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Laparoscopic sigmoidectomy is indicated in both benign and malignant conditions as long as it is performed by qualified surgeons with appropriate resources. In general, this approach is not recommended in patients with emergency conditions such as obstruction, perforation, or massive bleeding.
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PREOPERATIVE PREPARATION
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For patients having surgery for polyps and neoplasms, it is essential to have the lesion tattooed during colonoscopy because 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 antibiotic and mechanical bowel preparation, and prophylactic parenteral antibiotics are administered within 1 hour of the incision and are discontinued within 24 hours of surgery. Subcutaneous heparin is administered in high-risk patients, and sequential compression devices are placed for the prevention of venous thromboembolism. Then a time-out is performed.
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INCISION AND EXPOSURE
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The setup is similar to that for 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 right arm is tucked. 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 mobilization of splenic flexure and creation of the colorectal anastomosis. Port placement includes a 10-mm port in the infraumbilical region, a 5-mm trocar in the right upper quadrant in the midclavicular line, and a 10- to 12-mm trocar in the right lower quadrant in the midclavicular line (FIGURE 2A). Finally, an optional 5-mm trocar is placed in the left upper quadrant to facilitate mobilization of the splenic flexure. FIGURE 2B shows an alternative port placement.
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DETAILS OF THE PROCEDURE
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For 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 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 countertraction of the colon. As the dissection nears the splenic flexure, it is best to stay underneath the omentum and develop a plane between the omentum and the splenic flexure (FIGURE 4). Alternatively, the gastrocolic ligament can be divided using ultrasonic shears or a vessel-sealing device, leaving the omentum attached to the colon. 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 ...