Plate 68
Figure 10

Next, control and division of the mesenteric vessels is accomplished. The mesocolon is incised. The course of the ureter should be reverified at this point. A window is made in the peritoneum near the inferior mesenteric vessels. The mesenteric vessels may be divided with linear vascular staples, individually doubly clipped or with coagulation devices designed for this purpose (Figure 6). Figure 6 shows the line of division of the mesentery. Staple application provides the most efficient method, but most costly as well. A medial to lateral dissection may be employed, reserving the mobilization of the lateral attachments and splenic flexure until the mesocolon has been divided. Once the mesentery is divided, the transverse colon is brought into the pelvis ensuring adequate mobility for a tension-free anastomosis. The distal colon/rectum is divided using a reticulated linear stapler (Figure 7). This results in the distal staple line are shown in the figures labeled B. The proximal colon may be divided intracorporally with an endoscopic stapler or after the bowel is exteriorized with a linear stapler through extension of the midline or left lower quadrant trocar incisions. This results in the proximal staple line A. The umbilical incision is extended inferiorly to permit extraction of the specimen, extracorporeal division of the bowel and preparation of the proximal colon for the anastomosis. Alternatively a left lower quadrant transverse incision may be made. Prior to bringing the colon through the abdominal wall a plastic wound protector is usewd to prevent contamination of the subcutaneous tissue and skin. The anastomosis between A and B is created using a double staple technique. The exteriorized proximal colon is cleaned and the staple line removed. Dilators are used to dilate the opening of the proximal colon (A). A purse-string suture is placed in the proximal colotomy (Figure 8). The anvil for the circular stapler is placed in the bowel (Figure 9). The purse-string suture is tied and the colon returned to the peritoneal cavity. The circular stapler is inserted transanally and the stapler spike is placed through the distal staple line or posterior to it under direct vision (B). The spike is removed with a laparoscopic forceps and removed. The end of the anvil is then inserted into the circular stapler. The stapler is closed and discharged (Figure 10). The stapling device is removed and the donuts are inspected for completeness. An incomplete donut indicates an ...

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