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INDICATIONS

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Laparoscopic colectomy is indicated in both benign and malignant conditions as long as it is performed by qualified surgeons with appropriate resources. In general this approach is not recommended in patients with emergency conditions such as obstruction, perforation, or massive bleeding.

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PREOPERATIVE PREPARATION

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For patients having surgery for polyps and most neoplasms, it is essential to have the lesion tattooed during colonoscopy or localized by a preoperative barium enema. Identification of the tumor during laparoscopy is usually difficult. The use of intraoperative colonoscopy is difficult during laparoscopic procedures; hence, accurate preoperative localization is necessary. If intraoperative colonoscopy is necessary, the use of CO2 insufflation rather than air will speed the resolution of colonic distention that can greatly impede the laparoscopic approach. The patient should receive a standard mechanical bowel preparation, and prophylactic antibiotics are administered within 1 hour of the incision and are to be discontinued within 24 hours of surgery. Subcutaneous heparin is administered and sequential compression devices are placed for the prevention of venous thromboembolism.

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ANESTHESIA

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General anesthesia is required. An orogastric or nasogastric tube is inserted.

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POSITION

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The patient is positioned in the modified lithotomy position with the legs supported on stirrups. Padding is used to protect all pressure points. The left arm is tucked. The patient should be secured to the operating table with tape, as repositioning of the table may be needed to enhance exposure during the operation. The operating room setup is shown in figure 1a. The surgeon and camera operator stand to the patient’s left. The assistant stands between the patient’s legs. Two video monitors are used as shown.

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OPERATIVE PREPARATION

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The skin is prepared in the routine manner and a sterile drape is applied.

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INCISION AND EXPOSURE

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Access to the peritoneal cavity is achieved by an open or Hasson technique. An infraumbilical incision is made and a 10- to 12-mm Hasson port inserted. The abdomen is insufflated to 15 mm Hg. A 30-degree-angled scope is employed. After the Hasson port is inserted, there are three commonly used port placements (figure 1b). The first configuration, shown in figure 1b, has a 10- to 12-mm trocar to the left of the midline in the left lower quadrant with a 5-mm port in the left upper quadrant and another 5-mm port the right lower quadrant if needed. Using this method, the extraction incision is made as a vertical midline either at the level of the umbilicus or in the suprapubic area. The second configuration is a 10- to 12-mm port in the left lower quadrant and 5-mm ports in the suprapubic midline and a right upper quadrant in the subcostal location in the midclavicular line. The upper 5-mm port on the right side may allow better mobilization ...

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