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.
For patients having surgery for polyps and most neoplasms, it is essential to have the lesion tattooed during colonoscopy. 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 carbon dioxide insufflation rather than air will speed the resolution of colonic distension 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 discontinued within 24 hours of surgery. Subcutaneous heparin is administered in high-risk patients, and sequential compression devices are placed for the prevention of venous thromboembolism.
General anesthesia is required. An orogastric or nasogastric tube is inserted.
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 because repositioning of the table is often 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).
The skin is prepared in the routine manner. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.
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 is inserted. The abdomen is insufflated to 15 mm Hg. A 30-degree-angled scope is typically employed. There is significant variation in the reported port placement configurations for laparoscopic right hemicolectomy. The most commonly employed port 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 in the right lower quadrant, if needed. Using this method, the extraction incision is made as a vertical midline at the level of the umbilicus. While utilization of a hand port may be beneficial in the initial portion of surgeon’s leaning curve, its routine use is discouraged because of a higher risk of wound complications associated with this approach.