Chapter 37. Laparoscopic Colorectal Procedures

The practice of minimally invasive surgery has rapidly grown over the past two decades to the point that laparoscopic surgery has replaced open surgery for several abdominal procedures (such as cholecystectomy) and gained acceptance and implementation for many other procedures (such as colectomy).1 For many surgical practices laparoscopic techniques have become common place for the patient-related advantages they offer (Table 37-1). In part, the introduction of hand-assisted laparoscopic surgery (HALS) and the early exposure of trainees to diverse laparoscopic techniques have facilitated the availability of laparoscopic surgery to more practitioners and patients.2 Knowledge and experience gained from the evolving practice over the past nearly two decades has provided clarity on indications, contraindications, and technical advancements. This chapter provides a review of the principles behind the practice of laparoscopic colon and rectal surgery. It also provides a brief review of the special considerations for cancer of the colon and the rectum and focuses on providing a contemporary description of the technical approaches to laparoscopic and HALS approaches to segmental resections of the colon and the rectum, and the combined resections of the colon and rectum with creation of pelvic pouches. Finally, a perspective on NOSE (natural orifice specimen extraction), NOTES (natural orifice transluminal endoscopic surgery), and robotic surgery is offered at the conclusion of this chapter.

Indications, Contraindications, Evaluations

With the exception of rectal cancer cases, laparoscopic surgery can be considered an option for virtually any patient with a colon or rectal condition requiring surgery. With that said, not all patients will be ideal candidates and not all procedures can be performed by all surgeons. All surgeons must find their comfort zone with laparoscopic cases. The initiate to laparoscopy should consider limiting their early practice to right colectomies in patients who are thin and have limited risks of adhesions as well as benign disease process such as polyps or ileocolonic Crohn's strictures. Surgeons with advanced skills may be comfortable doing an entire total proctocolectomy and ileal pouch-anal anastomosis. All of these procedures have been technically described in this chapter to provide a range of procedures that are feasible. In addition to the technical range of possibilities, there is a range with respect to which patients will do well with the laparoscopic approach. As with any laparoscopic approach, for example, there would be some cases where a pneumoperitoneum is contraindicated and others where the disease or technical considerations represent contraindications. Indications and contraindications and pre- and intraoperative evaluations specific to the colon and rectal diseases and patient conditions are provided, followed by focused discussion on oncologic issues relevant to colon and rectal cancer and key points.

Indications

The indications for laparoscopic surgery for conditions of the colon and rectum are predominantly the same as those for open surgery (Table 37-2). For inflammatory bowel disease, the list of indications includes symptomatic failure of medical therapy; dysplasia; and presence of strictures, abscess, and fistula. In acute colitis, urgent subtotal colectomy with end ileostomy may be performed initially as a part of a two- or three-stage procedure. Procedures may include strictureplasty, small bowel resection, segmental colonic resection, or proctocolectomy. For diverticulitis, the current American Society of Colon and Rectal Surgeons (ASCRS) guidelines recommend that the decision for elective resection of sigmoid after recovering from acute diverticulitis should be made on a case-by-case basis and recommend the laparoscopic approach in selected patients.3 Large colonic polyps not amenable for resection through the endoscope may be resected through laparoscopic approach. The laparoscopic approach has been proved to produce equivalent outcomes with open resection for localized colon cancer, when oncological principles are practiced. Solitary metastatic lesion in the liver with localized tumor in the colon can also be resected laparoscopically in competent hands.

The laparoscopic approach is preferred in the repair of rectal prolapse. Resection rectopexy and mesh rectopexy both can be performed through the laparoscopic approach. Laparoscopic rectopexy has similar long-term functional outcomes and low recurrence rates.4 As discussed previously, a number of technical challenges are involved in performing laparoscopic rectal cancer resection. Large multicenter trials are going on in North America and Europe to evaluate the outcomes of rectal cancer for laparoscopic approach.

Contraindications

General health conditions that would contraindicate a minimally invasive approach requiring a pneumoperitoneum typically include any severe manifestation of organ failure (Table 37-3). Patients with severe chronic obstructive pulmonary disease (COPD), reactive airway disease, or other causes of respiratory compromise are usually not tolerant of the abdominal insufflation required for conducting intra-abdominal work. Patients with advanced cardiovascular disease are also typically intolerant of the pneumoperitoneum, as it can restrict the fragile dynamics of cardiac output. Finally, patients with end-organ renal failure and severe electrolyte or fluid disturbances and those with liver failure, ascites, or other sources of bleeding disorders are best served with a more controlled, open approach. At times, these conditions are not appreciated as problematic until the procedure is under way and the anesthesiologist is experiencing difficulties. Accordingly, open lines of communication between the surgeon and the anesthesiologist as well as a willingness to convert to open surgery should be the rule and not the exception.

Less absolute or relative contraindications of laparoscopy include the presence of adhesions, cardiac abnormalities, pulmonary gas exchange abnormalities, chronic liver disease, and obesity. None of these are clear-cut or absolute. For example, patients may have several abdominal scars and have undergone numerous prior procedures even near the site of the anticipated colon resection, but they may not have prohibitive adhesions. Unless we know the patient has prohibitive adhesions, we would approach the case laparoscopically with a cautionary note to the patient that the risk of conversion may be higher than 10–15%. The same can be said for obesity. At times, managing obese patients is facilitated by laparoscopy, such as when the fat is predominantly in the abdominal wall. That being said, some obesity cases cannot be conducted using laparoscopic techniques, for example when the tools will not reach from the port to the site of the surgical resection.

A final category of absolute and relative contraindications includes those specific to the disease under treatment. For inflammatory bowel disease a large phlegmonous mass, complex or large abscess, or complex fistulizing disease are likely not suitable for the bulk of the specimen to be extracted, not to mention the challenges of mobilization. Similarly, a toxic abdomen from sepsis or fecal contamination would not be ideal for laparoscopic surgery. Massive dilation of the large or small bowel could prohibit both intra-abdominal visualization and the safe movement of instruments throughout the abdominal cavity. In cases of cancer, there is little evidence in support of tackling large fixed or recurrent tumors through small incisions. The risk-benefit ratio for large, fixed, and recurrent tumors would likely favor open surgery, although it has never been prospectively studied.

Preoperative Evaluations Unique to Laparoscopic Surgery

A word must be said about the workup of patients who are intended for the minimally invasive surgical approach. Although the preoperative evaluations are usually the same as for any other laparotomy approach, it is generally advised that the diagnostic tests for the disease and the treatment be as definitive and clear as possible before laparoscopic surgery. The absence of tactile information demands better preoperative assessments than historically considered necessary for open surgery. This was first realized with tumor staging. The traditional approach with open surgery was to palpate the liver at the time of laparotomy to locate metastatic tumor deposits in the abdomen, including such sites as the liver, ovaries, peritoneal cavity, omentum, or retroperitoneal lymph nodes. Current imaging with computerized tomography (CT) has improved to the point that such novel findings at surgery are rare. Surgeons may identify small superficial hepatic metastases or peritoneal tumors at the time of surgery, but this is less common than it was when laparoscopic surgery was initiated in the early 1990s.

In a similar fashion, primary tumors need to be well localized prior to surgery. For the most part this can be accomplished by combining endoscopy with tattooing for small, benign lesions, or with CT imaging for large or malignant neoplasms. Endoscopy, although usually accurate, can be misleading because there are no consistent endoluminal landmarks for identifying colonic location. Early experiences with missed lesions and wrong-site resections brought these lessons forward. For malignant lesions it is often possible to see the mass on staging CT scan; this can be very reassuring for accurate localization. In addition to the preoperative testing, we advise that one never leave the operating room without first confirming that the target lesion has been confidently removed and identified in a specimen. Because colonoscopy can misjudge, anatomic colonic location by more than one colonic segment, this safety measure seems simple and warranted.

For benign conditions, it is equally important to localize the site of diseased bowel and understand the exact extent of disease, that is, complex versus simple fistula, contained mesenteric abscess versus poorly contained complex or perforated abscess. Of course, the size of the specimen will dictate the size of the extraction site. The larger the lesion to be extracted and the larger the incision, the less the benefit there is to the laparoscopic approach. For Crohn's disease, CT enterography may help reveal secondary sites of disease. We would also advise a complete intraoperative assessment of the small bowel in cases of Crohn's disease, especially in cases of stricturing disease.

Intraoperative Evaluations and Reasons for Conversion

Conversion of laparoscopic procedure to open procedure may be required when difficulties are encountered. The reasons for conversion may include unexpected disease, significant adhesions, and inability to identify vital structures such as ureters. It is important to remember that conversion itself is not a complication, even though intraoperative complications necessitate conversion. It should not be viewed as failure but rather as an application of sound surgical judgment. It is probably safer for a surgeon to have low threshold for conversion, because the timing of conversion is critical to reduce not only overall costs but also complications. A decision to convert is best made early in the procedure, thus avoiding an increased risk of complications and reducing operative time. An early decision to convert will ensure that the rates of morbidity and mortality are maintained at acceptable levels.

For patients who are known to have frail tissues from chronic immunosuppression or other systemic conditions with adverse affects on tissues, extra caution should be taken in handling the bowel in particular but other tissues as well during the surgery. It is more difficult to judge the impact of instruments when there is an inability to use tactile information. These cases may benefit from the hand-assisted approach for that reason.

A final note should be made about the use of ureteral stents in minimally invasive cases. In general, we would not use ureteral stents for any case when they are not required in the correlating open surgery. With that said, we have a low threshold for having ureteral stents placed either preoperatively or during surgery when an inflammatory or tumor process obscures the anatomic location of the either ureter. If they are available and make a difference, the lighted ureteral stents can also be used to get a visual sense of location of the ureter.

Oncologic Issues Specific to Laparoscopic Surgery in Colon and Rectal Cancer

Because of the unique controversies that emerged with the introduction of laparoscopic colectomy for cancer, we offer here a section that specifically covers this topic for both colon cancer and rectal cancer. Soon after the introduction of the laparoscopic colectomy in 1991,1 a number of concerns regarding the application of this technique in colon cancer arose, including reports of tumor wound recurrences at trocar sites and tumor extraction sites.5–7 Such reports were frequent enough that national statements were issued recommending a moratorium on laparoscopic colectomy for cancer outside of clinical trials.8 In response, a number of randomized clinical trials were initiated simultaneously in North America, Canada, and in Europe. At least four large prospective, randomized trials have been completed and have reported both short- and long-term outcomes. To date, 3133 patients have been studied by random allocation to laparoscopic versus open surgery and followed for cancer outcomes. These patients are reported from four international trials, including the Barcelona trial9 (219 patients), the COST (Clinical Outcomes of Surgical Therapy) trial10 (872 patients), the COLOR (COlon cancer Laparoscopic or Open Resection) trial11,12 (1248 patients), and the CLASICC (Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer) trial13,14 (794 patients). Short-term results from all four studies confirm equivalent mortality and rates of morbidity between the laparoscopic and the open arms. They also consistently demonstrate reductions in length of hospital stay, time to first feed, and time to first bowel movement. Quality of life, although modest, has also been confirmed.

At least three of these trials, the Barcelona, COST and COLOR trials, have completed 5-year follow-up for the entire cohort of patients. It has been reassuring that these trials have not demonstrated inferiority for the laparoscopic arm with respect to overall survival or disease-free survival. A pooled analysis of all four trials examining 3-year median survival was also conducted and it confirms the same, that is, no difference in overall survival or disease-free survival between the open and laparoscopic arms.15 These data have encouraged the adoption of laparoscopic colectomy for colon cancer in the absence of harm and in the presence of confirmed benefits.

The same is not true for laparoscopic rectal cancer. Indeed, although there have been several clinical trials testing the equivalence of laparoscopic colectomy in the setting of curable colon cancer, there are few studies available to examine the same question in rectal cancer. For rectal cancer, the concerns are different than they were for colon cancer. The initial concern with using laparoscopic techniques in colon cancer focused on the potential for abnormal distribution of cancer cells due to the pneumoperitoneum. It was thought that the pneumoperitoneum created a “chimney effect”16 that caused a focusing of tumor cells at wound sites such as trocar sites or wound extraction sites and increased the risk of tumor implants.17 There was also at least a theoretical risk that it could cause dissemination of tumor cells through abnormal patterns. This has not been borne out in colon cancer and is not considered relevant, therefore, in rectal cancer. What is considered of relevance in rectal cancer is whether laparoscopic techniques can achieve tumor-free margins with the same rate as open surgery.18 Some might argue that the pelvic dissection is facilitated by laparoscopic equipment and access to the deep pelvis with lighting and visualization superior to open surgery in some cases. This has not been proven in diverse practice settings. An additional concern is the ability to achieve distal stapling due to the limits of current instrumentation. These issues are being addressed by a prospective randomized trial conducted by the American College of Surgeons Oncology Group (ACOSOG).19

The ACOSOG Z6051 trial is a multicenter, phase III, randomized clinical trial with the primary objective that laparoscopic-assisted resection for rectal cancer is not inferior to open rectal resection, based on composite primary end point of oncologic factors that are indicative of a safe and feasible operation. The end point of this noninferiority trial is based on detailed and standardized pathologic evaluation of the specimen, including circumferential and distal margins and the completeness of the total mesorectal excision. The primary end point is a novel, surrogate end point for long-term oncologic outcome that reduces both the necessary accrual target of the trial and its time to maturation. The secondary end points include patient-related benefits (blood loss, length of stay, pain medicine utilization), 2-year local recurrence, and quality of life. The eligible criteria for the disease include T3N0M0, T1-3N1M0 adenocarcinoma of the rectum with the lower edge 12 cm or less from the anal verge and completion of 5-fluorouracil (5-FU) or capecitabine-based chemotherapy/radiotherapy in the last 4 weeks. The other patient criteria include age 18 years or greater, ECOG (Eastern Cooperative Oncology Group) performance status 2 or less, body mass index (BMI) 34 or less, no evidence of laparoscopic contraindications, no evidence of systemic disease precluding surgery, nonpregnant, nonlactating, no history of current or previous invasive pelvic malignancy, and no history of psychiatric illness. Surgeon credentialing in both laparoscopic colon and laparoscopic rectal surgery is required for participation in this study. It is based on having completed 20 laparoscopic-assisted resections each of the colon and rectum. The operative reports and the pathology reports of those cases and an unedited videotape of their laparoscopic rectal technique are reviewed by two designated investigators. This noninferiority trial is projected to enroll 650 eligible patients in the United States and Canada. The trial is sponsored by the National Cancer Institute (NCI). Further details and contact information can be obtained from the following website: http://www.cancer.gov/clinicaltrials/ACOSOG-Z6051.

Key Points

1. Accurate preoperative defining of the extent of the disease is a prerequisite to make the procedure successful.

2. Preoperative tattooing of the lesion with colonoscopy will aid in the localization of the tumor during the procedure.

3. Dense adhesions or extensive disease that prevents accurate identification of the vital structures and increases the risk of complications should cause the surgeon to convert early to an open procedure.

4. Care should be taken during handling of bowel in patients particularly on high-dose steroids due to increased fragility of the tissues. Atraumatic graspers or the HALS approach should be preferred to avoid direct grasping of the colon.

5. Placement of a ureteral stent should be considered when there is difficulty in locating one or both ureters as a result of inflammation or tumor in the retroperitoneum.

6. In case of malignancy or dysplasia, it is essential to perform a complete oncological resection. This includes adequate mobilization, high vascular ligation, satisfactory lymph node harvest, and negative resection margins. Intracorporeal ligation is required to achieve high vascular ligation.

Equipment and Instruments

Basic laparoscopic equipment is common for most of the cases and detailed in the previous chapters (Table 37-4 and Fig. 37-1). Surgeon acquaintance and comfort with the equipment is more important than the exact specifications. A 30-degree laparoscope is more useful than the 0-degree laparoscope, particularly for visualization during mobilization of the flexures and working in the pelvis. Trocars should have the ability to be sutured or have stability threads to prevent dislodgement or leakage during the case. Cautery attachment should be on the upper side of the instruments so it does not interfere with hand movements during dissection or slip off as a result of gravity and repeated hand movements. TV monitors, light source, camera unit, and CO2 insufflator should be placed on readily mobile units, to allow easy positioning and provide the surgeon with better ergonomics. Bowel handling graspers should be atraumatic in order to prevent serosal injury. The Babcock forceps are best applied along side the bowel, on the mesentery, or on opposing peritoneal surface. The atraumatic alligator bowel grasper can supplement the Babcock graspers while mobilizing the bowel because of its large surface area.

Although some might prefer the Veress needle for insufflating, we prefer the Hassan-type cannula and open insertion technique as they minimize the risk of injury to intra-abdominal structures. Instruments should be of sufficient length to reach up to the flexures and down into the pelvis from centrally located ports; this minimizes the need for extra ports. Total proctocolectomy and abdominal perineal resection (APR) procedures in particular require long instruments that are at least 38–40 cm. Care should be taken with the use of cutting devices (electrocautery and ultrasonic cutting devices) to minimize the risk of complications from the exposed metal components of the tools. The curved scissors allow more maneuverability, and the ability to cauterize with the curved scissors can save time.

Special Devices in Colon and Rectal Laparoscopic Surgery

Several options are now available for handling the colon mesentery. The automatic clip applier can be useful for dissecting the mesenteric vessels or controlling small- to medium-size bleeding vessels. LigaSure (ValleyLab, Boulder, CO) is used to fuse tissue bundles and vessels up to 7 mm diameter using a combination of pressure and thermal energy. The Harmonic scalpel utilizes ultrasonic energy in cutting and coagulating the tissues simultaneously and offers better precision. The laparoscopic linear stapler can serve a dual purpose as it allows transection of the colon without contamination and a vascular load can be used to transect a vascular pedicle. Special maneuvers with the linear stapler aid in the preparation of J-pouch and making of side-to-side anastomosis. Circular anastomotic stapler is used for making colocolic or ileocolic anastomosis.

Patient Position and Room Setup

Careful positioning and securing of the patient on the operating table is essential for safety of the procedure because steep inclinations of the operating table are required to assist in achieving proper exposure of the operative field. For the supine position, ankle straps ensure that steep Trendelenburg's position is tolerated and shoulder straps or bean bags can ensure that the patient does not shift side to side when the table is “air-planed” to the left or right. For synchronous cases, having the lower extremities secured in stirrups creates the same effect as ankle straps. For most cases, it is ideal to have the arms securely padded and strapped to the sides of the table. Generous padding at the elbow and neutral positioning of the wrist will minimize the risk of ulnar or median nerve injury, respectively, from pressure during long-duration surgery. A urinary catheter decompresses the bladder and a nasogastric tube decompresses the stomach to avoid inadvertent injury and to maximize space in the abdominal cavity. The surgeon and the surgical assistant stand on the patient's side with the monitor on the opposite side to achieve consistent and in-line orientation of the field. The surgeon's eyes, hands, trocars, instrument tips, and monitor should all be directly parallel and closely aligned to minimize the difficulties associated with reverse image operating (Fig. 37-2).

Port Placement Technique

A cut-down technique is used to insert Hassan's trocar, with Hassan's cannula as the first port. Pneumoperitoneum is achieved by insufflation of carbon dioxide to 12–14 mm Hg. A 30-degree laparoscope is the preferred camera as it offers the optimal operative view. The rest of the ports are inserted under direct visual guidance.

Wound Closure

Trocars are removed after the pneumoperitoneum is fully released through the cannulas to avoid sucking of the bowel into the port sites and to avoid the concentration of tumor cells at the trocar sites in cancer cases. The 5-mm port sites do not require fascial closure unless there is significant enlargement of the fascia during the procedure. Port site closure should include peritoneum and fascia when they are 10 mm or greater. The lateral ports are closed under direct visualization prior to closure of midline wounds. The “Endo Close” spring-loaded suturing device can be used to close the incision. The fascia is closed with a figure-of-eight suture and an extracorporeal knot is tied. A purse-string suture is an option for closing the periumbilical site.

Right Hemicolectomy

Step 1: Patient Position and Room Setup

The patient is carefully positioned supine and secured on the operating table as described previously. The surgeon and the surgical assistant stand on the patient's left side with the monitor on the right side to achieve consistent and in-line orientation of the field. The instrument table is easily accommodated at the foot of the bed and the scrub nurse on the patient's right side.

Step 2: Port Placement and Exploration

A 10- to 12- mm port is placed in the supraumbilical area using an open cut-down technique. A different site is preferred (typically left upper quadrant [LUQ]) when a midline scar is present and extensive adhesions are anticipated. A 30-degree camera is passed through this port, and under direct vision two 5-mm trocars are placed—one in the LUQ lateral to the epigastric vessels and 2 cm below the costal margin and the other in the suprapubic midline (Fig. 37-3). As an alternative, one can place three 10- to 12-mm trocars; this allows maximum flexibility for placement of instruments and the camera, but the more experienced surgeon may exchange one or more for 5-mm trocars.

Simple adhesions encountered at this stage should be divided. Then, an inspection of the abdominal cavity should be performed to confirm the pathology for which surgery was indicated and to exclude other pathology. The presence of a locally adherent or bulky tumor should be approached with a conversion to open surgery. The liver is carefully inspected for metastatic disease. If resectable metastases are identified, we would convert to open surgery. Some surgeons are comfortable with laparoscopic removal of hepatic metastasis or choose to address at subsequent surgery. Alligator or Babcock graspers are preferred to raise each liver lobe to view all surfaces. The peritoneal surfaces should then be inspected to exclude metastases. In cases of Crohn's disease the entire small bowel should be inspected for secondary sites of disease not detected by preoperative imaging.

Step 3: Mobilization of the Cecum

The patient is placed in a steep Trendelenburg position, with the right side of the table inclined upward. The 30-degree laparoscope is deployed through the LUQ port. The pelvis is viewed to ensure that the small bowel loops can be moved up into the upper abdomen; in the absence of adhesions it is often simplest to sweep the mesentery of the bowel along with the bowel into the left upper quadrant. Right lower quadrant (RLQ) adhesions are not uncommon due to the prevalence of hysterectomy, oophorectomy, and appendectomy procedures in the general population. Presence of significant adhesions in the pelvis (eg, inability to extract terminal ileum from the pelvis) is an indication for early conversion to open procedure at this point, as full exteriorization will not be possible later.

The next step is to identify the right ureter at the pelvic brim, where it runs over the bifurcation of the common iliac artery (Fig. 37-4). In an obese patient, the ureter is identified after opening peritoneum. It is important to be patient and wait to observe peristalsis in the ureter to avoid mistaking the psoas tendon or the gonadal vessels for the ureter. The cecum is then pushed or gently grasped with a Babcock from the supra umbilical port and elevated medially and toward the head. The peritoneum around the base of the terminal ileum and the cecum is then opened with the scissors through supraumbilical port, and correct retroperitoneal plane is entered. Using a grasper on the cut peritoneal edge and not on the bowel, the right lateral peritoneal reflection is opened along the white line of Toldt toward the hepatic flexure. Care should be taken to initially divide only the superficial layer of the peritoneum. As the dissection proceeds toward the hepatic flexure, the pneumoperitoneum helps separate the tissue planes. The plane between the colon mesentery and the Gerota fascia is then developed using a combination of blunt dissection and cautery and care must be taken to avoid dissection behind the kidney.

The peritoneum on the medial side of the terminal ileum should be incised to allow full mobilization of the cecum. Upward tension should be applied on the peritoneal fold medial to the terminal ileum, and incision is made in the superficial peritoneal layer along side the pelvic brim superior and parallel to the right iliac artery. The dissection is continued up to the level of the duodenum. Then the lateral dissection is advanced medially with care until the inferior vena cava inferiorly and duodenum superiorly. These two structures indicate the achievement of sufficient dissection.

Step 4: Mobilization of the Hepatic Flexure

The patient is now placed in reverse Trendelenburg's position with the right side steeply inclined upward. The laparoscope is shifted into the suprapubic port and the surgeon and the assistant trade positions. The hepatocolic ligaments are grasped just cephalad to the colon and traction placed obliquely to elevate the tissues toward the anterior abdominal wall and inferiorly. The hepatocolic ligament is divided with electrocautery scissors or an ultrasonic dissector, as preferred. Blunt dissection is then performed to separate the underlying tissue from the peritoneum. Occasionally larger vessels encountered require clips. The dissection is then continued along the gastrocolic ligament, identifying the plane between this and the transverse mesorectum, until the level of falciform ligament is reached. Care should be taken during this dissection not to damage the duodenum as the hepatic flexure is mobilized off the retroperitoneum in the right upper quadrant (RUQ) (Fig. 37-5). At this point, the whole right colon is mobilized to the midline and the right retroperitoneum is exposed, allowing visualization of the duodenum, Gerota's fascia, and the right ureter.

Step 5: Vascular Division

Vascular ligation and division of the mesenteric vessels can be performed either by intra- or extracorporeal method. The surgeon and the assistant are back to original positions with the laparoscope placed through the LUQ port. The intracorporeal method should be used for obese patients as it is difficult to exteriorize the ileocolic pedicle. Intracorporeal ligation is preferred for the malignant diseases to ensure proximal ligation of the vessels (Fig. 37-6). Upward tension is applied on the right colon to display the ileocolic and right colic vessels, and, once mesenteric windows are created, the vessels are ligated with hemoclip, Endoloop devices (Ethicon, Cincinnati, OH), or a linear vascular stapler. It is important to visualize or palpate the junction of the ileocolic and superior mesenteric vessels to provide proximal resection of lymphatics in cancer cases without compromising blood flow to the rest of the small bowel.

Step 6: Exteriorization

Once intracorporeal ligation has completed or if extracorporeal ligation has to be performed, the table is returned to a neutral position. A Babcock grasper is placed through the suprapubic port and applied to the appendix or ligament of Treves or the mesentery of the cecum. The pneumoperitoneum is vented out through the ports and the camera equipment removed. Then a small (4–6 cm) vertical incision is made for purposes of colon exteriorization; typically it is more cephalad than caudal to the umbilicus. The wound edges are protected with a wound guard and then the bowel is exteriorized with the help of Babcock grasper left already at the level of the cecum. The right colon is exteriorized from the terminal ileum to the transverse colon (Fig. 37-7). It is generally not necessary to have divided the omentum intracorporeally as it can also be exteriorized through the incision unless it is bulky. Once the bowel is exteriorized, vascular ligation is performed in a standard manner.

Step 7: Anastomosis

The mesenteric and bowel division, vascular ligation if appropriate, and anastomosis can be completed after exteriorization in an identical way to standard laparotomy. This degree of mobilization allows for a hand-sewn end-to-end anastomosis or a wide, stapled side-to-side anastomosis. Following anastomosis, the bowel is then gently returned into the abdominal cavity. Irrigation of the abdominal cavity is performed at this time. The irrigation process is conducted through the open wound and can make use of standard suction devices without the need for the laparoscopic suction irrigator equipment. The aspirate from the irrigation process is inspected to determine whether it is clear or bloody. If the aspirate is blood-stained, the abdomen may need to be reevaluated by reestablishing the pneumoperitoneum. In our experience, it is rare to have to reinspect using the pneumoperitoneum. By using Harrington-type retractor, inspection through the periumbilical incision allows for visualization of the port sites as the trocars are removed. Copious irrigation of all the wounds is then performed. The incisions are closed in two layers, fascia, and skin.

Alternative Technique for Right Hemicolectomy

An alternative technique, in which the dissection starts from the medial aspect and extends laterally, is also practiced for right hemicolectomy. The dissection commences with the opening the peritoneum of right mesocolon. This allows for the mobilization of the colon with minimal manipulations. The right colic and ileocolic vessels are identified first and ligated using clips or vascular stapler. Then the peritoneal incision is extended superiorly toward the transverse colon, and then the dissection continues along the transverse colon inferiorly and along hepatic flexure, ascending colon and cecum medially. After the colon is freed from the peritoneal attachments on the medial side, the dissection continues along the white line of Toldt, starting from the cecum to the hepatic flexure and the transverse colon (Fig. 37-8). The right colon is detached from all the attachments and it is then brought outside from the extended skin incision at the umbilicus. Then the right colon is resected extracorporeally and ileocolic anastomosis performed as described in the previously mentioned method. Although we do not practice this approach, it is gaining in popularity and seems to carry no major disadvantage.

Left Hemicolectomy

The left hemicolectomy procedure is similar to the right colectomy, only in mirror-image reverse. One major difference is the care that must be taken around the spleen. The hand-assisted approach can facilitate management of the splenic flexure and therefore it is described as an alternative approach.

Step 1: Patient Position and Room Setup

Positioning and securing of the patient on the operating table is done in a similar fashion as right hemicolectomy. The surgeon and the surgical assistant stand on the right side with the monitor on the left side and parallel in-line orientation is maintained. The instrument table is accommodated at the foot of the bed and the scrub nurse on the patient's left side.

Step 2: Port Placement and Exploration

A four-port technique is used with ports in the supraumbilical area, suprapubic area, right upper quadrant, and left lower quadrant (LLQ) (Fig. 37-9). Simple adhesions encountered at this stage should be divided. Then a careful inspection should be done to confirm the pathology and any presence of additional disease. Conversion to open procedure should be made for the same conditions and indications as described for the right colectomy.

Step 3: Mobilization of the Left Colon

The patient is placed in a steep Trendelenburg position, with the left side of the table inclined upward, and the small bowel loops are swept to the right side of the abdominal cavity using the graspers. The left ureter is identified before proceeding with the dissection. The dissection commences lateral to the proximal sigmoid colon. The peritoneum is incised and then dissected along the white line of Toldt toward the splenic flexure (Fig. 37-10). The plane is developed carefully avoiding kidney injury, between the colon mesentery and the Gerota fascia. Then the lateral dissection is advanced medially until the aorta is reached.

Step 4: Mobilization of the Splenic Flexure

The patient is now placed in reverse Trendelenburg's position with the left side steeply inclined upward. The surgeon standing between the legs of the patient and the assistant on the right side with in-line arrangement of camera, monitor, and the instruments provide better surgical ergonomics. The instruments are repositioned with grasper through the suprapubic port and the cutting instrument through the left lateral port. The assistant grasps the greater omentum superior to the distal transverse colon through right lateral port and retracts upward toward the abdominal wall cranially (Fig. 37-11). With the countertraction, the surgeon incises the peritoneum and enters the lesser sac. The dissection is then advanced parallel to the transverse colon to open up the lesser sac and mobilize the transverse colon. The dissection then advanced toward the lateral dissection so that the splenic flexure is completely mobilized to the level of the umbilicus.

Steps 5–7: Vascular Division, Exteriorization, and Anastomosis

Vascular ligation and division of the mesenteric vessels are performed either by incorporeal or extracorporeal method. The colon is exteriorized through the 4- to 6-cm midline vertical incision and anastomosis is performed in a similar fashion as in right hemicolectomy.

Hand-Assisted Laparoscopic Left Hemicolectomy

Step 1: Patient Position and Room Setup

The patient is positioned and secured on the operating table in a similar fashion as for a laparoscopic-assisted procedure.

Step 2: Port Placement and Exploration

Lower midline incision is made below the umbilicus. The hand port should be placed in such a position where the nondominant hand acts like a laparoscopic retractor. The incision size should be one-half size smaller than the operator's hand size, and the incision length should remain the same through all layers of the abdomen to avoid leakage of air around the hand port (Fig. 37-12). Gelport is the new generation of multifunctional hand port that allows the usage of hand, laparoscope, and laparoscopic trocars, and maintains an airtight seal when the hand is removed. The surgeon's hand through the hand port guides the insertion of 30-degree laparoscope in the periumbilical region. A 5/10-mm port for scissors with cautery is made in the left lower quadrant under laparoscopic visualization (Fig. 37-13).

Step 3: Mobilization of the Left Colon and Splenic Flexure

The traction is achieved when the hand and the colon is dissected in the similar fashion described previously for the laparoscopic hemicolectomy (Figs. 37-14 through and 37-16). A grasper can be introduced through 5-mm cannula in the right lower quadrant to achieve additional traction for adequate mobilization of the spleen.

Steps 4–6: Vascular Division, Exteriorization, and Anastomosis

Vascular ligation and division of the vessels is typically performed using intracorporeal techniques. The colon is exteriorized through the hand port and divided, and anastomosis is performed with either hand-sewn technique or standard stapled method.

Sigmoid Colectomy:

Step 1: Patient Position

The patient is placed and secured on the operating table in modified lithotomy position same as for left hemicolectomy. The surgeon and the surgical assistant stand on the right side of the patient, and the camera, trocars, and the monitor are aligned parallel to minimize reverse image operating.

Step 2: Port Placement and Exploration

The laparoscope is inserted through the supraumbilical port and the trocars are placed under visualization in suprapubic, right, and left lower lateral positions (Fig. 37-17). The abdominal cavity should be inspected with confirmation of the indicated pathology and other pathology excluded, as previously described.

Step 3: Mobilization of the Proximal Sigmoid and Descending Colon

The patient is placed in steep Trendelenburg's position with the left side of the table inclined upward. The 30-degree laparoscope is deployed through the supraumbilical port and the small bowel loops are swept to the right side. The left ureter is identified at the pelvic brim. Conversion to an open procedure is necessary if the ureter cannot be identified confidently. The ureter is swept down and away in order to avoid injury during ligation of the mesenteric vessels. The dissection commences lateral into the left ureter by incising peritoneum lateral to the sigmoid colon. The dissection continues along the white line of Toldt toward the splenic flexure in the same manner as done for left hemicolectomy. Mobilization of splenic flexure is performed as required.

Step 4: Mobilization of the Distal Sigmoid Colon and Upper Rectum

After mobilizing the descending colon completely, the dissection is now directed caudally. With the retraction of the sigmoid colon cephalad and medially, the peritoneal incision is then extended distally to the midrectum entering the presacral space. The left ureter and the iliac vessels are identified and protected throughout this part of the procedure (Fig. 37-18). The presacral space is developed by the division of the fine adhesions and care should be taken to protect hypogastric nerves by sweeping them backward toward the sacrum.

Steps 5 and 6: Vascular Ligation and Exteriorization

The sigmoid colon is elevated anteriorly and inferiorly to expose the mesenteric vessels. Then incision is made in the avascular plane on both sides of the vessels. The superior hemorrhoidal and sigmoid vessels are isolated and ligated at the level of aortic bifurcation using vascular staplers, clips, or Endoloop devices (Fig. 37-19). We ligate just distal to the takeoff of the left colic vessel. Some surgeons express a preference for ligation at the origin of the inferior mesenteric artery, proximal to the left colic branch. The sigmoid becomes more mobile after the ligation of the vascular pedicle. The upper rectum is then divided using a linear cutting stapler (Fig. 37-20).

Then the pneumoperitoneum is vented out via the laparoscopic ports. The divided sigmoid colon is brought out through the extension of the LLQ incision. The proximal colon is divided at the sigmoid and descending colon junction.

Step 7: Anastomosis

A purse-string suture is inserted around the colon that is tied around the anvil of the staple gun inserted into the lumen. Then the colon is returned to the abdominal cavity. The peritoneal cavity is irrigated and checked for blood, and the fascial defects are closed. After the reinsufflation of the abdominal cavity, the stapling device is introduced through the anus. The anvil attached to the shaft of the stapling device is advanced across the staple line under direct visualization. The anvil is attached to the gun, approximating the bowel ends, and then the device is fired. The anastomotic integrity and hemostasis can then be assessed using a proctoscope. The pneumoperitoneum is released after withdrawing cannulas under direct visualization.

The alternative approach is to perform a hand-sewn anastomosis through a small lower midline incision of 5–6 cm. After bowel exteriorization, the bowel is excised and end-to-end anastomosis is performed, taking care to ensure proper alignment of the mesentery.

Hand-Assisted Laparoscopic Sigmoidectomy

The patient is positioned in the same way as for the laparoscopic-assisted approach. The hand port is placed in the lower midline incision in the lower abdomen 1 cm above the pubic symphysis. The incision size should be one half-size smaller than the surgeon's hand to maintain effective pneumoperitoneum. Then the surgeon's left hand in the gel port guides the placement of other trocars. A 30-degree laparoscope is placed in the supraumbilical port and cautery attached to the scissors is placed in the RLQ port. The surgeon, standing on the left side of the patient, uses the left hand to provide retraction of the sigmoid colon while the cautery is operated with the right hand. The diseased specimen is extracted through the incision made for the hand port, and extracorporeal division of the vasculature can be performed. The anastomosis is made using the stapling device in the same manner as described previously. The pneumoperitoneum is reinstated, and the abdominal cavity is irrigated and inspected for hemostasis. Then the anastomotic site is inspected for leakage. Normal saline is placed in the abdomen and pelvis such that the anastomosis is submerged. A noncrushing clamp is placed proximal to the anastomosis and the rectum is then insufflated using a flexible sigmoidoscope. If bubbles are detected, either the anastomosis needs to be repaired at the site of the leak or the case needs proximal diversion with an ileostomy. Then the abdomen is closed after venting out the pneumoperitoneum.

Transverse Colectomy

Step 1—Patient Position and Room Setup

The patient is placed and secured well on the operating table in supine or modified lithotomy position, depending on whether the pathology is closer to the right or left colon, respectively.

Step 2: Port Placement and Exploration

The laparoscope is inserted through the supraumbilical port, and two cannulas are inserted in the right and left lower quadrants under direct visualization. The surgeon shifts sides depending on the mobilization of the hepatic flexure or the splenic flexure.

Step 3: Mobilization of the Hepatic Flexure

Dissection and mobilization of the hepatic flexure is performed as described under right hemicolectomy.

Step 4: Mobilization of the Splenic Flexure

Dissection and mobilization of the splenic flexure is performed as described under left hemicolectomy.

Step 5: Mobilization of the Transverse Colon

The stomach is lifted up, and with retraction of transverse colon downward the omentum is divided. Thus transverse colon is freed from its attachments on either side.

Steps 6–8: Vascular Division, Exteriorization, and Anastomosis

The vascular pedicle is divided intracorporeally, and the mobilized transverse colon is exteriorized through the extended incision in the supraumbilical area. Care should be taken around the vascular pedicle of the transverse colon. The middle colic vessels are quite short, and the vein branches easily tear and cause difficult bleeding. Too much traction on these vessels can result in disruption of venous branches and significant bleeding. The bowel is then divided and anastomosis of the free ends is done with hand-sewn technique or standard stapled technique.

Anterior resection, or sometimes referred to as a high anterior resection, is a surgical procedure used for resection of tumors or pathology present in the proximal rectum or distal sigmoid (>12 cm from the anal verge). In contrast to the anterior resection, the low anterior resection is used to treat tumors or pathology in the mid- to distal rectum, and an ultralow anterior resection is a sphincter-preserving approach where the anal canal is spared and a coloanal anastomosis or ileal J-pouch anastomosis is performed. APR is a two-part procedure that involves an abdominal and pelvic procedure where the rectum and colon is mobilized along with a perineal procedure where the rectum and the anus are resected. With this procedure, the patient is left with a permanent colostomy. An APR is required for tumors within 1 cm of the top of the anal canal (Fig. 37-21).

Rectopexy, or repair of rectum, is typically combined with sigmoid resection but can be performed by itself for treatment of rectal prolapse. We typically perform a sigmoid resection and colorectal anastomosis; also, we secure the lateral parts of the rectum to the presacrum to generate additional fixation.

Anterior Resection

Step 1: Patient Position and Room Setup

The patient is placed in modified lithotomy position or synchronous position and securely strapped to the operating table. The setup is similar to that for sigmoid colectomy.

Step 2: Port Placement and Exploration

A four-port technique is used in which trocars are positioned at supraumbilical, suprapubic, and right and left lower quadrants. The abdomen is inspected to confirm the pathology and rule out metastases. Estimation of lower margins of the rectum and the pathology is crucial to decide the procedure in advance of conducting the operation.

Step 3: Mobilization of the Left Colon and Sigmoid Colon

The dissection of the left colon and the sigmoid colon is carried out in the similar fashion as explained in the sigmoid resection.

Step 4: Vascular Ligation

For cancers, the vascular pedicle needs to be taken proximal, incorporating at least the superior hemorrhoidal and sigmoidal vessels. A vascular stapler, LigaSure, or a Harmonic scalpel can be utilized for intracorporeal ligation. Both ureters should be visualized and moved out of harm's way prior to vascular pedicle ligation. The left ureter courses close to the sigmoidal and hemorrhoidal vessel in the retroperitoneum above the pelvic brim. For nononcologic pathologies, vessels can be ligated at more distal locations. Extracorporeal ligation of the vessels is an alternative if adequate exposure can be obtained through the extraction site.

Step 5: Mobilization of the Rectum

After vascular ligation, the presacral space is entered to start the dissection of the rectum. The ureters should be identified to avoid injury to them. Presacral nerves are carefully protected by gently sweeping them down and away from the dissection plane. The dissection continues laterally on either side until it meets posteriorly developing a presacral plane (see Fig. 37-18). The rectum is mobilized by creating a plane anteriorly between the rectum and seminal vesicles and prostate in men and between rectum and posterior vaginal wall in women. Complete mesorectal excision along with distal and circumferential clearance is the key factor for achieving complete oncologic resection. For cancers, the level of rectum for the site of transection is marked using ink tattoo preoperatively and this is visualized at the time of the surgery with endoscopy. The level of transection is typically identified and tattooed before starting neoadjuvant chemoradiation for patients requiring it.

Step 6: Excision of the Rectum and Exteriorization

The rectum is excised at the marked position with the linear stapler gun (see Fig. 37-20) and then the specimen is extracted out through the extended incision in the supraumbilical region. Then the proximal end of the specimen is dissected extracorporeally and the remaining colon reintroduced with the anvil of the stapler gun held by the purse-string sutures.

Step 7: Anastomosis

The anastomosis is performed in a fashion similar to what was described for sigmoid colectomy and low anterior resection using the circular stapler. The integrity of the anastomosis is always checked prior to closing the abdomen. Conversion is rarely needed when the anastomosis is at this high level and is typically reserved for circumstances where the tissue is of poor quality.

Low Anterior Resection

Step 1: Patient Position and Room Setup

The patient is placed in the combined synchronous or modified lithotomy position and secured well on the operating table. The thighs can be kept more at the level of abdominal wall to avoid interference with the laparoscopic instruments used in the lower ports. The surgeon stands on the right side of the patient and faces toward the left lower quadrant of patient. The surgeon may have to shift to between the patient's legs if mobilization of the splenic flexure is required. The surgeon's assistant stands on the right while the scrub nurse on the left. The camera positioned to the left of patient's hips in the beginning is moved cephalad as the mobilization of the sigmoid colon and descending colon continues.

Step 2: Port Placement and Exploration

A 30-degree laparoscope is introduced through the supraumbilical position. Under direct visualization, three 5-mm trocars are in suprapubic position, right lower lateral quadrant, and left lower lateral quadrant positions (see Fig. 37-17). Lower quadrant trocars are inserted lateral to the epigastric vessels.

Step 3: Mobilization of the Left Colon

The patient is placed in the steep Trendelenburg position with the left side of the abdomen inclined upward. The peritoneum lateral to the sigmoid colon is grasped and pulled medially to expose the left peritoneal reflection, which is then opened along the white line of Toldt using cautery or scissors. The left ureter is identified at the base of the sigmoidal fossa on the medial aspect. Remaining in the correct retroperitoneal plane exposes Gerota's fascia and left ureter. Care should be taken to avoid injury to the ureter and left kidney. Depending on the need for splenic flexure mobilization, the dissection can be extended further cephalad at this moment. Mobilization of the splenic flexure is performed as described earlier in the Left Hemicolectomy section.

Step 4: Vascular Pedicle Ligation

By scoring the right and perirectal peritoneum on a cephalad direction, the origin of superior hemorrhoidal and sigmoidal vessels can be exposed. The window in the mesentery on either side of the vessels is identified and developed. After ensuring that both ureters are not in the field, the vascular pedicle at the level of superior hemorrhoidal and sigmoidal vessels can be divided at the level of aortic bifurcation or just below the takeoff of the left colic vessels. The vascular stapler, Harmonic scalpel, or LigaSure can be used according to the comfort of the surgeon.

Step 5: Mobilization of the Rectum

During oncologic resection, care should be taken to avoid penetration of the mesorectal fascia. With the left side of the table inclined upward, the rectum is retracted anteriorly and right, and the left lateral dissection of the sigmoid is continued along the left lateral aspect of the rectum. The proximal aspect of the presacral space is exposed, which can be partially entered and developed. The operating table is now positioned with the right side inclined slightly upward. Retraction of the sigmoid colon and proximal rectum anteriorly, the right perirectal area is open and further retraction on the peritoneum allows for creating the presacral space. The presacral space is now developed with sharp dissection to the pelvic floor. Care should be taken to identify and protect the hypogastric nerves; they should be gently swept down toward the sacrum. The right presacral plane is opened to meet the left presacral plane. The rectum is then elevated anteriorly with sufficient traction that the presacral plane can be developed as far distally as needed to achieve at least 4 cm of distal mesorectal and 2 cm of distal bowel clearance below the tumor. It is generally necessary to work from the posterior section to the lateral section and anterior section and then again going deeper to all, repeating the steps until the dissection is carried well below the tumor. The anterior dissection should include the Denonvilliers fascia in cases of cancer. We would go above the peritoneal reflection anteriorly and take the anterior peritoneal reflection with the specimen. The lateral stalks would typically need to be divided to facilitate deep exposure of the pelvis and mobilization of the rectum for any tumors that present below the upper rectum.

Once the dissection is carried to levators, endoscopy can confirm the optimal level of rectal and mesorectal transection.

Step 6: Excision of the Rectum

The mesorectum can be divided with a LigaSure or Harmonic scalpel. A stapler is required to transect the rectum. The introduction of the stapler typically occurs through a small suprapubic incision or the hand port. The dissected rectum can be divided intracorporeally with a laparoscopic articulating linear stapler at both the ends. The resected specimen is then extracted out through the supraumbilical incision. Of note, it is also feasible to transect the distal rectum with a TA stapler, introduced through a small suprapubic incision that can be used later for specimen extraction (Fig. 37-22).

Step 7: Anastomosis

A purse-string suture is placed in the proximal resection margin and the anvil is tied around the margin of the colon. Then the proximal colon with the anvil is returned to the abdomen. Then the incision is closed and the pneumoperitoneum is reestablished. The circular stapler is inserted through the anus, and the anvil attached to the shaft of the stapling device is advanced across the staple line under direct visualization (Fig. 37-23). The anvil of the proximal colon is attached to the stapler, approximating the bowel ends and then the device is fired under direct visualization. Then the abdomen is irrigated with saline and hemostasis ensured. The anastomosis is checked for any leaks by filling the pelvis with saline, insufflating the rectum with air from the flexible scope, including the proximal colon with an alligator clamp, and observing for any air bubbles. If there is evidence of a leak, that area should be reinforced with sutures or diversion created. The pneumoperitoneum is vented out and the port sites are closed as described previously.

Hand-Assisted Laparoscopic Low Anterior Resection

The patient is positioned in the same way as for the laparoscopic procedure. A 6- to 8-cm lower midline longitudinal incision is made to accommodate the hand port. The incision size should be a half-size smaller than the surgeon's hand to maintain effective pneumoperitoneum. Then the surgeon's left hand in the gel port guides the placement of other trocars. A 30-degree laparoscope is placed in the supraumbilical port and cautery attached to the scissors is placed in the RLQ port. The surgeon's left hand provides retraction of the sigmoid colon and the rectum to aid in the dissection. The vessels are divided intracorporeally with the help of LigaSure or vascular stapler. After a clear plane is developed around the rectum, the rectum is divided with the linear TA stapler at the marked site. The rectosigmoid along with the mesorectum is extracted out through the incision made for the hand port. The coloanal anastomosis is performed using the circular stapling device in the same manner as detailed for the laparoscopic procedure above. Then the anastomotic site is checked for any leakage before closing of the abdomen.

Laparoscopic Abdominal Perineal Resection

Step 1: Patient Position and Room Setup

Preoperative marking of the stoma site is essential to ensure proper stomal positioning and optimal postoperative care and function. The patient is placed in a modified lithotomy position and securely strapped. The surgeon stands on the right side of the patient initially during sigmoid and left colon dissection and later moves toward the patient's left side for majority of the rectal dissection. The monitor should be positioned according to the position of the surgeon. Using two monitors can alleviate the problem of repositioning the monitor during surgeon relocation.

Step 2: Port Placement and Exploration

The use of five ports offers more flexibility in doing an abdominal perineal resection (APR). A 30-degree laparoscope is introduced through infraumbilical trocar. One of the trocars is introduced at the stoma site marking, while the other three trocars are inserted in the right upper, right lower, and left lower quadrants (Fig. 37-24). Using 10-mm trocars allow the surgeon to transfer the laparoscope to other ports to get better access in the procedure. Inspection of the abdomen is carried out to confirm the pathology.

Step 3: Vascular Ligation

The origin of the super hemorrhoidal and sigmoidal vessels can be exposed by scoring the right and perirectal peritoneum in the cephalad direction. After the window in the mesentery on either side of the vessels is developed and it is ensured that both ureters are not in the field, the vascular pedicle at the level of superior hemorrhoidal and sigmoidal vessels can be divided at the level of aortic bifurcation or just below the takeoff of the left colic vessels as described for the anterior resection.

Step 4: Mobilization of the Sigmoid Colon and the Rectum (Abdominal Portion)

The mobilization of the sigmoid colon and the rectum is performed as described in low anterior resection. During oncologic resection, care should be taken to avoid penetration of the rectum or the mesorectal fascia. With the left side of the table inclined upward, the rectum is retracted anteriorly and right, and the left lateral dissection of the sigmoid along the white line of Toldt is continued along the left lateral aspect of the rectum. Then the left ureter should be identified at the base of the sigmoidal fossa. The proximal aspect of the presacral space is exposed, which can be partially entered and developed (see Fig. 37-18). The operating table is now positioned with the right side inclined slightly upward. Retraction of the sigmoid colon and proximal rectum anteriorly, the right perirectal area is open and further retraction on the peritoneum allows for creating the presacral space. The presacral space is now developed with sharp dissection to the pelvic floor. Care should be taken to identify and protect the hypogastric nerves; they should be gently swept down toward the sacrum and to identify the ureters. The rectum is then elevated anteriorly with sufficient traction that the presacral plane can be developed as far distally as needed to achieve at least 4 cm of distal mesorectal and 2 cm of distal bowel clearance below the tumor. It is generally necessary to work from the posterior section to the lateral section and anterior section and then again going deeper to all, repeating the steps until the dissection is carried well below the tumor. The anterior dissection should include the Denonvilliers fascia in cases of cancer. We would go above the peritoneal reflection anteriorly and take the anterior peritoneal reflection with the specimen. The lateral stalks should be divided to facilitate deep exposure of the pelvis and mobilization of the rectum for any tumors that present below the upper rectum. Then the mesorectum is divided at the chosen level with the ultrasonic scissors. The rectal dissection is now performed anteriorly without drifting away from the mesorectal plane into the seminal vesicles and prostate or the vagina anteriorly.

Step 5: Perineal Resection

The perineal dissection is performed as for conventional APR. A purse-string suture is used to close the diamond-shaped perianal incision that is created just outside the sphincter complex to include the sphincters in the specimens. The dissection of the ischial rectal fat is carried out posteriorly all the way to level of levators. Next, the anterior fat is divided in a similar fashion. Using the tip of the coccyx as a guide, a scissors is brought just anterior to the tip of the coccyx and placed into the pelvis and spread. Withdrawing the scissors in a spread position creates a common hole between the pelvis and the perineum. A finger then can be placed along the left levator and the levators divided on both the left and right sides. Hemostasis is achieved with the cautery and suture ligation as need be. The resulting defect in the pelvic floor is typically large enough that the rectum can be brought out from the abdomen and pelvis through the posterior perineal wound.

Step 6: Exteriorization of the Specimen and Wound Closure

Anterior levators are divided on both sides along the edge of the everted rectum. Care must be taken to avoid inadvertently creating a defect in the rectum in cases of cancer. Last, the direct anterior dissection is completed and here we would avoid any excessive use of cautery in the male in particular. The urethra is quite close to the rectal dissection and it is highly sensitive to heat. A delayed urethral leak will occur if excessive heat is applied during the anterior dissection. Finally, the rectum is extracted out through the perineal wound. The perineal wound is closed in sequential layers with absorbable sutures leaving closed-suction drains either from the abdomen down to the pelvis or, if preferred, through the perineum. The drains are clamped and pneumoperitoneum can be recreated. The descending colon is inspected to ensure that it is not twisted or rotated on its mesentery as it is going to be used for the colostomy.

Step 7: Colostomy

The distal end of the colon is now brought to the colostomy orifice using a grasper. At least 3 cm of colon is extracted out through the skin and the colostomy is matured in a Brooke fashion by inverting the bowel wall so that the stoma is slightly raised above the skin.

Hand-Assisted Laparoscopic Abdominal Perineal Resection

The abdominal portion of the procedure is assisted using the hand port. The sigmoid colon and the rectum are mobilized as detailed previously for the low anterior resection. The perineal resection is performed as for conventional APR.

Laparoscopic Rectopexy

Resection Rectopexy

This procedure is essentially the same as for anterior resection with the exception being the addition of presacral fixation.

Step 1: Patient Position and Room Setup

The patient is placed in the modified lithotomy position and carefully positioned and strapped on the operating table. The surgeon and the assistant stand on the right side of the patient, while the monitor is placed on the patient's left side in the caudal end.

Step 2: Port Position and Exploration

A 30-degree laparoscope is introduced through the 10/12-mm subumbilical port. A careful inspection of the liver, small bowel, and the peritoneal surfaces is performed. Under direct visualization, three ports are made in right lower, right upper, and left lower quadrants.

Step 3: Vascular Ligation

The table is now positioned with left side and feet upward, and then the bowel loops are swept to the right side of the abdomen to make the operative field clear. The retroperitoneal structures are dissected to identify the sigmoidal and superior hemorrhoidal vessels and ureters. Because this procedure is indicated for benign cases, the vascular ligation can be performed more distally. The nerves should be spared and the ureters identified. The mesentery can be taken close to the bowel if surgeon attempts to preserve the vascular pedicle.

Step 4: Mobilization of the Rectosigmoid

The sigmoid colon is mobilized by developing a plane between the mesentery and the sigmoid colon. The rectosigmoid junction is drawn toward the patient's right side and the lateral attachments are divided. The dissection of the descending colon should be kept as minimal as possible.

Step 5: Mobilization of the Rectum

The rectum is mobilized in the similar fashion as detailed in low anterior resection with some modifications. To minimize chances of rectal prolapse reoccurrence (particularly in patients presenting with early-onset prolapse), we would dissect the rectum all the way to the levators. Although we favor transection of the lateral stalks, this should be at the discretion of surgeon and based on factors of risk of recurrence versus risk of pelvic floor dysfunction. To not divide the rectal stalk puts the patient at a higher risk of recurrent prolapse. However, to transect both rectal stalks makes the patient at least theoretically at risk for more pelvic floor dysfunction and also removes a source of blood supply (ie, the middle hemorrhoidal). We typically preserve the superior hemorrhoidal and then transect the lateral stalks, so the rectum is supplied by inferior and superior hemorrhoidal vessels.

Step 6: Division of the Rectum and Anastomosis

Before the proximal or distal rectum is divided, careful measurements should be made of where the two ends of the colon and rectum match up. There should be no tension on the anastomosis once it is complete, and yet there should be little to no laxity in the residual bowel as it lies in the pelvis. This will help reduce the risk of recurrent prolapse. Of note, some do not prefer to conduct a colon resection, and we would agree that if there is no redundancy in the colon and the patient suffers from fecal incontinence rather than from constipation, we might also choose not to resect the bowel. Once the level of colon and rectal transsection has been determined to create a tension-free but nonlaxed anastomosis, the rectum is divided with a linear stapler. The division point of the rectum should be just below the level of the sacral promontory. The specimen is extracted through a small lower midline incision. In those cases where a hand port is performed, the specimen is readily extracted through the port site. The proximal end of the colon is divided, and the angle of the circular stapler is inserted and closed with a purse string suture. The circular stapler is inserted through the anus with the trocar brought out just in front of or behind the transverse staple line. The two parts of the stapler are coupled and the device then fired. We often place a row of seromuscular sutures around the anastomosis, especially if there is any evidence of leakage when it is tested in a saline-filled pelvis.

Step 7: Rectopexy

Once the anastomosis is complete, the mesorectum is then attached to the sacral promontory or as one of two with two or three nonabsorbable sutures. We would incorporate the lateral edge of the rectal tissue with care being taken to find the mesorectal tissue without major vessels or nerves. We would also take care to offset the left and right sutures to avoid “crimping” or occluding the rectal lumen from this fixation process. Care should also be taken to insert the needle into some of the presacral periosteum and away from the area of the sacral nerve and internal iliac vessels.

Laparoscopic Subtotal Colectomy with Ileorectal Anastomosis

Step 1: Patient Position and Room Setup

The patient is carefully placed in a modified lithotomy position and securely strapped and padded to the operating table, thus keeping the patient stable when the operating table is tilted side to side during surgery. The surgeon stands on the right or left side of the patient depending on the segment of the colon. The video monitors are adjusted according to the surgeon's position to maintain the alignment of the camera, instruments, and surgical fields. Two monitors are used for convenience because the surgeon will have to reposition at least twice. If an ileostomy is planned, the site should be identified by stomal therapists preoperatively and marked before surgery starts.

Step 2: Port Placement and Exploration

A 10/12-mm port is made in the supraumbilical region and laparoscope is introduced. Under direct visual guidance, four ports are placed, one each in all four quadrants of the abdomen. A 10-mm port is placed in the right lower quadrant to allow the endoscopic stapler; the remaining ports are 5 mm in size. If camera position needs to be changed, a 5-mm port can be changed to a 10-mm cannula.

Step 3: Mobilization of the Colon—Left Colon, Sigmoid Colon, and Right Colon

The colon is mobilized sequentially starting from splenic flexure and left colon, followed by right colon and then the sigmoid colon as previously described under individual hemicolectomies. The vessels are ligated intracorporeally and simultaneously along with the dissection of its respective segment. In case of benign pathology, the vessels can be ligated closer to the bowel and a LigaSure or other vascular transecting device can be used for most, if not all, of the vessels.

Step 4: Exteriorization of the Colon and Division of the Vasculature

The colon is confirmed free from all attachments with the help of a grasper before exteriorization of the specimen. The pneumoperitoneum is vented out and supraumbilical incision is extended for 4–6 cm inferiorly. The colon is exteriorized through this incision. Any remaining vascular pedicles can be ligated using standard open technique extracorporeally. The orientation of the ileal mesentery should be preserved to prevent torsion and small bowel internal herniation.

Step 5: Formation of Ileorectal Anastomosis

An ileorectal anastomosis performed with help of the circular stapler in a fashion similar to what is described previously for colorectal anastomosis. The tricky part of the ileorectal anastomosis is finding the optimal orientation for the small bowel and its mesentery as it comes to a lie within the pelvis. It is often difficult to get the best orientation because the ileum typically is in the right lower quadrant, not in the left lower quadrant. In some cases, it will easily work end to end for an anastomosis, but in most other cases a side ileum to end of rectum may be best to achieve a mesenteric alignment to avoid seeping. If a side of ileum to end of rectum anastomosis looks best, the stapled distal end of the small bowel can be oversewn with seromuscular sutures and a separate antimesenteric site chosen to conduct the anastomosis. In this case, the anvil of the stapler can be placed in the bowel and closed with a purse-string suture and the shaft of the stapler brought across the anus into the rectum and coupled, closed, and fired in the typical fashion.

Laparoscopic Ileal Pouch-Anal Anastomosis

This procedure is essentially the same as the subtotal colectomy plus ultralow anterior rectal resection. The main difference here is the creation of an ileal J-pouch rather than a colon J-pouch.

Step 1: Patient Position and Room Setup

The patient is placed in modified lithotomy position and securely and safely strapped to avoid movements and injury during the procedure. The position of the surgeon should be ergonomically altered depending on the dissection of individual segment of the colon. The key to the appropriate position of the surgeon is to maintain a parallel view with the laparoscope, working instruments, and the monitors.

Step 2: Port Placement and Exploration

The 30-degree laparoscope is introduced through the 10-mm trocar in the infraumbilical site. The abdomen is inspected to confirm the pathology. Under direct visual guidance, four trocars are introduced in the four quadrants (Fig. 37-25). A 10-mm trocar is inserted in the right lower quadrant while the rest of the trocars can be of 5 mm caliber. Using 10-mm trocars at all the ports will allow flexibility to the surgeon in using the laparoscope from any of the ports.

Step 3: Colon Mobilization

The colon is mobilized sequentially starting from splenic flexure and left colon, followed by right colon and then the transverse and sigmoid colon as previously described under individual hemicolectomies. We prefer to mobilize the splenic flexure early while all natural attachments are in tact. Intracorporeal vascular ligation and division is performed simultaneously with the dissection and mobilization of the colon using a vascular stapling device for larger vessels such as ileocolic and the LigaSure or similar device for smaller vessels.

Step 4: Rectal Mobilization

The surgeon continues the dissection from the sigmoid colon toward the rectum. The rectum is fully mobilized to the pelvic floor as previously described in the section on ultralow anterior resection. The rectum is then divided at the pelvic floor using an Endo GIA (Covidien, Mansfield, MA) linear cutting stapler. If the stapler cannot reach the pelvic floor, the stapler can be introduced through a small suprapubic incision or the hand port incision or alternatively using a transanal approach. For the transanal approach, the anal canal is exposed using a Lone Star retractor (Lone Star Medical Products, Stafford, TX) or Gelpi retractor. Diluted epinephrine solution is then injected to raise the mucosal layer to assist in mucosectomy and to minimize bleeding. Cautery dissection starts at the dentate line and continued cephalad by lifting the mucosal layer up to the level of puborectalis, that is, the top of the anal canal. At this point, the dissection is carried full thickness to complete the distal transection of the rectum with complete mucosal removal but with the preservation of the internal sphincter. This approach is used when the entire specimen can be removed through the anus.

Step 5: Exteriorization of Colon and Rectum

The infraumbilical incision is extended by 4–6 cm inferiorly after the pneumoperitoneum is vented through the cannulas. The colon is exteriorized through this incision if it has not been removed through the anus while in transanal resection. The vascular pedicles are ligated and divided using standard open technique extracorporeally unless the vessels are ligated and cut intracorporeally. The ileum at the junction with the right colon is stapled and transected.

Step 6: Formation of Ileal J-Pouch–Anal Anastomosis

The distal staple line of the ileum is oversewn with a seromuscular layer. Next, one makes sure that the blood supply and the vascular pedicle of the ileum are properly oriented without twists. Further, at this juncture one needs to make sure that the apex of the pouch can reach the level of the top of the anal canal. Lengthening of the ileum to achieve the pouch-anal anastomosis must be performed before the pouch is stapled and actually created. The mesentery of the small bowel needs to be fully mobilized all the way up to the base of the stomach near the pancreas. Vascular arcades can be ligated in order to get the pouch to reach in extreme cases, and after a period of temporary bulldog clamping has been performed to ensure good blood supply. Once the pouch is thought to reach, the “J” configuration is created using two 15-cm limbs of small bowel. Seromuscular suture helps secure the correct orientation and reinforce the staple line that is to be created. At this juncture, a small enterotomy is made in the apex of the pouch, and this allows multiple firings of the 80- to 100-mm linear stapler to create the pouch itself. Once the stapling is completed (two, at most three firings), look for and correct any defects at the intersections of the staple line and check for pouch hemostasis prior to placing the handle and the purse string in the apex.

The purse string is made in the pouch apex, and the circular stapler is placed and suture is tightened. The pouch is returned to the abdominal cavity with proper orientation and laid in the pelvis. The midline incision is closed so that the pneumoperitoneum can be restored and the anastomosis completed. The circular stapling device is inserted through the anus and the trocar advanced under direct vision across the transverse staple line or purse string at the anal level. The anvil of the stapler is then attached using a specially designed laparoscopic instrument ensuring that the pouch and its mesentery are lying in the correct orientation and not rotated. The stapler is coupled, closed, fired, and withdrawn. Removing the purse strings allows us to see if the donuts are intact. Anastomotic integrity of the pouch is checked before wound closure (Fig. 37-26).

When a transanal approach is utilized to transect the distal end of the rectum, the pouch is delivered to the anal opening and two layers of absorbable sutures are placed. The first layer is seromuscular suturing of the pouch to the anal canal musculature, that is, an anchoring layer. The pouch is then opened and four quadrant sutures are next placed between the full thickness of the pouch and the residual anal mucosal layer. Supplemental sutures complete this layer.

Step 7: Formation of Loop Ileostomy

The ileum proximal to the pouch by roughly 30–50 cm is grasped and brought out to the RLQ port. A defunctioning loop ileostomy is made, ensuring that the orientation is properly defined. Pelvic drains are placed through the laparoscopic ports. The skin is then closed and the ileostomy matured.

Hand-Assisted Ileal J-Pouch–Anal Anastomosis

The patient is placed in modified lithotomy position and securely strapped to the operating table. The hand port is placed in a lower midline incision. Three ports are made respectively at supraumbilicus, right lower, and the left upper quadrants. The surgeon may stand on the right or left of the patient; alternatively it is often convenient for the surgeon to stand between the legs especially for takedown of flexures and the transverse colon. A 10-mm port is preferred to a 5-mm port as it allows the surgeon to use the laparoscope from any of the ports. The colonic mobilization commences at the splenic flexure. Additional assistance for the splenic mobilization can be provided with a grasper placed in the right lower quadrant. After mobilizing the splenic flexure and left colon, the surgeon shifts position to mobilize the right colon and the transverse colon. Vascular ligation and division can be performed in intra- or extracorporeal manner depending on the mobilization of the colon. The rectum can be mobilized and resected at the pelvic floor with a linear stapler or with a transverse stapler as described above. The rectum and colon are then delivered through the wound and the terminal ileum divided with the linear stapler. A J-pouch is then fashioned in the same manner as described previously and anastomosed to the anus with circular stapler inserted through the anus. If a defunctioning loop ileostomy is planned, a loop of proximal ileum is passed through the RLQ port and the ileostomy matured. Care should be taken to avoid torsion of the vascular pedicle and small bowel intussusception. Drains are placed into the pelvis through the lower quadrant port. After checking for anastomotic integrity and hemostasis is done, the hand port wound is closed in two layers as regular wound incision.

Intraoperative complications including management and prevention can be seen in the following tables (Tables 37-5 to 37-7). Table 37-8 shows the advantages and disadvantages with robotics.

Laparoscopic colectomy is different from other laparoscopic surgery as it requires working in multiple fields and different orientations. Proper training and experience along with appropriate help from the first assistant and the scrub nurse are vital in performing laparoscopic colectomy. There is a significant learning curve during which the length of each procedure may be longer and rate of conversion to open may be greater, although the incidence of complications is not altered.20 It is recommended that surgeons develop their laparoscopic skills initially with simpler procedures such as appendectomy, cholecystectomy, and right colectomy before they graduate to benign complex operations and undertake cancer resections. Based on the prerequisite of 20 laparoscopic colectomies for COST trial, American Society of Colon and Rectal Surgeons (ASCRS) recommended that surgeons perform 20 laparoscopic resections before undertaking procedures for cancer. Hand-assisted laparoscopic surgery (HALS) is easily adaptable for routine and complex cases.21 The steep learning curve of laparoscopic-assisted colectomy can be overcome by starting with the HALS approach.

Successful telerobotic-assisted laparoscopic sigmoid and right colectomies were first reported by Weber et al22 in 2002 when actual dissection and mobilization were performed with robotic assistance and a lot of progress was achieved in technological inventions and its application in various operations. D'Annibale et al reported the results of 53 robotic colorectal surgeries in 2004 and concluded that the outcomes are similar to laparoscopic surgery.23 Short-term outcomes of a randomized pilot study by Baik et all comparing robotic-assisted low anterior resection and laparoscopic low anterior resection concluded the safety and feasibility of robotics (da Vinci robots [Intuitive Surgical, Inc., Sunnyvale, CA]) in colorectal surgery.24

Robotic-assisted surgery (da Vinci robots) offers many advantages over laparoscopic surgery such as 3D visualization, increased degrees of freedom of movement, absence of fulcrum effect, reduced fatigue, and elimination of tremor and better ergonomics for surgeon.23 The biggest drawback for robotics is the high cost. Minor drawbacks include the absence of tactile sensation and the lengthy time required for setup.23 In the future, robotics may find its applicability in rectal operations such as total mesorectal excision, rectal rectopexy, and pelvic floor reconstruction.25 With the new technological advances rapidly developing in the field of robotics, robotic-assisted surgery may replace the laparoscopic-assisted surgeries in the future.

NOSE (natural orifice specimen extraction) technique was performed in colon and rectal surgery specimen extraction through transanal and transvaginal route in the recent past and was considered a prequel to NOTES (natural orifice transluminal endoscopic surgery).26

NOTES is an interesting concept that is gaining enthusiasm. It utilizes the concept of approaching the internal viscera through natural openings such as the mouth (stomach), the anus, and the vagina. NOTES was first performed in India by Reddy and Rao in a burn patient where abdominal incision was not feasible.27 Initial studies were focused mainly on animal studies.28 The Natural Orifice Surgery Consortium for Assessment for Research (NOSCAR) was formed in 2005, and it identified the potential barriers in clinical practice of NOTES and set guidelines for future research and development.29 Patients prefer to undergo NOTES approach over laparoscopic cholecystectomy for lack of pain (99%) and external scarring (89%).30 The potential advantages of NOTES include no scars, less pain, fewer wound complications, earlier mobility,28 and potential to offer therapy outside operating room (intensive care unit [ICU]).31