Plate 64

Laparoscopic resection of the colon is most commonly indicated for benign colon conditions such as chronic diverticulitis and large polyps that are not amendable to removal during colonoscopy. The laparoscopic approach is being used with increasing frequency for carcinoma. 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 occult 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. The patient should receive a standard mechanical bowel preparation, and prophylactic antibiotics are administered within one 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 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, 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.

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

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 is shown in Figure 1B has a 10-12 mm trocar to the left of the midline in the left lower quadrant with 5 mm ports in the left upper quadrant and the right lower quadrant. 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 of the hepatic flexure in some patients. With this configuration, the extraction incision is either midline as described above or in the transverse direction at the site of the 5-mm right-upper-quadrant port or a transverse right-lower-quadrant incision. The third configuration uses a hand port in the midline, a 10- to 12-mm port if the left lower quadrant, and 5-mm ports at the subxiphoid midline location and the right subcostal area. A hand port is used to extract the specimen.

Mobilization of the right colon is shown by a lateral to medial approach. A medial to lateral approach may be used but is not described here. In the lateral medial approach, mobilization begins at the cecum. The patient is placed in the Trendelenburg position and tilted 30 degrees to the left. The cecum is grasped with an atraumatic instrument and retracted medially and anteriorly (Figure 2). Using a monopolar cautery endoscissors or an ultrasonic device, an incision is made in the peritoneal reflection close to the lateral wall of the bowel at the tip of the cecum (Figure 2). The assistant then grasps the ascending colon and retracts it medial and cephalad, permitting the incision to be extended upward to the region of the hepatic flexure using a traction counter-traction technique (Figure 3). As the dissection begins, care should be taken to avoid ureteral injury (Figure 3). As one approaches the hepatic flexure, the duodenum may be visualized and protected (Figure 3). For mobilization of the hepatic flexure, the patient should be placed in the reverse Trendelenburg position. If there is a 10- to 12-mm trocar in the right lower quadrant, repositioning the laparoscope to this sight may provide better visualization. The hepatic flexure is then retracted medially and inferiorly. An ultrasonic device is used to divide the peritoneal attachments (Figure 3). Care is taken to avoid injury to the underlying duodenum during hepatic flexure mobilization. For mobilization of the hepatic flexure the patient should be placed in the reverse Trendelenburg. If there is a 10-12 mm trocar in the right lower quadrant reposition the laparoscope to this site may provide better visualization. The hepatic flexure is then retracted medially and inferiorly. An ultrasonic device is used to divide the peritoneal attachments (Figures 4A and 4B). Next the proximal transverse colon is mobilized by dividing the omental attachments along the line of dissection in Figure 2. The assistant grasps the omentum and holds this upward. The surgeon grasps the mesenteric side of the transverse colon to put tension on the omental attachments. The omental attachments are divided with ultrasonic shears or electrocautery taking care not to injure the colon. Division of the gastro colic ligament is frequently necessary to completely mobilize the hepatic flexure from the liver. The extent of omental detachment may vary depending on the location of the lesion and the degree of reach needed.

The mesentery is divided in the next series of steps. The ileocolic vessels are grasped and retracted toward the anterior abdominal wall. The peritoneum overlying the mesentery is incised at a point beneath the ileocolic vessels with electrocautery endoscissors and a window created. For malignancy, this should be near the root of the mesentery. The cecum is grasped and retracted laterally to elevate the ileocolic vessels. The vessels are skeletonized and then divided with the linear laparoscopic stapler with 2.5-mm staples or clips (Figure 4A and 4B). The dissection is carried toward the hepatic flexure and the stapling process repeated until the mesentery is divided. The dissection is continued to and including the right branch of the middle colic artery.

In Figure 4A, the right colic artery is being dissected. Figure 4B shows the ligated ileocolic artery, right colic artery, and the right branch of the middle colic. The line of resection is shown in Figure 5. After complete mobilization the bowel is externalized through a 6- to 10-cm incision by extending the right-lower-quadrant incision or the umbilical incision. A plastic wound protector is used. The terminal ileum and colon are exteriorized through this opening. The proximal and distal margins of the specimen are then divided using a linear stapler (3.5 mm staples). Larger staples may be needed depending on the thickness of the bowel wall. A side-to-side hand-sewn or stapled anastomosis may be performed. To perform a side-to-side stapled anastomosis, stay sutures are placed to secure the two antimesenteric walls of the ileum and the colon. An enterotomy for the introduction of the stapling device is created by excising a small portion of the staple lines along the ileum and transverse colon with curved Mayo scissors (Figure 6A). The linear stapler is then introduced and closed (Figure 6A). The posterior aspect of the bowel is examined to be certain that no mesentery is included in the closed stapler. Once this is ensured, the stapler is discharged and the anastomosis created. Through the enterotomies, the staple line is inspected for bleeding. Small bleeding points are sutured with 000 silk figure-of-eight sutures. The enterotomy is closed with a stapler (Figure 6B). The final appearance is shown in Figure 6B. The mesenteric defect is closed and the bowel returned to the peritoneal cavity.

The incision used to exteriorize the bowel and complete the extracorporeal anastomosis is closed with interrupted or running sutures. The port sites greater than 5 mm are closed with sutures as well.

The orogastric or nasogastric tube is removed in the postoperative care unit. Intravenous fluids are administered and vital signs and urine output monitored every 4 hours. Prophylactic antibiotics are discontinued within 24 hours of the surgery. The bladder catheter is removed on postoperative day 1 or 2. An initial postoperative diet consisting of clear liquids is started on postoperative day 2 if there is no distention or indications of complications and this is advanced as tolerated.