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INDICATIONS

Diverticular disease, colonic malignancy, endoscopically unresectable polyps, rectal prolapse, and sigmoid volvulus are the most common indications for elective sigmoid colectomy. A primary resection and anastomosis is often considered after one or more episodes of acute sigmoid diverticulitis and is generally performed after resolution of acute inflammation. Laparoscopic surgery for colon cancer is based on the same oncologic principles as open colon cancer surgery. Open surgery may still be recommended for patients with locally advanced large tumors or tumors penetrating adjacent organs or the abdominal wall. Other relative contraindications to laparoscopic colectomy include multiple previous abdominal operations, bleeding disorders, and/or severe cardiopulmonary comorbidity.

PREOPERATIVE EVALUATION AND PREPARATION

Preoperative assessment and preparation are the same for laparoscopy and laparotomy. If the lesion is small or resected at the time of colonoscopy, it should be preoperatively tattooed with India ink; additionally, the patient should be prepared for intraoperative colonoscopy. Mechanical bowel preparation, deep venous thrombosis prophylaxis, and oral and intravenous broad-spectrum antibiotics are administered before surgery. Ureteral stents are inserted preoperatively for advanced cancers and advanced diverticular disease where retroperitoneal inflammation or fibrosis is a concern.

OPERATIVE TECHNIQUE

The patient is placed in the supine, modified lithotomy position, using Allen stirrups, and secured to the operating table with the arms and legs well padded. Both arms are carefully tucked at the patient’s side. The surgeon stands on the right side of the patient, and the first assistant stands on the opposite side. Two video monitors are placed on the patient’s left side, one over the shoulder and one over the left leg. An additional monitor is placed over the right shoulder (Figure 1). Pneumoperitoneum is established using an open Hasson technique. An 11-mm Hasson cannula is inserted through a vertical infraumbilical incision, and pneumoperitoneum is created with CO2 to a pressure of 15 mm Hg. A 30-degree camera is introduced, and under direct vision, a 12-mm port is placed in the right iliac fossa. A 5-mm port is placed in the right midclavicular line below the costal margin. A fourth trocar is placed in the left lateral abdomen to facilitate splenic flexure mobilization. This port site will be expanded to bring the specimen onto the abdominal wall later in the procedure (Figure 2).

In obese patients, an additional left-sided port may be used to facilitate exposure (Figure 3).

The operation begins by incising the white line of Toldt with scissors in a lateral-to-medial approach from the iliac fossa along the left colon to the splenic flexure (Figure 4). ...

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