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34
Fig. 3.3 Room setup for
HAL sigmoid colectomy.
(Used with permission of
Springer Nature from
Sonoda [25])
J. T. Saraidaridis and P. W. Marcello
in the left lateral, right lateral, and umbilical positions (Fig.3.3). The trocars are
placed with the hand inside the abdomen to protect the intestines from injury.
Following access to the abdomen, the procedural steps of the operation are performed
in the same sequence whether the procedure is performed by straight laparoscopic
or a hand- assisted laparoscopic approach.
Left/Sigmoid Colectomy
The surgeon and assistant stand on the patient’s right side. The patient is placed in
a mild Trendelenburg and left-side up position. In our practice, we perform a medial
to lateral mobilization of the left/sigmoid colon. To do this, the omentum is lifted
over the transverse colon, and the small bowel is moved out of the pelvis to the right
upper quadrant (Fig.3.4). The “bare area” of the left colon (the mesentery just lateral to the IMV between the left colic and rst sigmoidal branches) is grasped and
lifted. This mesentery is incised just lateral to the IMV, and a dissection begins
between the left colon mesentery and Gerota’s fascia. The gonadal vessels will be
3 Masters Program Colorectal Pathway: Laparoscopic Left andSigmoid Colectomy…
Fig. 3.4 The omentum is
lifted over the transverse
colon and the small bowel
is moved to the right side
of the abdomen. (Used
with permission of
Springer Nature from
Leroy etal. [26])
Fig. 3.5 Medial to lateral
mobilization. (Used with
permission of Springer
Nature from Leroy etal.
[26])
35
below with Gerota’s fascia, and the dissection continues out to the lateral side wall.
The left ureter is typically under the IMA pedicle and will not be seen unless
dissection is carried backwards toward the aorta. The rst one or two sigmoid
branches are then identied, isolated, and divided with the bipolar vessel sealer. The
left colon is then mobilized from medial to lateral in a plane overlying Gerota’s
fascia (Fig.3.5). This dissection extends out to the left pelvic sidewall, inferiorly
into the upper retrorectal space, and superiorly up towards the splenic exure.
36
Fig. 3.6 Taking down the
lateral attachments. (Used
with permission of
Springer Nature from
Sonoda [25])
J. T. Saraidaridis and P. W. Marcello
After the medial to lateral mobilization has been performed, the lateral attachments
starting with the white line of Toldt are divided (Fig.3.6). This maneuver connects
the medial dissection plane to the lateral dissection plane. Moving up towards the
splenic exure, the lateral aspects of the splenic exure are divided. For this part of
the procedure, the assistant moves to the area between the legs and holds the camera
with his left hand and the hook cautery with his right hand through the left-sided
trocar. In this same position, the omentum is taken off of the distal transverse colon
allowing the splenic exure to be approached from a medial direction. Then the distal
transverse mesocolon is freed from the inferior boarder of the pancreas. At this point,
the colon should be assessed for reach down to the proximal rectum. If the reach is
adequate, the mesentery can be taken with a bipolar device up to but not crossing the
marginal artery on the proximal transection margin (the rest of the mesentery will be
ligated once the colon is exteriorized). For the distal transection margin, the mesentery
can be taken up to the edge of colon laparoscopically. However, if the procedure is
being performed with a hand-assisted, that portion of the case can be done via the
hand-port in an open fashion. At that point, the bowel can be exteriorized (Fig.3.7),
and the specimen can be brought out through the hand- port (in the case of handassisted) or through an extraction site (straight laparoscopy). In the situation of
straight laparoscopy, a small wound protector should be used to ease specimen
extraction and to protect the wound from contamination.
The proximal transection and distal transection are completed via the extraction
site. For straight laparoscopy, the anvil is placed in the proximal colon which is
returned to the abdomen. The stapled colorectal anastomosis can be performed
while under laparoscopic view (or in some cases through the wound directly if a
Pfannenstiel or lower midline incision is used). It is critical to ensure that there are
no twists in the proximal colon or the mesentery and that the small bowel is not
trapped under the left colon mesentery before the stapler is red. For hand-assisted
cases the anastomosis can be performed through the hand-port site. The anvil is
secured to the stapler and closed under direct visualization. However, prior to ring
3 Masters Program Colorectal Pathway: Laparoscopic Left andSigmoid Colectomy…
Fig. 3.7 Exteriorizing the
sigmoid colon. (Used with
permission of Springer
Nature from Leroy etal.
[26])
37
of the stapler, a pneumoperitoneum is reestablished to ensure that the proximal
colon and its mesentery are not twisted, that the small bowel is not trapped under the
left colon mesentery, and that there is no tension upon the anastomosis. In either
approach, the omentum is brought down over the small bowel and colon to an anatomical position. Following the anastomosis, air leak testing is performed with CO2
colonoscopy, and the mucosa is examined for perfusion. The anastomosis may be
reinforced with a few additional sutures depending upon the surgeon’s preference.
For cases without signicant spillage or concern for colovesical stula, no closed
suction drain is left behind. For patients in whom a colovesical stula repair was
performed, a closed suction is placed in the pelvis.
Pitfalls andTroubleshooting
Some of the most common pitfalls in this operation are extensive scarring due to
diverticular inammation which distorts the anatomy, a lack of reach of the proximal colon into the pelvis, or a positive leak test. Extensive scarring from repeated
episodes of uncomplicated diverticulitis or complicated diverticulitis with abscess/
stula can preclude a straight laparoscopic approach. This is where the hand- assisted
approach can be the most helpful. The hand and ngers allow for safe blunt dissection. In addition, portions of the procedure can be performed via the hand-port in an
open fashion, should the situation demand it. If the procedure cannot be performed
in a straight laparoscopic fashion, or if failure to progress occurs, one should consider a hand-assisted approach prior to converting to a midline laparotomy. A metaanalysis of the three published RCTs comparing hand-assisted laparoscopic to
38
J. T. Saraidaridis and P. W. Marcello
conventional laparoscopic colorectal resection showed a signicantly lower rate of
conversion in the hand-assisted patients, while morbidity rates and outcomes were
equivalent [15].
Another possible intraoperative difculty in surgery for diverticulitis is extensive
residual disease requiring more distal transection onto the patient’s rectum. Usually, the
goal is to keep the distal transection margin at the colorectal junction. However, in
some scenarios such as a residual phlegmon/abscess involving the top of the rectum or
a colovaginal stula, it is necessary to dissect further distally onto the rectum than initially planned. In these scenarios, it is important to consider and warn the patient of
potential functional consequences. More than 50% of patients who undergo low anterior resection for benign or malignant disease will develop signs and symptoms of low
anterior resection syndrome. This is a defecatory dysfunction dened by urgency, frequent stools, incontinence, and incomplete emptying. These patients may require ber
supplementation and antidiarrheals to assist in improving quality of life. In more severe
cases, biofeedback, sacral nerve stimulation, and colostomy can be considered.
Another common intraoperative difculty is a lack of reach of the proximal
transection margin to the rectum. This is particularly common if the patient’s disease
extends up into the descending colon. There is a stepwise approach to achieving
more laxity to allow for a tension-free anastomosis. First, the bowel must be assessed
for what is holding it from the pelvis. If the splenic exure has not been fully
released, then that should be performed. Second, the IMV and or left colic can be
transected close to the inferior margin of the pancreas to allow further mobility. The
transection margin must be assessed for viability after that maneuver. Here, every
lateral 1 centimeter of division provides two additional centimeters of reach. Third,
the rectum can be mobilized below Waldeyer’s fascia, thereby straightening the
rectum, which typically provides several additional centimeters of length. A nal
option is the Turnbull maneuver, wherein the distal transverse colon is brought
down to the right of midline, through an ileal mesenteric defect [16]. All of these
maneuvers can be performed via hand-assisted or straight laparoscopic methods.
Lastly, one of the most concerning pitfalls is a positive intraoperative leak test. If
leaking is demonstrated, our recommendation is to either redo the anastomosis or, if
an attempt at repair of the anastomosis is performed, strong consideration should be
made for a diverting loop ileostomy. Data from our own institution demonstrate that
out of 2360 patients who underwent left-sided anastomosis, 119 had a positive intraoperative leak test. Sixty-eight underwent suture repair alone, of which 9% had a
clinical leak postoperatively. Fifty-one patients underwent either proximal diversion
or reconstruction, and none of these patients had evidence of clinical leak postoperatively. Given these data, our strong recommendation is to either redo or divert the
anastomosis in this clinical scenario. For all other patients, the decision to proceed
with a diverting loop ileostomy to protect the colorectal anastomosis is based on
three factors: the integrity and perfusion of the bowel, the degree of intraabdominal
contamination, and the status of the patient. If following resection of the specimen
the bowel is intact and well-perfused, the abdomen is free of infection, and the
3 Masters Program Colorectal Pathway: Laparoscopic Left andSigmoid Colectomy…
39
patient has remained hemodynamically stable during the case, there is no strict
indication for a prophylactic diverting loop ileostomy. However, if any of those
three factors are concerning, a diverting loop ileostomy should be strongly
considered.
Outcomes
When considering laparoscopic approaches for patients with benign disease, there
are two questions that need to be answered. The rst is whether the laparoscopic or
hand-assisted techniques are equivalent to an open surgical approach. In some ways,
this is a difcult question to answer as, unlike cancer, there are not specic criteria
of the surgical specimen that need to be obtained for the operation to be considered
a success. Instead we have to rely on outcome measures like operative time, conversion rate, length of stay, and complications to assess whether the procedures are
equivalent (or superior). The second question is which laparoscopic approach is
appropriate (straight laparoscopic versus hand-assisted laparoscopy).
When laparoscopic colectomy was rst introduced in the 1990s, diverticular
disease-related complications were the last indications to be evaluated scientically given the concerns of extensive scarring and/or inammation as potentially
precluding a minimally invasive approach. Following this initial hesitation, studies were conducted to compare laparoscopic versus open sigmoid colectomy for
diverticulitis in the late 1990s/early 2000s (Table3.1). Most studies found that
the laparoscopic approach had longer operative times with conversion rates ranging from 6% to 20%. Length of stay was signicantly shorter in the laparoscopic
groups. With regard to complications, some studies found no differences between
the groups, while other studies found that there were fewer complications with a
laparoscopic approach. Even patients with complicated disease such as abscess
or stula were completed by a laparoscopic approach. This was detailed by
Bartus and colleagues in 36 patients who underwent laparoscopic colovesical
stula takedown [17]. The conversion rate was higher for procedures involving
stula (25% versus 5%, p<0.001), but demonstrated that for many, the procedure
could be performed successfully. Overall, for elective benign indications like
diverticulitis, these studies demonstrated that a laparoscopic approach was possible and that it had a positive effect on the length of stay and extent of complication prole.
When comparing straight laparoscopic to hand-assisted approaches, there are a
number of studies that evaluated colectomies for all indications (Table3.2). Three
of the studies are randomized controlled trials [18–20]. However, all three included
a wide range of surgical indications and are not limited to left/sigmoid colectomy.
Regardless, their ndings can be extrapolated to the diverticular population. A
meta-analysis of these three randomized controlled trials concluded that there was
40
Complications
Morbidity:
lap=18%, open=50%,
p=0.02
Not calculated in composite
J. T. Saraidaridis and P. W. Marcello
Pulmonary: lap=1.6%
open=5.6%, p<0.05
wound:
lap=0%, open 7%, p<0.05
Morbidity:
lap=42.3%, open 53.8%,
p=0.239
Morbidity: lap=37%,
open=40%, p=0.899
Morbidity:
lap=13.5%, open=9%,
p=0.56
open=20.2days, p=0.003
9% Lap=13.1days,
Operating room time
(minutes) Conversion Length of stay (days)
Lap=136
Patient
population
All
Date
19.7% Lap=4.8days, open=8.8days,
open=234, p=0.001
Lap=212, open 143,
diverticulitis:
lap=22,
open=24
All
1998
1995–
p<0.05
p<0.05
diverticulitis:
2000
p<0.05
6.6% Lap=3.1days, open=6.8days,
Lap=109,
lap=66,
open=88
All
1999–
open=101, p=NS
diverticulitis:
lap=61,
open=71
2000
19.2% Lap=5days,
Lap=183,
All diverticulitis
2002–
Open=7days, p=0.046
p=0.168
Lap=5days, open=7days,
p<0.0001
9% Lap=9days, open=10days,
open=127
(p=0.0001)
Lap=180, open 140,
lap=54,
open=54
All
2006
p=0.001
diverticulitis:
lap=75,
open=68
2008
Not stated in
article
Lap=165,
open=110, p<0.0001
All
diverticulitis:
2009
lap=59, open
54
Table 3.1 Laparoscopic approach versus open surgical approach for diverticulitis
Study
Tuech etal. [21] 1993–
Dwivedi etal.
[8]
Senagore etal.
[7]
Klarenbeek
etal. [6]
Raue etal. [10] 2005–
Gervaz etal. [9] 2005–
3 Masters Program Colorectal Pathway: Laparoscopic Left andSigmoid Colectomy…
Lap=2.8%,
HAL=5.3%, lap-assist
Complication:
lap=4.5%,
Complications
HAL=22%, p=NS
Lap=6.0, HAL=7.0,
p=0.25
Morbidity: lap=23%,
HAL=14.6%, p<0.05
Lap=6days,
HAL=23%, p=NS
HAL=6days, p=NS
Open=28%,
lap=29.4%,
Open=7.9, lap=5.1,
HAL=5.0, p<0.05
Complication:
lap=19%,
HAL=21%, p=0.68
Lap=8.9, HAL=6.9,
p=0.58
Not calculated
Lap=4.45,
HAL=4.99,
open=6.52, p<0.0001
3.2%, p=0.25
Lap=3.6, HAL=4.1,
lap-assist=4.0,
p=0.009
41
Lap=13.6%, HAL=22%,
p=0.68
Lap=141, HAL=152,
p=0.58
(multiple
operations)
lap =18,
2000 All disease
Date Patient population Operating room time Conversion Length of stay
HALS Study
Group [18]
Study
Table 3.2 Hand-assisted laparoscopic surgery versus laparoscopic surgery
Lap=23.5% (conversion to HAL
17.6%)
HAL=6.1%, p<0.05
Open=111.6,
lap=153.0,
HAL=142.0, p<0.05
All diverticular:
open=110,
lap=17,
HAL=22
2000–
2005
Anderson
etal. [22]
Lap=12.5%, HAL=2%,
Lap → HAL=15%, lap →
open=7%, HAL → open=7%,
Lap=135, HAL 120,
p=NS
lap=27,
HAL=98
2002 All disease:
Targarona
etal. [20]
p=0.11
p=NS
Lap=208, HAL=175,
p=0.021
All disease
(sigmoid, total
HAL=27
2005–
2006
Marcello
etal. [19]
colectomy)
lap=48,
HAL=47
Lap->HAL=8.5%, lap →
open=3.0%, HAL →
open=2.4%, p=0.02
Lap=180,
HAL=191.2,
open=204.4,
p=0.0001
All diverticular:
lap=133,
HAL=291,
open=37
2005–
2011
Jadlowiec
etal. [23]
(only counted patients who were
performed successfully)
Lap=165,
HAL=172.8,
lap-assist=132,
p<0.001
All pathology:
lap=71,
HAL=57,
lap-assist=63
2010–
2014
Midura etal.
[24]
42
J. T. Saraidaridis and P. W. Marcello
no difference in operating time between the straight laparoscopic and HAL patients.
There was a lower conversion rate for HAL versus straight laparoscopic approaches.
Finally, there was no difference in complication occurrences between the two
groups [15]. For this reason, in our patients who have the highest likelihood of conversion (obesity and complicated diverticulitis), we choose to start with a handassisted approach.
Conclusions
Laparoscopic or hand-assisted laparoscopic left/sigmoid colectomy is the preferred
approach for patients with benign indications such as diverticulitis. Even diverticular disease complicated by abscess, phlegmon, or stula should not preclude an
attempt at a laparoscopic approach. In our practice, patients with repeated bouts of
uncomplicated diverticulitis will undergo a straight laparoscopic approach, whereas
patients with complicated disease or morbid obesity will undergo a planned handassisted procedure. Hand-assisted laparoscopy has a decreased conversion rate (in
comparison to laparoscopic procedures) and facilitates increased adoption of minimally invasive colectomy in patients with complex diverticulitis and obesity or a
combination of both.
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