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158
H. M. Ross
Operative Techniques
1. To recreate pneumoperitoneum after having
created a wound for specimen extraction:
(a) An existing wound protector can be
twisted and clamped with an instrument
like a Kelly (Fig.37.2).
(b) A wound protector with replaceable cap
can be inserted.
(c) A purse-string closure of the peritoneum
can be rapidly created (Fig. 37.3). The
purse string can be cinched reversibly by
threading the suture through a short segment of a red rubber catheter.
Technical Pearls (Tips andTricks)
1. The operative team should have equipment
necessary to recreate pneumoperitoneum in
the operating room.
2. Practicing selected techniques to recreate
pneumoperitoneum can be helpful for surgeons and surgical teams. Many surgeons perform routine second-look laparoscopy at the
end of every laparoscopic colon resection.
Special Postoperative Care
1. None required
Fig. 37.2 Twisting of a
wound protector to
recreate
pneumoperitoneum
37 Re-look After Laparoscopic Resection
Fig. 37.3 Creation of a
purse string for closure
of peritoneum
159
Retraction ofa“Floppy Uterus”
Encountered During Minimally
Invasive Rectal Resection
HowardM.Ross andMeredithGunder
38
Clinical Scenario
Ms. M, a 31-year-old woman, was found to have a
T1 mid-rectal cancer and presents for laparoscopic
LAR.After ports are placed, access to the pelvis is
prevented from a uterus that continually falls into
the deep pelvis. Simple position changes do not
provide relief, and the operation cannot progress
given the uterus position. Ms. M. denitely wants
to preserve her uterus and desires children.
Key Points
1. The ability to have an unobstructed view of
the pelvis is mandatory when performing
operations on the mid and distal rectum.
2. Retraction of a “oppy uterus” is simple and
effective when surgeons are familiar with the
available technical options.
3. Suspension of the uterus can be readily
achieved via a Keith needle placed through
H. M. Ross (*)
Division of Colon and Rectal Surgery,
Lewis Katz School of Medicine at Temple University
and the Temple University Health System,
Philadelphia, PA, USA
e-mail: Howard.Ross@tuhs.temple.edu
M. Gunder
Department of Surgery, Temple University Hospital,
Lewis Katz School of Medicine at Temple University,
Philadelphia, PA, USA
the uterine fundus, suture looped around the
broad ligament, or the use of a retractable fan
retractor.
Operative Assessment
1. If the pelvis cannot be visualized adequately
due to the uterus obstructing exposure, uterine
suspension should be performed.
Operative Checklist
1. Additional helpful equipment includes a Keith
needle and an expandable fan retractor.
Operative Techniques
1. Suspension of the uterus via Keith needle is
performed with the patient in Trendelenburg
position. Direct visualization of the needle at
all times is critical. The needle is placed
through the skin, through the anterior portion
of the uterus where suspension will be maximal, and then placed back through the skin
(Fig.38.1). If the entry and exit points in the
skin are close in distance, a single clamp may
be used to anchor the suture.
2. Suspension of the broad ligament is performed
by looping the suture around the broad
© Springer Nature Switzerland AG 2019
S. W. Lee et al. (eds.), Colorectal Surgery Consultation,
https://doi.org/10.1007/978-3-030-11181-6_38
161
162
H. M. Ross and M. Gunder
Fig. 38.1 Suture
retraction of the uterus.
(With permission.
Leroy J, Henri M,
Rubino F, Marescaux
J.Sigmoidectomy. In:
Milsom JW, Böhm B,
Nakajima K, editors.
Laparoscopic
colorectal surgery.
Springer, NewYork;
2006. p.145–69)
ligament with same precaution of needle visualization mentioned above.
3. A fan retractor can provide effective uterine
retraction. It is inserted underneath the uterus
and expanded to give the desired effect. The
upward force of retraction on the uterus can be
maintained by an assistant or by use of an
instrument clamping system.
4. An additional port can always be placed to
facilitate additional approaches to retraction.
5. A uterine manipulator used in gynecology can
be helpful, if personnel are familiar with its
use.
Technical Pearls (Tips andTricks)
1. Create uterine retraction early in the operation. Suspension techniques are simple and
effective. Delaying their utilization is
unnecessary.
Special Postoperative Care
1. After removal of the uterine suture, monitor
effectively for bleeding.
Suggested Reading
1. Ashley SW.Left hemicolectomy and sigmoid colon.
In: Matteotti R, editor. Minimally invasive surgical oncology state-of- the-art cancer management.
Springer; New York, NY: 2016. p.224.
2. Lichliter WE.Techniques in total mesorectal excision
surgery. Clin Colon Rectal Surg. 2015;28(1):21–7.
https://doi.org/10.1055/s-0035-1545066.
3. Puntambekar SP, Patil AM, Rayate NV, Puntambekar
SS, Sathe RM, Kulkarni MA.A novel technique of
uterine manipulation in laparoscopic pelvic oncosurgical procedures: “the uterine hitch technique”.
Minim Invasive Surg. 2010;2010:836027. https://doi.
org/10.1155/2010/836027.
Bleeding During Colectomy
ShirleyShih andDavidE.Rivadeneira
39
Clinical Scenario
You are performing a low anterior resection for a
rectosigmoid cancer in a 68-year-old male,
smoker, diabetic with signicantly calcied vessels. You identied the inferior mesenteric vascular pedicle and proceed to apply the energy-based
vessel sealing device when suddenly extensive
bleeding occurs from the pedicle and a pulsatile
stream of blood covers the tip of your laparoscope and obscures your entire screen with red.
Now what?
Key Points
1. Methods to approach major vascular pedicle
bleeding during a laparoscopic colectomy:
S. Shih
Northwell Health, Department of Colorectal Surgery,
Woodbury, NY, USA
D. E. Rivadeneira (*)
Surgical Strategic Initiatives, Northwell Health,
New Hyde Park, NY, USA
Surgical Services and Colorectal Surgery,
Huntington Hospital, Huntington, NY, USA
Hofstra University-Northwell School of Medicine,
Hempstead, NY, USA
e-mail: DRivadeneira@northwell.edu
(a) Maintain a calm composure and think
clearly without panicking.
(i) Although easier said than done, it is
imperative that the surgeon maintains
composure and a clear head during
this critical time. The surgeon must
maintain “equanimity under duress”
and stay in control, exude condence,
and communicate clearly with the
staff. The chance of having a good
outcome will depend on everyone in
the operating room; however, the tone
will be set by the surgeon. This
approach allows the operating theater
to remain drama free and for the
nurses and technicians to provide you
with the assistance and equipment you
need efciently and expeditiously.
2. Be prepared for the worst when dealing with
ligation of major vascular pedicles.
(a) Always prepare before coming across a
major vascular pedicle. Expect failure of
any blood vessel sealing device, such as
bipolar or ultrasonic energy devices, clips,
and staplers as they can all fail. Have a
game plan ready to deal with a major failure of one of these devices, if and when
this happens.
(b) Make sure to communicate with your
assistant to maintain the exposure if there
is bleeding from a major vascular pedicle.
Often the rst response from the assistant
© Springer Nature Switzerland AG 2019
S. W. Lee et al. (eds.), Colorectal Surgery Consultation,
https://doi.org/10.1007/978-3-030-11181-6_39
163
164
S. Shih and D. E. Rivadeneira
is to drop the tissues being held and
attempt to suction the area or grasp the
bleeding pedicle indiscriminately. That
should not be done. Instruct the assistant
to maintain the exposure while the surgeon guides the efforts. Before coming
across a pedicle, it is helpful to remind
your assistant that in the event of bleeding, do not let go of the tissue, etc.
(c) Have a clear visualization of the vascular
pedicle and a grasper nearby in order to
grasp the bleeding vessel. Do not reapply
vessel sealing devices, clips, or staplers in a
pool of blood without a clear view of the
bleeding vessels, as this may lead to inadvertent injury to other structures, such as
the ureter or bowel. You often have more
time than you think. Take time to clearly get
the area clear of blood and secure the
pedicle.
(d) Pre-knotted endoloop ligature. Before
coming across a pedicle, it is good practice to conrm that there is a pre-knotted
endoloop available in the room and that
the suction irrigator has been primed and
is working. You don’t need to open the
endoloop at this point; just have it available for this type of scenario. An
endoloop will often allow you to secure
and ligate a large bleeding pedicle with
relative ease.
(e) As demonstrated by the clinical scenario,
patients with calcied vessels require special attention, as the calcied vessels may
not seal properly with energy-based
devices. Calcied vessels will often cause
annoying oozing from a vascular staple
line. If an energy device or stapler is used
across a signicantly calcied vessel, it
may be best to reinforce the stump closure
with an endoloop ligature.
Operative Assessment
2. Communicate with the anesthesia team
regarding signicant hemorrhage so supportive measures can be initiated, including:
(a) Type and cross.
(b) Transfusions of not only PRBC but also
FFP and other blood products, as needed.
(c) Pressure bags for resuscitation and for
administration of blood products.
(d) Insertion of central lines, additional large
bore IV lines, or arterial lines, as needed.
(e) Notify the staff that the patient may need
close monitoring in the postoperative
setting.
(f) Gain exposure via suctioning/irrigating,
adding a 5mm port for further assistance,
introducing a 4 × 4 gauze, converting to
hand-assisted approach, and isolating and
controlling the bleeding pedicle manually.
(g) Electrocautery can be applied to smaller-
caliber vessels or friable oozing tissue
3. Topical coagulants such as surgical are best
used for small-caliber vessel bleeding and
usually will have minimal role in large bleeding vessels.
4. Medium- to large-caliber vessels.
5. Suture ligation of medium to large vessels can
be used once proximal and distal control has
been obtained.
6. Topical coagulants such as Floseal (thrombin
with gelatin) are more appropriate for moderate arterial bleeding. When placed in contact
with blood, it serves as source of brinogen
for reasonable bleeding control. Has the
bleeding been adequately controlled to the
point where hemodynamic instability is not
contributing to coagulopathy?
(a) Has anesthesia caught up in terms of IV
resuscitation and transfusion of blood
products?
(b) Have all available OR methods been uti-
lized in obtaining hemostasis?
(c) Is there additional assistance required in
the OR? Vascular consult? Another experienced surgical attending?
1. Identify and plan for rapid control of a bleeding pedicle, should this occur. Remember that
the vascular pedicle will often contain both
arterial and venous vessels.
Operative Checklist
1. Laparoscopic endoloop available in the room.
39 Bleeding During Colectomy
165
2. Suction/irrigation setup: suction the eld and
make the area as dry as possible. Remember
not to cauterize or use energy-based devices,
clips, or staplers without having a clear view
of the bleeding pedicle.
3. Raytec (radiopaque 4 × 4) gauze readily available to put down the trocar and use for tamponade propose.
4. Laparoscopic Maryland or ne-tip graspers
will allow you to precisely hold blood
vessels.
5. Energy-based blood vessel sealing device of
surgeon’s choice.
6. Clips or Hem-o-lok® polymer clips (Teleex,
Morrisville, NC, USA).
Operative Technique
1. Maintain the exposure, and grasp the bleeding
pedicle with a laparoscopic Maryland or
bowel grasper.
2. Once you have controlled the bleeding pedicle with a grasper, use suction or gauze to
clean up the area. You can use the gauze and
pressure to help tamponade the bleeding
pedicle. Ensure that no other inadvertent
tissue is being caught up and potentially
injured. If you can, reapply the vessel sealing device to the bleeding pedicle; it may
require several applications to achieve
hemostasis. If a stapler has failed, there is
usually very little space to apply another
stapler line. Regular laparoscopic clips and
synthetic Hem-o-lok can be applied
(Fig.39.1).
3. Application of an endoloop is essential when
dealing with bleeding from a major pedicle,
usually can be placed safely through a 5mm
assistant port. The suture is formed in a ligature loop with a knot. Once the ligature is in
place, simply snap the scored end, and pull
upward to tighten the loop and secure the knot
(Fig.39.2).
4. Conversion to a hand-assisted laparoscopic
technique may be necessary if you are unable
to control the bleeding using the discussed
methods. Hand-assisted approach will allow
for rapid manual compression of the pedicle
and, usually, immediate cessation of bleeding.
During this time your anesthesia team should
be prepared to transfuse, as necessary. While
you maintain manual compression of the pedicle, you should clean up and dry the surgical
bed and again identify essential structure so
they are not inadvertently injured as you
achieve hemostasis.
5. If all maneuvers fail to achieve hemostasis,
convert to an open approach, and address the
pedicle.
Fig. 39.1 Laparoscopic
grasper and energy
device controlling the
mesenteric root bleeding
166
Fig. 39.2 Placement of
the endoloop around a
bleeding pedicle
Technical Pearls (Tips andTricks)
1. Be prepared! Always assume that any device
you use to come across a major vascular pedicle will fail and you will have massive
bleeding.
2. Alert your assistant to keep the exposure and
not to drop the retracted tissues in an attempt
to assist.
3. Keep a laparoscopic grasping instrument near
the pedicle that you are coming across. Often,
when reviewing videos of vascular pedicle
bleeding, one of the rst things that is apparent is that there is no grasper near the pedicle
as it starts to bleed.
4. Have an endoloop available in the operating
room. You don’t have to open this unless it is
needed, and therefore you don’t have to waste
the expense in most cases. In the authors’
experience, this has come in handy in many
cases.
5. Be especially careful and cautious with
patients with calcied vessels, as these vessels
may not seal properly with energy-based
devices. In these patients a laparoscopic stapler with a vascular cartridge may be
preferred.
6. Do not clip, seal, burn, or staple a pedicle without clearly identifying critical structures. You
often have more time than you think. Use suc-
S. Shih and D. E. Rivadeneira
tion to get clear, blood-free visualization.
Remember that the bleeding always seems
worse with a laparoscopic view. When dealing
with a bleeding ileocolic pedicle, make sure to
see the duodenum, right ureter, and gonadal
vessels clearly. When dealing with the middle
colic pedicles, make sure to clearly see the duodenum, pancreas, and superior mesenteric pedicle, as an injury to any of these could be
devastating. When dealing with left colic or
inferior mesenteric pedicle, you should clearly
see the left ureter, gonadal vessels, and hypogastric nerves.
Postoperative Care
1. If bleeding is minimal to moderate, then nothing special is needed.
2. If bleeding is significant, then postoperative hemoglobin and hematocrit is ordered
and blood transfusion given if clinically
indicated.
Suggested Reading
1. Lee S, Ross H, Rivadeneira DE, Steele S, Feingold
D, editors. Advanced colonoscopy and endoluminal
surgery. Cham: Springer; 2017.
39 Bleeding During Colectomy
167
2. Merchea A, Wolff BG. Pelvic bleeding. In: Steele SR,
Maykel JA, Champagne BJ, Orangio GR, editors.
Complexities in colorectal surgery: Decision making
and management. Seiten: Springer; 2014. p. 305–9.
3. Ross H, Lee S, Mutch M, Rivadeneira D, Steele
SR, editors. Minimally invasive approaches to colon
and rectal disease: technique and best practices.
NewYork: Springer Publishing; 2015.
4. Ross H, Lee S, Champagne B, Pigazzi A. In:
Rivadeneira DE, editor. Robotic colorectal surgery.
NewYork: Springer Publishing; 2015.
Cannot Find theUreter
ScottR.Steele andAndrewT.Schlussel
40
Clinical Scenario
A 55-year-old morbidly obese female is undergoing a laparoscopic sigmoid colectomy for recurrent diverticulitis. Eight weeks ago, she presented
with a complicated episode of diverticulitis
where she developed a 5cm pericolonic abscess
requiring percutaneous drainage. She recovered
from this acute episode but continued to have left
lower quadrant abdominal pain. The colon was
being mobilized in a lateral to medial fashion,
and the left ureter could not be identied during
the dissection.
Key Points
1. How is the ureter injured?
(a) Failure to recognize surrounding structures
and understand anatomic relationships.
(b) Disease severity and/or location.
(c) Poor dissection technique.
2. Consider which patients may have complicated anatomy that may interfere with the
identication of the ureter, and consider ureteral stenting.
(a) Reoperative surgery.
(b) Severe recurrent and/or complicated
diverticulitis.
(c) History of radiation.
(d) Large malignancies.
(e) Morbidly obese patients undergoing pel-
vic surgery.
(f) Inammatory bowel disease.
(i) Crohn’s disease.
(ii) Ulcerative colitis with fulminant
colitis.
(g) Any anatomic variations like a double
ureter.
3. Identify the iliac artery where the ureter will
cross over.
4. The ureter should always be identied on the
left side.
(a) This should be performed prior to division
of any vascular pedicle.
5. Identication of the right ureter during right
colectomy is not typically needed but may be
required depending on the dissection.
S. R. Steele (*)
Case Western Reserve University School of
Medicine, Cleveland, OH, USA
Department of Colorectal Surgery, Cleveland Clinic,
Cleveland, OH, USA
A. T. Schlussel
Madigan Army Medical Center, Department of
Surgery, Tacoma, WA, USA
© Springer Nature Switzerland AG 2019
S. W. Lee et al. (eds.), Colorectal Surgery Consultation,
https://doi.org/10.1007/978-3-030-11181-6_40
Operative Assessment
1. The ureter is a retroperitoneal structure that
measures 25–30 cm in length and lies on
the anterior surface of the psoas muscle
(Fig.40.1).
169