Plate 67

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 thromoembolism.

The setup is similar to the laparoscopic right colectomy. However, the surgeon and camera operator stand on the patient's right and the first assistant on the patient's left (Figure 1). The surgeon and camera operator may switch places during the procedure to facilitate exposure and operating angles. The surgeon moves between the legs during portions of the operation, in particular during the creation of the colorectal anastomosis. The port placement is the same as the right colectomy except that the upper abdominal 5-mm trocar is the right upper quadrant in the midclavicular line (Figure 2A and Figure 2B). This port may facilitate mobilization of the splenic flexure (Figure 3). Figure 2B shows an alternative port placement.

For the initial mobilization of the sigmoid colon, the patient is rotated to the right. The sigmoid colon is grasped with an atraumatic forceps and retracted medially. The peritoneal attachments are then divided using the ultrasonic shears and blunt dissection (Figure 3). Care is taken to identify the ureter and avoid ureteral injury. The peritoneal attachment is divided up to the splenic flexure. This is facilitated by the first assistant or surgeon providing counter-traction of the colon. As the dissection nears the splenic flexure, it is best to stay underneath the omentum and develop a plan between the omentum and the splenic flexure (Figure 4). Dissection between the omentum and spleen can lead to splenic injury. The omentum is separated for a variable distance along the transverse colon depending on the amount of colon to be removed and the amount of mobility that will be necessary to complete a tension-free anastomosis. Mobilization of the splenic flexure and the transverse colon may be facilitated by a reverse Trendelenburg position. The proximal rectum is mobilized (Figure 5). In Figure 5, the orientation of the dissection is rotated so the head is to the reader's left and the foot to the right. The line of mesenteric incision is shown. The surgeon needs to know the anticipated position of the left and right ureter.

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