannenstiel incision for UC cases,
though we prefer a lower midline incision for Crohn’s
patients to keep the lateral abdomen free of incisions for
possible future ostomy [ 1 , 2 ]. Too small of a wound may
complicate free and deep insertion of the device, therefore,
interfering with the HALS procedure. After confi rming the
adequacy of wound size by inserting surgeon’s hand into
the abdomen, a hand-access device is assembled to the
K. Nakajima et al.
wound. Our favorite device is GelPort laparoscopic system
(Applied Medical, Rancho Santa Margarita, CA), which
provides stable wound retraction during open procedure
and enables unlimited hand exchanges into every abdominal quadrant without signifi cant gas leakage during laparoscopic procedure [ 5 , 6 ].
Surgical Ports and Energy Devices
Two standard trocars are used: one in the periumbilical
region for laparoscopy and the other in the left mid-abdomen
for the energy device, respectively (Fig. 9.2 ). We currently
prefer bipolar vessel-sealing device (LigaSure™, Covidien,
Mansfi eld, MA) for colonic mobilization, takedown of the
omentum, and mesenteric division. We do not fi nd that the
LigaSure™ device gets too hot, even after repeated activations, and thus enables safe use of surgeon’s hand simultaneously [ 6 ]. We do not use monopolar electrocautery or
ultrasonically driven scalpel since these devices may make
hand assist diffi cult with an inability to take large vessels
(monopolar) and increased heat production. We also do not
routinely use any laparoscopic clips. However, device and
instrumentation selection is up to the individual surgeon, and
preferences differ pending experience and comfort level.
Fig. 9.1 Patient positioning and OR setup. The operating surgeon stands between patient’s legs. The surgeon stands on patient’s right side for left
colon procedure and then moves to left side for right colon procedure
9 Total Abdominal Colectomy: Hand-Assisted Approach
The “Palm-Down” and “Palm-Up” Techniques
HALS requires logical and systemic use of surgeon’s hand.
A random use of hand may interfere with the procedure,
rather than assist the procedure. The authors have systematized and categorized the use of hand into two simple techniques: “palm-down” and “palm-up” techniques.
Most of HALS procedures can be performed using “palmdown” technique (Video 9.1 ). This technique facilitates free
and delicate use of the 2nd/3rd fi ngers. This is best suited for
extending an avascular plane under continuous traction, e.g.,
colonic mobilization (Fig.
2nd fi nger is possible, as needed.
9.3a ). A blunt dissection using
105
In “palm-up” position, on the contrary, the surgeon can
more positively use his/her 1st fi nger (Video 9.2 ). This technique is effective for palpation and for dividing structures
containing vessels. In mesenteric division, for example, a
fi ne palpation and rapid division is possible by pinching the
mesentery with 1st and 2nd fi ngers (Fig. 9.3b ). Additionally,
a wider displacement/retraction is possible with intentional
use of dorsal surface of the hand. This is extremely useful in
dividing the mesentery while keeping small-bowel loops out
from the operative fi eld.
Technical Aspects Step-by-Step
Our technical principles of TAC are similar either in open,
straight laparoscopic or HALS approach, which involve
entire colonic mobilization followed by the mesenteric division, both in an inferior-to-superior fashion initially, followed by counterclockwise approach. Since the high ligation
of major colonic arteries is often unnecessary (except in the
rare situation of multiple synchronous cancers), the authors
exclusively use a “lateral-to-medial” approach for colonic
mobilization. A “medial-to-lateral” approach can still be
used; however, it is not as straightforward as in usual cancer
cases due to infl amed mesentery and fragile peri-colonic tissue. The key is to maximally utilize the minilaparotomy to
facilitate “open” procedures, i.e., procedures achievable
under direct vision, such as small-bowel exploration, partial
colonic mobilization, and anastomosis.
Step 1. Partial Colonic Mobilization Under
Direct Vision (Fig.
Fig. 9.2 The sites for hand-access device, laparoscope, and energy
device
Fig. 9.3 Schematic representations of ( a ) “palm-down” and ( b ) “palm-up” techniques
The procedure begins under direct vision with the handaccess device left uncapped (opened). First, the small bowel
9.4 )
106
K. Nakajima et al.
Fig. 9.4 Step 1 (partial colonic mobilization under direct vision)
Fig. 9.5 Mobilizing the sigmoid-descending colon junction under
direct vision
is identifi ed and exteriorized to evaluate any “extracolonic”
pathologies. This step is extremely important in Crohn’s
patients, since additional strictureplasty and/or small-bowel
resection can be immediately performed under direct vision
when a signifi cant lesion is identifi ed during the exploration.
This exploration is also important in UC patients to exclude
any possibility of “Crohn’s disease mimicking UC.”
While the hand-access device is kept uncapped, the
descending colon and its junction to the sigmoid colon is
exposed and partially mobilized (Fig. 9.5 ). The left ureter
can be identifi ed as it crosses over the iliac bifurcation in
thin patients (Video 9.3 ). The dissection can be extended
towards the splenic fl exure as long as the exposure is adequate and constant. The ileocecal mobilization is then performed on the right side as well (Fig.
9.4 ). The key is to use
long retracting devices for effective displacement of the
small-bowel loops.
Fig. 9.6 Step 2 (completion of colonic mobilization under HALS)
Step 2. Completion of Colonic Mobilization
Under HALS (Fig.
The hand-access device is then sealed, and a pneumoperitoneum is established. HALS begins with the insertion of surgeon’s nondominant hand into the abdominal cavity. The
colonic mobilization under HALS is initiated from the left
side by extending the dissecting plane made at Step 1
(Fig. 9.7 ). The descending colon is medially retracted using
“palm-down” technique. The 2nd and 3rd fi ngers are used to
maintain the dissecting plane onto the lateral attachment.
After mobilizing the descending colon, the splenic fl exure is
cupped with the palm and gently retracted caudally (Fig. 9.8 ).
The splenocolic ligament is thus stretched and effectively
taken down with LigaSure™ device. Care is taken to avoid
too much traction at this stage to avoid an inadvertent tearing
of the splenic capsule.
The omentum is then freed from the transverse colon at its
attachment, from the left side to the right side, by inserting
the hand between the omentum and transverse mesocolon
using “palm-down” technique. During the omental
dissection, each fi nger can be used for effective retraction:
stretching the omentum with 2nd and 3rd fi ngers, while displacing the transverse colon with 4th fi nger (Fig. 9.9 ).
Alternatively, the lesser sac is fi rst opened at the mid-transverse colon, and the window is then extended to the left side
to meet the initial dissecting plane over the splenic fl exure.
As the omentum takedown proceeds beyond the midtransverse colon, the dissection gradually becomes challenging due to mismatch of the working axis of LigaSure™
device and the direction of dissection. This can be solved
simply by moving the dissecting area into the effective working area of LigaSure™ device. This so-called “move-theground” technique is also useful when the operative fi eld is
too close to the laparoscope (Fig.
9.6 )
9.10 ). The overview can be