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
190
J.A. Tyler and M.G. Mutch
Fig. 17.1 Stoma in a patient with morbid obesity. Notice the large
bulge around the stoma indicating the possible presence of a parastomal
hernia
Fig. 17.2 Strangulated parastomal hernia with associated cellulitis
Preoperative Planning
As with most surgical procedures, patients offered PH
repair should have an appropriate surgical indication and
should be cleared as good operative candidates from a
Fig. 17.3 CT demonstrating a large fascial defect with a moderatesized parastomal hernia
cardiopulmonary risk standpoint. Physical examination
often reveals the presence of a hernia, and this may be better
defi ned by asking the patient to Valsalva. It is important to
note if the hernia is reducible. Cross-sectional imaging is
often helpful in preoperative planning, especially in defi ning hernia anatomy, elucidating presence of hernia in
patients whose exam is limited due to habitus, as well as
accounting for the presence of other hernias in the vicinity
of the PH that may impact the repair or size of mesh used
17.3 ). In addition, patients should be up-to-date on
(Fig.
their colonoscopic screening, as well as any cancer surveillance that might impact the operative plan. Controllable hernia risk factors should be emphasized when PH repair
occurs in the elective setting to optimize success of the
repair and decrease recurrence risk. These factors may
include smoking cessation, weight loss, cessation of steroids (if possible), and control of medical factors that cause
frequent Valsalva such as benign prostatic hyperplasia
(BPH) and chronic cough or obstructive pulmonary disease.
In preoperative holding, deep venous thrombosis chemoprophylaxis and broad-spectrum intravenous antibiotics to
cover both skin and enteric fl ora within one hour of incision
are given. A thorough discussion with the patient should
occur regarding the operative plan and the risks of conversion to an open repair, need for relocation, or substitution of
biologic for permanent mesh. A successful laparoscopic
approach is dependent upon safe access to the peritoneal
cavity, adhesiolysis, and reduction of the hernia contents.
The presence of an associated incisional hernia also
increases the risk of conversion or need for relocation.
17 Laparoscopic Parastomal Hernia Repair
Procedure
Setup
After induction and intubation, an orogastric tube and Foley
catheter should be placed. The patient may be positioned at
the discretion of the operating surgeon either in supine or in
low lithotomy position. Generally, the arms should be tucked
with pressure points padded, but this may not be necessary
on all cases. The patient should be well secured to the operating room table to allow for intraoperative positioning changes
such as Trendelenburg position that may be necessary during
the procedure.
The operating surgeon stands on the contralateral side of the
PH to allow maximal working room in the abdominal cavity.
The assistant may stand either on the same or opposite side.
Two monitors should be utilized—one directly across from the
operating surgeon to allow for in-line tissue manipulation and
visualization and a second for the assistant to view. The
approach to PH repair is quite variable as stomas may be right
or left sided and have associated incisional hernias. Principles
described here are general guidelines, but the operating surgeon must be comfortable with some variation in monitor and
port placement to allow for variation based on patient anatomy.
All equipment for both a laparoscopic and open procedure
should be in the room in the event that the procedure must be
converted. The abdomen should be shaved and prepped and
draped in the usual standard fashion. The stoma appliance
should be removed and the stoma prepped into the fi eld and
then covered with gauze and an occlusive dressing to control
effl uent during the case (Fig.
mize the exposure of enteric contents and contamination to the
mesh while it is being introduced into the abdomen.
17.4 a, b ). This will help mini-
191
Procedure Steps
Insuffl ation and Port Placement
After the patient has been prepped and draped, and the
laparoscopic equipment has been passed onto the fi eld and
situated, a time-out is completed, and intraperitoneal access
is established. This is accomplished based on surgeon preference, typically with a 12 mm camera port placed fi rst either
with an open Hasson technique or after insuffl ation with a
Veress needle usually placed in an abdominal quadrant
deemed to have the fewest adhesions and is far enough away
from the hernia to provide good visualization for dissection
and mesh placement (Fig.
17.5 ). The abdomen should be
insuffl ated to a pressure of 15 mmHg. The working ports are
typically 5 mm in size, and generally 2–3 ports are required.
Ports should be triangulated to the location of the hernia.
A third port for the assistant is not always necessary, but can
facilitate tissue retraction for the operating surgeon. This
also helps if an extensive adhesiolysis is necessary prior to
hernia reduction, and often some adhesions must be taken
down to facilitate port placement. It must be kept in mind
that the dissection of the hernia and its contents requires
exposure of all 360° around the stoma and hernia.
Adhesiolysis and Hernia Reduction
Once adequate space has been cleared to facilitate port placement, attention is directed at completing an intra-abdominal
survey for unexpected pathology, extent of adhesions, and the
hernia and its contents. The hernia should be identifi ed
(Fig. 17.6 ) and reduced, taking care to protect the stoma. If
adjacent small bowel or omentum is within the hernia, this
can often be reduced with fi rm traction. However, fi rst ensure
that any adhesions to the stoma or the hernia sac are lysed,
which may be accomplished sharply with laparoscopic
Fig. 17.4 Prepping and draping of the stoma. ( a ) The appliance is removed and the area around the stoma is cleaned. ( b ) The site is covered with
a gauze and occlusive dressing. Courtesy of Joshua Bleier , MD , with permission
192
J.A. Tyler and M.G. Mutch
Fig. 17.5 Port placement and patient positioning for laparoscopic parastomal hernia repair
Fig. 17.6 Initial appearance of hernia following port placement Fig. 17.7 Hernia appearance after reduction of hernia contents and
adhesiolysis
scissors with or without monopolar cautery or an alternative
energy device can be used. Care should be taken to identify
the bowel proximal to the stoma as well as to avoid any enterotomies. Omentum and small bowel may often be adherent to
the stoma limb and adhesions in this area may be dense, so
sharp dissection without energy is preferred in this scenario.
The hernia contents should be reduced completely, and the
limb to the stoma should be mobilized as completely as
possible. Once this is complete, all that should remain is the
afferent limb to the stoma and the fascial defect (Fig.
17.7 ).
Mesh Measurement and Preparation
At this point, the size of the hernia defect should be measured. This may be accomplished intracorporeally using a
measuring device or with an open grasper as an estimate of
size (an open grasper is typically 3–4 cm). Alternatively, a
spinal needle can be passed transabdominally at the medial,
lateral, cephalad, and caudad aspects of the defect and size
measured in this fashion (Fig. 17.8 ). Once the defect has been
measured, a piece of mesh should be selected to allow for
4–5 cm of overlap in all directions of the defect. If additional
17 Laparoscopic Parastomal Hernia Repair
193
Fig. 17.8 Measurement of hernia defect with needle to determine
mesh size
defects are present, the mesh must be enlarged to accommodate coverage of all defects. Any mesh shape may be used
(round, oval, square, or rectangular), but it is crucial to ensure
that the overlap is adequate. As long as no enterotomies have
been made, synthetic mesh may be used. If synthetic mesh is
used, it should have an anti-adhesion barrier on the dorsal
side of the mesh that will be exposed to the abdominal contents. If an enterotomy is made, the risk of mesh infection is
increased, and synthetic mesh should be avoided. In this case,
a biologic mesh is an acceptable alternative.
Once the mesh has been selected, it should be prepared
according to the manufacturer’s package insert if it needs to
be manipulated prior to use (i.e., saline hydration). Once
ready for use, the mesh should be laid fl at extracorporeally,
and the transfascial sutures should be placed. For the
Sugarbaker technique, transfascial sutures should be placed
at the cephalad and caudad aspects of the lateral side of the
mesh far enough apart to allow the stoma to exit the from the
mesh, and then circumferentially from there approximately
every 5 cm. Generally a nonabsorbable monofi lament suture
(1 Prolene) is used, and these should be tied in the mid-point
of the suture to allow for long tails of equivalent length on
each side. For a Sugarbaker repair typically six to eight
transabdominal fi xation sutures are used. On the lateral
aspect of the mesh, the gap should be left large enough to
allow the stoma limb to pass between the mesh and anterior
abdominal wall without causing obstruction. Once all transfascial sutures have been placed, the sutures are laid in the
middle of the mesh and the mesh is rolled like a cigar and
inserted through the 12 mm camera port. It is often helpful to
label the fi xation sutures and mark the anterior surface of the
mesh to help facilitate intraperitoneal orientation.
Mesh Securement
Sugarbaker Technique (Videos 17.1 and 17.2 )
Once inserted, the mesh should be unrolled and oriented in
its planned position. At this point, it is helpful to desuffl ate
Fig. 17.9 Placement of fi rst transfascial suture (lateral side, caudad to
stoma)
Fig. 17.10 Placement of second transfascial suture (lateral side, cephalad to stoma)
the abdomen to a pressure of around 10 mmHg to take tension off the abdominal wall and allow the mesh to lay as it
will when the abdomen is completely desuffl ated. If the
mesh is secured at full insuffl ation pressure, it will become
undulated upon desuffl ation, often leading to mesh laxity
and the appearance of a hernia recurrence over time. The lateral sutures are fi xated fi rst. Starting with the caudad-most
suture to the stoma (Fig. 17.9 ), a suture-passing device (i.e.,
Carter-Thompson needle) is placed transabdominally
through a small stab incision. One of the tails is passed intracorporeally into the suture device and it is extracted and
secured with a clamp. This is repeated for the second tail of
the suture, with care taken to pass the suture-passing device
through the same skin stab wound but a separate fascial
puncture site. This second tail is delivered and secured with
a clamp but not tied. Attention should then be directed to the
cephalad-most suture to the stoma on the lateral side of the
mesh (Fig. 17.10 ), which should be secured next. By secur-
ing the cephalad and caudad sutures, this allows for proper
mesh orientation, making the remainder of the sutures more
194
J.A. Tyler and M.G. Mutch
Fig. 17.11 Mesh appearance while maintaining traction on the two
transfascial sutures closest to stoma
Fig. 17.13 Securing remaining transfascial sutures
Fig. 17.12 Checking suture placement with a grasper to ensure ade-
quate space for stoma to pass lateral to mesh
easily positioned, and sets the gap where the stoma exits the
mesh. It is of utmost importance that the transfascial sutures
closest to the afferent limb of the stoma not be too close or
tied so tight that it causes an obstruction of the stoma at the
level of the mesh. If need be these sutures can be adjusted to
give stoma adequate space between the mesh and abdominal
wall (Fig. 17.11 ). This may be checked by ensuring a grasper
can fi t between the mesh and the stoma while maintaining
tension on the transfascial sutures (Fig. 17.12 ). Once the
cephalad and caudad sutures are placed, the remainder of
sutures are secured starting farthest from the camera position
and working circumferentially around the mesh leaving the
sutures closest to the camera position for the end (Fig. 17.13 ).
The mesh should be oriented so that the stoma deviates
around the lateral side of the mesh and then back medially
towards the stoma fascial defect in a Sugarbaker fashion. At
any point if an undesirable suture position has been created,
the sutures can be delivered back into the abdomen, and a
separate position chosen by repeating the same procedure. It
is important to note that none of the sutures are tied until all
Fig. 17.14 Final appearance of mesh with all sutures tied
have been passed transabdominally. This allows for ensuring
adequate coverage and tension on the mesh and avoidance of
buckling or areas of poor coverage. Once all sutures are
delivered, traction can be placed on each suture simultaneously to check for optimal mesh positioning as well as to
ensure that neither the sutures nor mesh will cause a bowel
obstruction. If the mesh is acceptably positioned, each suture
can be tied at this point (Fig. 17.14 ). Once each suture has
been tied, the remainder of the circumference of the mesh
can be secured approximately every centimeter with a laparoscopic tacking device with care taken to avoid the afferent
limb of the stoma. Either metal or absorbable tacks may be
used based on surgeon preference. Some surgeons also prefer to tack in the middle portion of the mesh as long as care
is taken to avoid both the stoma and the hernia defect.
Keyhole Technique
For the keyhole technique, a slit is created in the middle of
the cephalad border of the mesh. Again, a sublay position is
utilized with a mesh that consists of an anti-adhesive barrier
17 Laparoscopic Parastomal Hernia Repair
195
on the intra-abdominal side. The slit is carried to the middle
of the mesh where a cruciate incision is made to allow for a
large enough opening for the stoma. The transabdominal
fi xation sutures are placed circumferentially around the mesh
as previously described. Once the mesh is passed intracorporeally, it is positioned so the slit is passed around the stoma.
The fi xation sutures are passed transabdominally in the same
fashion as the Sugarbaker technique, and the gaps between
the sutures are closed with an endoscopic fascial tacking
device. The slit in the mesh is then closed by intracorporeal
suturing using a heavy, monofi lament, permanent suture.
The fi rst stitch is placed to create an appropriate opening for
the stoma to pass through the mesh. Given that this stitch sits
in the hernia defect, it cannot be fi xated to the fascia.
Additional sutures are then placed to close the slit in the
mesh in the same fashion.
Repairing the Hernia with Stomal Relocation
A laparoscopic approach may also be utilized even if the
stoma is relocated. If this is planned, one method to do this is
to initially lyse the adhesions and reduce the contents of the
hernia sac laparoscopically as previously discussed. An
endoscopic stapler may then be used to divide the bowel at
the level of the fascia (i.e., leaving the matured portion that
runs through the abdominal wall intact). The bowel is then
mobilized to ensure adequate length is available for the
stoma to reach its new location. The skin is opened at the
new site and (after opening the subcutaneous tissue and
bluntly dividing the rectus muscles as described in the chapter by Dr. Fleshner in Chap. 15 ) the bowel passed through the
abdominal wall for maturation at the completion of the case.
The abdomen is then desuffl ated, the remaining portion of
the “old” stoma is resected from abdominal wall, and an
“open” incisional hernia repair with mesh is performed per
the operating surgeon’s preference. We then re-insuffl ate,
evaluate the repair, ensure adequate hemostasis and mesh
coverage of the hernia defect, and inspect the abdomen for
proper orientation of the new stoma and any other abnormalities. After the trocars are removed, the new stoma site
can be matured in standard fashion.
Postoperative Care
Patients progress along our institution’s standard postoperative care pathway, including early ambulation and full liquids the night of surgery. Nasogastric tubes are not routinely
used, and the Foley catheter is removed postoperative day 1.
Diet is advanced to regular diet on postoperative day 1 provided that the patient has tolerated liquids without issue.
Depending on the amount of adhesiolysis, these patients may
be more prone to ileus, and their diet should be advanced
accordingly. Early and frequent ambulation is important, and
we also utilize standard chemoprophylaxis for deep venous
thrombosis.
Pain control is a major factor in the postoperative setting
and usually contributes to the ultimate length of stay requirements. Given that these patients may be prone to ileus, pain
adjuncts to minimize narcotics including ketorolac and acetaminophen should be employed. In addition, regional pain
control may be considered in the form of an epidural, liposomal bupivacaine, or regional pain catheters if desired. We
routinely utilize a narcotic patient-controlled anesthetic
device and transition to oral narcotics once the patient tolerates oral intake.
Complications
Intraoperative complications are relatively infrequent (<5 %)
and may occur in the form of enterotomy or bleeding.
Enterotomy may occur if an extensive adhesiolysis is
required and can usually be repaired primarily if present.
Depending on surgeon comfort, this can usually be done
laparoscopically, but if conversion to open is required, this
should be performed. Consideration should also be given to
utilization of biologic mesh rather than synthetic in this situation. Bleeding is usually rare but may occur during adhesiolysis or due to injury of the epigastric vessels during port
or transfascial suture placement. Injury to the epigastric vessels may occur with trocar placement or with the transfascial
suture device. It is normally successfully managed laparoscopically by performing suture ligation with the suturepassing device.
Postoperative complications may be grouped into early and
late categories. Early complications include ileus, surgical site
infection, respiratory and urinary tract infections, and hemorrhage. If with postoperative hemorrhage, the patient should be
taken back to the OR for identifi cation and control of the
bleeding source if determined to be necessary. Ileus may be
managed with limitation of narcotics through the use of pain
adjuncts, and if emesis occurs, nasogastric decompression
may become necessary. Ileus will resolve with time and narcotic limitation but should raise the question as to if the mesh
or sutures may be causing iatrogenic bowel obstruction. This
situation may be further delineated with cross- sectional imaging to look for a mesh-level obstruction with decompressed
distal bowel between the mesh and the stoma site or a contrast
study through the stoma. Deep surgical site infection is rare
with this procedure provided that no enterotomies are made.
Superfi cial surgical site infection may be treated with opening
and packing of surgical wounds, with or without antibiotics. If
the stoma is relocated as part of the procedure, the wound from
the old stoma site may simply be packed daily with dry gauze
196
Fig. 17.15 Stoma site after relocation closed with staples and wicks
between staples
to heal by secondary intention. Another option is to approximate the skin loosely with 2–3 skin staples, with Telfa wicks
placed in between (Fig. 17.15 ). These wicks are removed prior
to hospital discharge (usually by postoperative day 3). Urinary
tract infection may be avoided with careful Foley placement
sterile technique, as well as early removal. Respiratory tract
infection may be mitigated with early ambulation and incentive spirometer use, as well as effective pain control to avoid
limited or shallow breathing due to pain.
The most common late complication is hernia recurrence.
There is a wide range reported in the literature (6–46 %)
depending on the type of repair, mesh used, comorbidities of
the patient (i.e., obesity, COPD), and experience of the surgeon. Additionally, a number of factors can limit this, starting
with patient selection. While parastomal hernias may be common in ostomates, surgeons must carefully weigh risk and
benefi t of repair coupled with the patient characteristics.
Modifi able factors should be controlled to the extent possible,
such as encouraging patient weight loss and smoking cessation. Utilization of mesh rather than primary repair will also
limit hernia recurrence. Most surgeons will limit patient activity and lifting for 6–8 weeks after surgery, and some surgeons
routinely employ abdominal binders in the postoperative setting, although data on benefi t of binders has been lacking.
Meticulous technique in mesh placement is critical to recurrence prevention, ensuring adequate overlap on all sides of the
defect. Mesh infection is relatively rare but can be a devastating complication, as it requires the mesh to be excised.
J.A. Tyler and M.G. Mutch
Outcomes
Multiple techniques have been described for parastomal hernia repair. These repairs have traditionally been done open, but
with the advent and ever-increasing utilization of laparoscopic
surgery, laparoscopic parastomal hernia repair has been shown
to be safe and technically feasible, with the added benefi ts of
laparoscopic over open surgery. The benefi ts of laparoscopic
surgery have been shown to translate to PH repair, to include
shorter operative time and length of stay, as well as to lower
overall morbidity and surgical site infection [
5 ].
Repair options include open primary repair, stoma resiting, and laparoscopic keyhole and Sugarbaker techniques.
Although little prospective randomized data exist, several
meta-analyses and cohort studies have shown that mesh
repair is superior to primary repair, with primary repair
nearly nine times more likely to recur [ 4 ]. Data comparing
keyhole versus Sugarbaker techniques are variable, with
some studies showing no difference in recurrence rates
between the two [ 1 ], although most studies show lower
recurrence rates with the Sugarbaker technique (Sugarbaker
0–29 % recurrence rate vs keyhole 58–72 %) [ 3 – 8 ]. Over
40 % of patients undergoing PH repair also have incisional
ventral hernias, which have been shown to be simultaneously
successfully repaired [ 9 ]. Data on the use of biologic mesh in
PH repair show similar recurrence rates to synthetic mesh;
however, data are limited by their small retrospective nature
and short length of follow-up [ 10 ]. No study has demon-
strated a superior type of biologic over another (cross-linked
vs non-cross-linked, bovine vs human scaffolding).
Given the incidence of parastomal hernia and diffi culty in
their repair, many surgeons have looked to a means of prevention. There are some data from a meta-analysis of several
randomized trials to suggest biologic mesh reinforcement at
the time of permanent ostomy creation may decrease recurrence rates [ 11 ]. Other prospective randomized trials have
not shown benefi t to this technique. While encouraging, this
technique has not been widely adopted and should be studied
in larger randomized prospective trials.
Pearls and Pitfalls
Several key points may optimize PH repair. Preoperative
identifi cation of other ventral hernias is critical in operative
planning and mesh selection. This will allow for successful
repair of the PH, as well as any concomitant incisional hernias. Additionally, it cannot be overstated that utmost care
must be taken to ensure that the lateral aspect of the mesh
provides adequate overlap of the defect, yet not be so tight so
as to occlude the afferent limb of the stoma. Mesh selection
and appropriate suture placement on the mesh are imperative.
17 Laparoscopic Parastomal Hernia Repair
197
This should always be assessed prior to fi nal tying of the
transfascial sutures. Finally, ensuring the mesh remains sterile and is not contaminated is of paramount importance to the
success of the repair.
Conclusion
Parastomal hernia is a common problem in ostomates and is
challenging to repair. Laparoscopic repair of PH is safe and
effective, with numerous benefi ts compared to open repair to
include shorter length of stay and decreased overall morbidity and surgical site infection. Surgical technique is a critical
component of successful PH repair, and the Sugarbaker technique may provide the lowest recurrence rate compared to
other techniques.
References
1. Helgstrand F, Rosenberg J, Kehlet H, Jorgensen LN, Wara P,
Bisgaard T. Risk of morbidity, mortality, and recurrence after parastomal hernia repair: a nationwide study. Dis Colon Rectum.
2013;56(11):1265–72.
2. Turnbull GB. Ostomy statistics: the $64,000 question. Ostomy
Wound Manage. 2003;49(6):22–3.
3. Asif A, Ruiz M, Yetasook A, Denham W, Linn J, Carbray J,
Ujiki MB. Laparoscopic modifi ed Sugarbaker technique results in
superior recurrence rate. Surg Endosc. 2012;26(12):3430–4.
4. Hansson BM, Slater NJ, van der Velden AS, Groenewoud HM,
Buyne OR, de Hingh IH, Bleichrodt RP. Surgical techniques for
parastomal hernia repair: a systematic review of the literature. Ann
Surg. 2012;255(4):685–95.
5. Halabi WJ, Jafari MD, Carmichael JC, Nguyen VQ, Mills S, Phelan
M, Stamos MJ, Pigazzi A. Laparoscopic versus open repair of parastomal hernias: an ACS-NSQIP analysis of short-term outcomes.
Surg Endosc. 2013;27(11):4067–72.
6. Pastor DM, Pauli EM, Koltun WA, Haluck RS, Shope TR, Poritz
LS. Parastomal hernia repair: a single center experience. JSLS.
2009;13(2):170–5.
7. Craft RO, Huguet KL, McLemore EC, Harold KL. Laparoscopic
parastomal hernia repair. Hernia. 2008;12(2):137–40.
8. Muysoms EE, Hauters PJ, Van Nieuwenhove Y, Huten N, Claeys
DA. Laparoscopic repair of parastomal hernias: a multi-centre retrospective review and shift in technique. Acta Chir Belg.
2008;108(4):400–4.
9. Hansson BM, Morales-Conde S, Mussack T, Valdes J, Muysoms
FE, Bleichrodt RP. The laparoscopic modifi ed Sugarbaker technique is safe and has a low recurrence rate: a multicenter cohort
study. Surg Endosc. 2013;27(2):494–500.
10. Slater NJ, Hansson BM, Buyne OR, Hendriks T, Bleichrodt
RP. Repair of parastomal hernias with biologic grafts: a systematic
review. J Gastrointest Surg. 2011;15(7):1252–8.
11. Wijeyekoon SP, Gurusamy K, El-Gendy K, Chan CL. Prevention of
parastomal herniation with biologic/composite prosthetic mesh: a
systematic review and meta-analysis of randomized controlled trials. J Am Coll Surg. 2010;211(5):637–45.
Part III
Technical Challenges and Tips
Overcoming Technical Challenges: The Abdomen
Eric K. Johnson
18
K e y P o i n t s
• Gravity is an ally in laparoscopy. Exploit it to your
advantage.
• Don’t be afraid to add a port. Assistance with traction/
countertraction is invaluable in laparoscopy.
• Use of hand assistance may avoid conversion to an open
procedure.
• Splenic fl exure mobilization can be challenging. Be familiar
with several techniques and be prepared to combine them.
• Transverse colon mobilization and division of the middle
colic vessels can be the most challenging part of laparoscopic colectomy.
• High ligation of the main blood supply to the colon facilitates mobilization, requires less division of the mesentery,
and is sound from an oncologic standpoint. Take care to
preserve the marginal artery to ensure adequate blood
supply to the distal colon/anastomosis.
Introduction
The utilization of laparoscopy in colorectal surgery has
increased exponentially since the publication of the COST
trial in 2004 [
mainstream in general surgery in the early 1990s, the technique didn’t immediately catch on with colonic procedures.
There are several reasons for this, not the least of which was
the technical diffi culty associated with performing a colonic
resection using laparoscopic instruments.
Electronic supplementary material: Supplementary material is available
in the online version of this chapter at
Videos can also be accessed at
videos/978-1-4939-1580-4
E. K. Johnson , M.D., F.A.C.S., F.A.S.C.R.S. (*)
Associate Professor of Surgery , Uniformed Services University
of the Health Sciences and Madigan Army Medical Center ,
Joint Base Lewis, McChord , WA 98431 , USA
e-mail:
1 ]. While laparoscopy was beginning to become
10.1007/978-1-4939-1581-1_18 .
http://www.springerimages.com/
.
doktrj@gmail.com
Patients come in all shapes and sizes, and the presence
of obesity, large amounts of intra-abdominal adipose
tissue, and diffi cult anatomy can make a laparoscopic
approach quite challenging. These factors, coupled with a
lack of technique familiarity, a lack of data, and some poor
initial outcomes, slowed the adoption of laparoscopy in
this setting. While techniques and instrumentations have
improved over time, laparoscopic colectomy continues to
present several challenges and pitfalls. The learning curve
of the surgeon also plays a big part in the successful utilization of the laparoscopic approach. This is a twofold phenomenon, as the initial phase is ascending the learning
curve and the second phase is the more comfortable the
surgeon feels, the more willing they become to take on
more diffi cult cases. It is the aim of this chapter to assist
the reader in these specifi c areas.
Positioning and Restraining the Patient
Performing effective laparoscopic surgery depends heavily
on the use and exploitation of gravity. Because nature has
only equipped us with two hands and we are handling organs
of signifi cant mass with 5- and 10-mm instruments, we must
allow gravity to assist us with retraction during the procedure. Clever use of gravity may allow a surgeon to operate
with fewer ports, or it may ensure that we are not forced to
convert a case to a laparotomy. The surgeon must use
Trendelenburg and reverse Trendelenburg positions with
both right and left tilt. Often, many or all of these positions
are used in a single case to ensure adequate exposure. The
low lithotomy position not only provides access to the
perineum and anus, but it also allows the surgeon or assistant
to stand between the patients legs to operate, which may ease
fl exure mobilization and aid in ergonomics by keeping the
surgeon and assistant in line with the direction of dissection
and camera point of view.
It is not infrequent for very steep positioning to be
required. Placement of a beanbag on the operating table
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_18, © Springer Science+Business Media New York 2015
201