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135
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Fig. 15.7 Presacral plane dissection. A triangulation technique is utilized ( a , b ), which facilitates exposure and dissection of the retroperitoneal
plane with minimal clashing. At this point, it is imperative to identify critical structures such as the left ureter ( c ) and the superior rectal artery ( d )
ab
Fig. 15.8 Superior retroperitoneal plane dissection. The peritoneum is
incised immediately superior to left colic artery ( a , b ). The retroperito-
neal plane is developed superiorly to the Gerota’s fascia along the inferior
border of the pancreatic body and laterally to the white line of Toldt. The
concept of single-incision triangulation technique becomes again evident ( d ). The left ureter is identifi ed and preserved ( c )
15 Sigmoid Colectomy and Left Hemicolectomy: Single-Port Laparoscopic Approach
136
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Fig. 15.9 The “eagle” sign and vascular division. The vasculature is
isolated ( a ). The “body” of the “eagle” corresponds to the inferior mes-
enteric artery, the superior “wing” to the left colic artery, and the infe-
rior “wing” to the superior rectal artery ( b ). The base of the inferior
mesenteric artery is divided ( c ). The inferior mesenteric vein is readily
identifi ed and highly ligated ( d )
cd
Fig. 15.8 (continued)
R. Pedraza et al.
137
achieved with one instrument retracting the descending
colon medially and the bipolar sealing device releasing the
lateral attachments (see Fig. 15.10 and Video 15.5 ).
Transection of the Sigmoid Colon
Attention is drawn to specimen division. Additional rectosigmoid attachments are further released so as to achieve proper
mobilization of the proximal rectum (see Fig. 15.11c, d ).
Often the mobilized bowel can be fl ipped to facilitate mesentery division. An incision in the mesentery is performed
establishing a window (see Fig. 15.12a ). The linear stapler is
placed through this window and the mesentery is divided or
taken down with an energy device (see Fig.
15.12b–d ). The
bowel is then fl ipped back to its normal anatomic confi guration, and the rectosigmoid is divided with a linear stapler (see
Fig. 15.13a, b and Video 15.6 ). The specimen is extracorpo-
realized, and the division of the proximal bowel is performed
(see Fig.
15.13c, d ).
Anastomosis with Leak Test
An end-to-end anastomosis is performed with a circular stapler in a conventional fashion. The anastomosis is performed
after reestablishing pneumoperitoneum and under direct
laparoscopic visualization (see Fig. 15.14 ). Confi rmation of
a viable and intact anastomosis can be achieved both with
direct endoscopic visualization and the absence of leak on
the air insuffl ation test (see Video 15.7 ). If a leak is noted,
consideration of conversion to a laparoscopic technique for
revision of the anastomosis is warranted. In extreme cases,
proximal diversion may be required.
Approaches
Left/sigmoid colectomy may be performed in a lateral-tomedial or medial-to-lateral approach. The lateral-to-medial
approach is typically utilized for open resections, whereas
the latter is typically used for the laparoscopic approach.
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Fig. 15.10 Lateral-to-medial dissection. The lateral attachments of the descending colon are taken down while retracting the descending colon
medially ( a – d )
15 Sigmoid Colectomy and Left Hemicolectomy: Single-Port Laparoscopic Approach
138
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Fig. 15.11 Rectosigmoid attachments release. Additional rectosigmoid pelvic attachments are further released to achieve proper mobilization of
the proximal rectum ( a – d )
Fig. 15.12 Rectosigmoid mesentery division. The mobilized bowel can be fl ipped to facilitate mesentery division. An incision in the mesentery
is performed establishing a window ( a ) through which a linear stapler (or energy device) is placed. The mesentery is divided ( b – d )
ab
R. Pedraza et al.
139
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Fig. 15.13 Rectosigmoid division and extracorporealization. The rectosigmoid is divided with a linear stapler ( a , b ) and the bowel is extracorpo-
realized to divide it proximally ( c , d )
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Fig. 15.12 (Continued)
15 Sigmoid Colectomy and Left Hemicolectomy: Single-Port Laparoscopic Approach
140
For the single-incision laparoscopic technique, the medialto- lateral approach is more suitable. This approach enables
the identifi cation and preservation of critical structures –
left ureter, pelvic plexus, and iliac vessels – early in the
procedure and facilitates the “triangulation technique,”
which is crucial for single-incision colectomy (see above).
Furthermore, the lateral attachments of the descending
colon to the abdominal sidewall serve as fi xed point facilitating the medial-to-lateral retroperitoneal dissection. In
addition, the instruments are located in the midline; thus, it
is more ergonomic to dissect forward laterally rather than
backward from lateral to medial.
Single-Port Laparoscopic Reversal of a Hartmann’s Resection
Laparoscopic reversal of a Hartmann procedure is a minimally invasive procedure that can afford to the patient many
short-term benefi ts as compared with open surgery [ 11 , 12 ].
In addition to the avoidance of a large incision, laparoscopic Hartmann’s reversal is associated with a reduction
of surgical blood loss, postoperative morbidity, and length
of stay [ 11 – 14 ]. Consequently, laparoscopic Hartmann’s
reversal has gradually gained acceptance and widespread
adaptation.
More recently, single-incision laparoscopic Hartmann’s
reversal was introduced [ 15 , 16 ]. In this technique, the
entirety of the procedure is performed via the ostomy site in
which the single-incision device is placed. As with conventional laparoscopy, the single-incision approach affords thorough assessment of the abdominal cavity, lysis of adhesions,
and bowel resection if required. In contrast to conventional
laparoscopic surgery, however, single-incision Hartmann’s
reversal completely avoids the use of additional ports and
incisions, eliminating the associated morbidity. Hence, this
procedure may be one of the most benefi cial for the singleincision laparoscopic modality.
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Fig. 15.14 Colorectal anastomosis. An end-to-end anastomosis is performed with a circular stapler in a conventional fashion. The anastomosis is performed after reestablishing pneumoperitoneum and under
direct laparoscopic visualization ( a – c ). An air insuffl ation test may be
performed to confi rm the viability and integrity of the anastomosis ( d )
R. Pedraza et al.
141
The reversal of the Hartmann procedure may represent a
challenge, especially in cases with history of severe infl ammatory reaction. Entering through the ostomy site is often
faced with parastomal hernia sac and adhesions. If one cannot
release the adhesion safely under direct visualization, the laparoscopic approach can aid in visualization before the pneumoperitoneum is established. In cases in which the abdominal
entry through the ostomy site is unsafe or the placement of the
single-port cannot be achieved, consideration of multiport is
prudent.
It is imperative to perform a comprehensive preoperative assessment. Proctoscopic evaluation in the offi ce setting is typically required to evaluate the rectal stump. As
an aid for the identifi cation of the rectal stump during the
reversal procedure, it may be tattooed during proctoscopic
examination. An abdominal CT scan may be also warranted so as to evaluate the presence of an abscess, in
which case, a percutaneous drainage and antibiotic therapy
are indicated prior to the reversal. Water-soluble contrast
enema is indicated if there is the suspicion of a sigmoid
remnant in the rectal stump, which demands its resection
during the reversal. The timing for Hartmann’s reversal
remains controversial. Numerous studies have shown safe
Hartmann’s reversal following 10–15 weeks of the index
procedure. It should be noted, however, that the preoperative clinical judgment in a case-by- case basis is the best
indicator for optimal reversal timing. In fact, in some cases
of severe diverticulitis, other procedures such as laparoscopic lavage may be warranted prior to considering the
reversal procedure.
Surgical Technique
The surgeon/patient confi guration during single-incision
laparoscopic reversal of Hartmann’s operation varies to that
of left/sigmoid colectomy. Since the single-incision device is
going to be placed at the ostomy site, the surgeon and assistant are located at the patient’s left side. Conversely, patient
positioning is identical to that described for left/sigmoid
colectomy.
The colostomy is freed in a conventional fashion. A circumferential skin incision around the colostomy is performed and further deepened to the underlying fascia and
peritoneum. In order to completely release the colostomy,
further lysis of adhesions may be required. Once completely
mobilized, the exposed colostomy is stapled across in a tangential fashion and the bowel is replaced into the peritoneal
cavity.
The single-incision device is placed in the ostomy site and
the trocars are introduced through the port. The peritoneal
cavity is evaluated, and further lysis of adhesions is performed as required to mobilize the proximal bowel in anticipation of a tension-free anastomosis. This often requires
splenic fl exure takedown. These steps can be extensive and
technically challenging and may comprise a signifi cant portion of the procedure. The rectal stump is then identifi ed. The
stump is often adhered to the adjacent tissues and care should
be taken to mobilize the portion required to achieve an anastomosis. The utilization of an EEA stapler placed transanally
may facilitate retraction. The rectum itself may require partial mobilization to facilitate the placement of the stapling
device transanally. The proximal colon is extracorporealized
and an end-to-end colorectal anastomosis is performed as
previously described.
Summary
Single-incision laparoscopic surgery is a safe and effective
minimally invasive alternative for diseases requiring left or
sigmoid colectomy. The procedure typically commences
with laparoscopic exploration followed by the mobilization
of the rectosigmoid entering to the presacral avascular space
and with early identifi cation of the ureter and critical vascular structures. The left colon is then mobilized medial-tolateral and inferior-to-superior to the splenic fl exure followed
by the IMA division. The descending colon lateral attachments are then taken down from the pelvic brim to the splenic
fl exure. The bowel is then transected and an end-to-end anastomosis is performed. The utilization of the triangulation
technique facilitates tissue dissection and avoids instrument
confl ict and clashing.
Single-incision laparoscopic Hartmann’s reversals,
although recently described, have shown to be a safe and feasible approach. This technique avoids the necessity for additional incisions, as the entirety of the procedure is performed
through the colostomy site. Once the colostomy is mobilized, the single-port device is placed and abdominal lysis of
adhesions as well as rectal stump mobilization is performed
in a single-incision laparoscopic fashion. The anastomosis is
performed in a conventional fashion utilizing an end-to-end
stapling device.
References
1. Ahmed I, Paraskeva P. A clinical review of single-incision laparo-
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3. Remzi FH, Kirat HT, Kaouk JH, Geisler DP. Single-port laparos-
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Young-Fadok TM, Lee EC, et al. Single-incision versus standard
multiport laparoscopic colectomy: a multicenter, case-controlled
comparison. Ann Surg. 2012;255(1):66–9.
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colectomy: a case-matched series. J Gastrointest Surg.
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10. Orcutt ST, Balentine CJ, Marshall CL, Robinson CN, Anaya DA,
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Hartmann’s procedure. Dan Med Bull. 2010;57(6):A4149.
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versus open restoration of intestinal continuity after Hartmann procedure. Hepatogastroenterology. 2010;57(98):232–5.
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assisted Hartman’s reversal is an effi cacious and effi cient procedure: a case control study. Minerva Chir. 2009;64(1):1–8.
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O. Bardakcioglu (ed.), Advanced Techniques in Minimally Invasive and Robotic Colorectal Surgery,
DOI 10.1007/978-1-4899-7531-7_16, © Springer Science+Business Media New York 2015
Introduction
Following the overview of laparoscopic techniques to
sigmoid resection and Hartmann’s reversal in the previous
chapters, we will expand on the utilization of the da Vinci
robotic system for this procedure. Certain operative steps
described in this chapter are part of a total robotic low anterior resection and proctectomy described in a later chapter
for this book.
Background
Robotic-assisted laparoscopic surgery was fi rst introduced to
colorectal surgery in 2002 [ 1 ] and has since been shown to
be safe and feasible for various colorectal procedures including colectomy, rectal resection, and rectopexy [ 1 – 4 ].
Currently, the majority of cases involve rectal resection and
total mesorectal excision for rectal cancer. These cases tend
to accentuate the benefi ts of the unique features of the robotic
platform, since the majority of the procedure involves confi ned spaces in the pelvic cavity.
The benefi ts of robotic-assisted laparoscopic surgery
include three-dimensional visualization, stable camera,
motion scaling, and wrist-like movements of the tip of the
instruments. These features facilitate visualization,
maneuverability, and dissection, especially in confi ned and
narrow operative fi elds such as the pelvis. However, the
robotic approach for procedures involving multiple
quadrants may be cumbersome and require robot
re-docking and patient repositioning, which may add to the
complexity of the case. Thus, when utilized for left/
sigmoid colectomy, a hybrid approach may be a suitable
alternative. In this approach, conventional laparoscopy is
utilized for lysis of adhesions and splenic fl exure takedown followed by robotic technique for the remaining
colon dissection (Box 16.1 ).
The most common indications for robotic left/sigmoid colectomy include adenocarcinoma of the colon, complicated
diverticulitis, and large polyps not amenable to endoscopic
removal [
4 ]. Other less common indications include resection
rectopexy for rectal prolapse and infl ammatory bowel disease.
The utilization of robotic left/sigmoid colectomy for benign
pathologies has been advocated as a bridge to attain competency
on one learning curve before entering into more complex procedures, such as rectal resection with total mesorectal excision.
Room Setup and Positioning
The operating room confi guration varies depending on the
operating suite design. The operating room should be large
enough to accommodate the three robotic surgical system
components (cart, console, and video tower). For left colon/
sigmoid procedures, the video tower and robotic cart are
typically on the left side of the patient and the assistant is
located in the right side (Box 16.2 ).
Sigmoid Colectomy and Left Hemicolectomy: Robotic Approach
Rodrigo Pedraza and Eric M. Haas
1 6
R. Pedraza , MD (*) • E. M. Haas , MD, FACS, FASCRS
Division of Minimally Invasive Colon and Rectal Surgery,
Department of Surgery , The University of Texas Medical
School at Houston , Houston , TX , USA
e-mail:
rpedraza@houstoncolon.com
Electronic supplementary material Supplementary material is available
in the online version of this chapter at
10.1007/978-1-4899-7531-7_16 .
Videos can also be accessed at
http://www.springerimages.com/
videos/978-1-4899-7530-0
.
Box 16.1 Tip
The introduction of the robotic vessel sealer and stapling
device expands the use of wristed instruments with
increased maneuverability for abdominal procedures.
144
The patient is secured to the operating table with both
arms tucked and placed in modifi ed lithotomy position in
moderate Trendelenburg with the left side elevated. This
positioning will allow for the initial laparoscopic exploration. One must be cognizant that in order to take advantage of the gravitational forces during the robotic segment
of the procedure, the patient may be placed in steep
Trendelenburg position. Care must be taken so as to
ensure that the patient is adequately secured to the operating room table. In our institution, we employ a “wrapped”
technique. This entails securing the patient to the operating room table with a 3-in. silk tape at the level of the
upper chest in a secure fashion, yet allowing chest expansion. Anti-slip rubber pads may be alternatively utilized
so as to prevent the patient from sliding while in a steep
Trendelenburg position. It should be noted that improper
positioning may result in signifi cant injury. Furthermore,
patient positioning cannot be altered once robotic docking
is achieved.
Port Placement and Extraction Sites
Port placement varies depending on several factors, including location and type of disease process, body habitus, and
preoperative clinical/radiological evaluation (Box 16.3 ).
Additionally, port placement will often vary on surgeon
experience and preference. The optimal port confi guration
must be carefully planned preoperatively so as to avoid the
need for additional incisions, unnecessary procedure interruptions, and instrument or robotic arm confl ict. Initial
entry is achieved typically starting with the 12 mm robotic
camera port. This is either at the periumbilical region 2 cm
to the right and 2 cm superiorly from the umbilicus or
supraumbilical, similar to laparoscopic port placement.
Commonly, initial entry is achieved by utilizing optical
port entry technique (OptiView®, Ethicon Endo-Surgery,
Cincinnati, OH), which allows direct visualization entry in
a bladeless fashion. However, abdominal cavity entry may
be performed through a Veress needle technique or other
techniques in which the surgeon has experience. This can
be established in the left upper quadrant (LUQ) at Palmer’s
point, followed by the optical port entry described above
for the robotic camera port.
Once the pneumoperitoneum is created, the remaining trocars are placed under direct visualization. Planned
port sites should not be marked before the creation of the
pneumoperitoneum, as the location usually alters following
the incremental change in the abdominal girth.
Two port confi gurations are recommended. Figure 16.1
provides two working robotic instruments for the splenic fl exure mobilization and three for pelvic dissection and therefore
suited for the abdominal part of a total robotic LAR. Figure 16.2
provides three working robotic instruments for the splenic
fl exure mobilization and two for possible upper pelvic dissection and therefore suited for a robotic sigmoid resection.
R4
C
R2
R1
R3
L1
Fig. 16.1 Port confi guration. C 12 mm camera port. L1 5 mm laparo-
scopic assistant port. R1 and R2 8 mm robotic working ports for arms 1
and 2 during splenic fl exure mobilizations. R1 , R3 , and R4 8 mm robotic
working ports for arms 1, 2, and 3 for sigmoid colon and possible pelvic
dissection
Box 16.2 Tip
When the patient is placed in stirrups, the patient
should be positioned in Trendelenburg and left-side up
positioning to check that the patient’s left knee in the
stirrups will not intervene with the docking.
Box 16.3 Tip
Moving the camera port off midline to the right of the
patient might improve the visualization of the base of
the IMA.
R. Pedraza and E.M. Haas