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Number of ports is irrelevant: place as many as needed to have good retraction.
Umbilicus: the mere fact that there is that anatomic structure in the center of the abdomen by no means mandates
its use as a port site; it is often better to locate the port at more of a distance.
Plan ports such that working instruments do not get into each other's way: use a semi-circle with target as the
center. Retraction ports may be off that circle.
Hand-port: select a location not too close to target but "wrist-to-fingertip" distance away from it; place such that the
remaining bowel end will reach.
Closure of ports: anything 10 mm.
Examples
(A1) Right Hemicolectomy (Figure 5–13A)
1. Supraumbilical optical port later enlargement for specimen delivery.
2. RLQ midclavicular line working port.
3. LUQ midclavicular line working port.
4. Additional ports: right side, level of umbilicus.
Figure 5–13A.
Laparoscopic port placement: right hemicolectomy.
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(A2) Right Hemicolectomy
1. Supraumbilical hand-port specimen delivery.
2. RUQ camera port.
3. RLQ working port.
4. LUQ midclavicular line working port.
5. Additional ports: LLQ.
(A3) Right Hemicolectomy
1. Suprapubic Pfannenstiel incision for hand port
specimen delivery.
2. Umbilical optical port.
3. LUQ midclavicular line working port.
4. LLQ working port.
5. Additional ports: RLQ.
(B1) Sigmoid Colectomy
1. Infraumbilical optical port
later enlargement for specimen delivery.
2. RLQ midclavicular line working port.
3. LLQ midclavicular line working port.
4. Additional ports: right side level of umbilicus, suprapubic.
(B2) Sigmoid Colectomy
1. Periumbilical hand port
specimen delivery.
2. RLQ midclavicular line optical port.
3. LLQ midclavicular line working port.
4. RLQ working port.
5. Additional ports: suprapubic port.
(C1) Left Hemicolectomy (Figure 5–13B)
1. Infraumbilical optical port
enlargement for specimen delivery.
2. RLQ midclavicular line working port.
3. RUQ midclavicular line working port.
4. LLQ midclavicular line working port.
5. Additional ports: right side, level of umbilicus.
Figure 5–13B.
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Laparoscopic port placement: left hemicolectomy.
(C2) Left Hemicolectomy
1. Periumbilical hand port
specimen delivery.
2. RUQ working port.
3. LLQ working port.
4. RLQ working port.
5. Additional ports: suprapubic port.
(C3) Left Hemicolectomy
1. Suprapubic Pfannenstiel incision for hand port
specimen delivery.
2. Umbilical optical port.
3. RLQ working port.
4. LLQ working port.
5. Additional ports: RUQ.
(D1) Subtotal Colectomy/Proctocolectomy
1. Infraumbilical optical port
later enlargement for specimen delivery.
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2. RLQ working port.
3. LLQ working port.
4. RUQ working port.
5. LUQ working port.
(D2) Subtotal Colectomy/Proctocolectomy
1. Supraumbilical optical port.
2. Right umbilical line working port.
3. Left umbilical line working port.
4. Suprapubic working port
later enlargement for specimen delivery.
(D3) Subtotal Colectomy/Proctocolectomy
1. Periumbilical hand port
specimen delivery.
2. RUQ working port.
3. LLQ working port.
4. RLQ working port.
5. Additional ports: suprapubic port.
(D4) Subtotal Colectomy/Proctocolectomy
1. Suprapubic Pfannenstiel incision for hand port
specimen delivery.
2. Umbilical optical port.
3. Right umbilical line working port.
4. Left umbilical line working port.
5. Additional ports: epigastric.
(E) Hartmann Reversal (Figure 5–13C)
1. Right umbilical line optical port (away from midline).
2. RUQ midclavicular line working port
free adhesions.
3. RLQ midclavicular line working port
free adhesions.
4. Additional ports: midline (after takedown of adhesions), at colostomy site.
Figure 5–13C.
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Laparoscopic port placement: laparoscopic Hartman reversal.
(F) Rectopexy (Figure 5–13D)
1. Infraumbilical optical port.
2. RLQ midclavicular line working port.
3. LLQ midclavicular line working port.
4. Additional ports: suprapubic.
Figure 5–13D.
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Laparoscopic port placement: laparoscopic rectopexy.
Anatomic Structures at Risk
Epigastric vessels, falciform ligament, bowel, parenchymatous organs, major vessels.
Cross-Reference
Rectal prolapse—rectopexy (laparoscopic vs open) (Ch. 5)
Sigmoid resection (open, anastomosis vs Hartmann) (Ch. 5)
Left hemicolectomy (open) (Ch. 5)
(Sub-)-total colectomy, ileorectal anastomosis (open) (Ch. 5)
Proctocolectomy, ileal J-pouch anal anastomosis (open) (Ch. 5)
Adhesiolysis (laparoscopic vs open) (Ch. 5)
Laparoscopic colorectal surgery (Ch. 5)
Hartmann reversal (laparoscopic vs open) (Ch. 5)
Lower anterior resection (LAR)/total mesorectal excision (TME) (Ch. 5)
COLONOSCOPIC STENT PLACEMENT
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Principle
Colonoscopic insertion of a self-expandable metallic stent to reopen a LBO, either as a bridge to a definitive resection or as
palliation only. Successful decompression converts an emergency situation into a (semi-)elective one and allows for patient
recovery, normalization of fluid and electrolyte imbalances, medical tune-up, bowel cleansing, and colonic clearance, and
hence reduces the risk that an ostomy will be required.
Setting
Inpatient, endoscope suite or radiology suite (fluoroscopy).
Alternatives
Surgical exploration for LBO.
Indication
Left-sided colonic obstruction: (1) as bridge to definite surgery, (2) for palliation.
Right-sided colonic obstruction: only for palliative condition (definitive right-sided resection does not need preceding
decompression in order to perform primary enterocolonic anastomosis).
Absolute contraindication: evidence of perforation.
Relative contraindication: low rectal cancer (risk of discomfort or stent end hanging out).
Preparatory Considerations
Resuscitation with rehydration.
Conventional x-rays to rule out perforation.
Limited water-soluble contrast enema (just to level of obstruction, not beyond, otherwise risk of perforation if hyperosmolar
contrast causes more fluid to accumulate in distended colon).
Surgical Steps
1. Patient positioning: left lateral decubitus (or supine) position.
2. Insertion of colonoscope and advancement up to distal end of obstruction.
3. Insertion of soft-tipped guidewire through working channel of endoscope: the wire markings should allow for
observation of its advancement.
4. Attempting to advance wire through obstruction. These attempts can be fairly aggressive because:
a. Perforation would typically occur in nondistended and empty part of colon.
b. Only alternative to stent would be an operation (which at the same time would take care of whatever
perforation occurred).
5. Once wire has been placed, endoscope is removed while pushing wire forward to keep it in situ: this step facilitates
insertion of actual stent as it has not to be squeezed through biopsy channel.
6. Possible fluoroscopy verification of wire position.
7. Reinsertion of colonoscope to distal end of obstruction.
8. Insertion of stent delivery system over guidewire through lesion: before deployment, correct position in prestenotic
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colon can again be verified by fluoroscopy while injecting water-soluble radiographic contrast through respective port
in delivery system.
9. Careful deployment while keeping distal end of stent about 2 cm distal to obstruction; as long as stent has not been
completely deployed, it can be pulled back into sheath.
10. Assessment of deployment success
a. Successful
immediate decompression of colon with evacuation of gas and liquid stool.
b. Incomplete
additional stent(s) to be placed through first one (or proceed to surgery).
11. X-ray to rule out perforation.
Anatomic Structures at Risk
Colonic integrity.
Aftercare
Observation for minimum of 24 hours, individualize subsequent workup and plan.
Colonic evaluation: contrast enema vs colonoscopy (after complete decompression and bowel prep).
Plan for definitive surgical care 1–2 weeks after stent placement.
Complications
Unrelieved obstruction, perforation, lost stent, malpositioned/obstructing stent, secondary tumor rupture.
Cross-Reference
Large bowel obstruction (LB0, 560.9) (Ch. 1), (Ch. 4)
Contrast enemas (Ch. 2)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
(Sub-)total colectomy, ileorectal anastomosis (open) (Ch. 5)
On-table lavage for primary anastomosis in LBO (Ch. 5)
ON-TABLE LAVAGE FOR PRIMARY ANASTOMOSIS IN LBO
Principle
Intraoperative resection of an obstructing segment in the setting of a complete or nearly complete left-sided LBO with
washout elimination of the stool (Figure 5–14). This approach avoids an ostomy and therefore is an alternative to two-stage
colonic resection (eg, Hartmann resection).
Figure 5–14.
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On-table lavage for LBO.
Caveat: while a bowel cleansing is not considered necessary in elective surgery, it may still be desirable under emergency
circumstances to eliminate the stool load and decompress the distended colon before effectuating an anastomosis.
Setting
Inpatient, OR procedure.
Alternatives
Colonoscopic stent placement as bridging.
(Sub-)total colectomy with direct enterocolonic anastomosis.
Hartmann-type resection.
Indication
Left-sided colonic obstruction in stable patient.
Absolute contraindication: patient "in extremis," significantly compromised colonic bowel wall.
Caveat: Right-sided colonic obstruction or even descending (or sigmoid) colon obstruction can be addressed with right or
extended-right hemicolectomy or a (sub-)total colectomy with primary ileocolonic or ileorectal anastomosis, without bowel
prep or preceding colonic decompression.
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Preparatory Considerations
Resuscitation with rehydration.
Conventional x-rays to rule out perforation.
Rigid or flexible sigmoidoscopy up to point of obstruction: rule out more distal pathology.
Surgical Steps
1. Patient positioning: modified lithotomy position.
2. Incision and exploration of abdomen to assess extent of disease and rule out secondary pathology.
3. Isolation and resection of obstructing segment in oncologic technique (see respective topics discussed elsewhere)
with adequate vascular ligation and stapling off both proximal and distal ends.
4. Macroscopic assessment of specimen.
5. Assessment of bowel quality and patient stability: primary anastomosis justified or Hartmann-type resection
indicated?
6. Logistic preparation for on-table lavage:
a. Getting a large-diameter tube, eg, corrugated tubing used by anesthesia to connect endotracheal tubing with
machine: available sterile or can be soaked in povidone-iodine solution.
b. Placing intact double plastic bags into trash can next to operating table, secure upper end to edge of trash
can to avoid downward traction and disconnection as it fills with fluid.
7. Surgical preparation for on-table lavage:
a. Massaging colonic content ~10 cm away from distal resection margin and placement of noncrushing bowel
clamp; placement of sponges around distal end to minimize uncontrolled spillage.
b. Opening of distal colon end, insertion of end of corrugated tubing for 3–4 cm and securing it to bowel end
with heavy ties around it.
c. Leading other end of corrugated tubing to bags in trash can and creation of closed system by taping it in
securely.
d. Release of noncrushing bowel clamp
some liquefied stool and gas should start to evacuate through tubing.
e. Mobilization of both flexures to facilitate massaging colonic content toward tubing.
f. Appendectomy with placement of two concentric pursestring sutures, insertion of large-diameter Foley
catheter, followed by insufflation of catheter balloon.
g. Connection of Foley catheter to infusion tubing.
8. Pressured infusion of several liters of saline or mixture of saline/povidone-iodine solution into colon until it is
completely decompressed and outflow clears.
9. Resection of most distal 5-cm segment of colon and removal from field together with tubing.
10. Staple closure of cecal pole and oversewing of staple line with additional sutures.
11. Continuation of surgery, performing primary anastomosis in the fashion most appropriate for individual patient
(stapled, hand-sewn).
Anatomic Structures at Risk