TY  - CHAP
M1  - Book, Section
TI  - Common Essential Steps in Laparoscopic Colorectal Surgery
A1  - Mishra, Nitin
A1  - Saleem, Abdulaziz M.
PY  - 2024
T2  - Handbook of Minimally Invasive Colorectal Surgery
AB  - Before  you  start,  mark  the  midline  from  the  xyphoid  to  the  pubis  with  a  marking  pen.  This  will  help  you  to  extend  the  incision  in  the  midline  if  you  need  to  do  so  for  extraction  of  the  specimen  or  conversion  to  an  open  operation.A  supraumbilical  skin  incision  about  2  to  3  cm  in  size  is  made  using  electrocautery  or  a  knife.  If  the  plan  is  to  use  the  midline  for  extraction  of  the  specimen,  then  it  is  beneficial  to  make  a  larger  skin  incision  (5  cm)  at  the  very  beginning  of  the  case,  especially  in  morbidly  obese  patients.Use  two  S-retractors  or  Army-Navy  retractors  to  expose  the  fascia.  This  can  be  done  by  blunt  dissection  using  the  retractors  or  by  dividing  the  adipose  tissue  with  electrocautery  while  the  tissue  is  placed  under  tension  by  the  retractors.  The  choice  of  method  is  dependent  on  the  thickness  and  quality  of  each  patient’s  body  wall.  A  combination  of  blunt  and  sharp  dissection  works  best  for  morbidly  obese  patients.Use  two  Kocher  clamps  to  elevate  the  fascia,  and  then  divide  it  with  scissors.When  you  divide  the  fascia,  limit  it  to  the  size  of  the  port.  Otherwise,  it  will  be  a  source  of  leakage  of  the  pneumoperitoneum,  this  is  especially  important  if  the  initial  skin  incision  is  large,  for  example,  you  plan  to  extract  from  the  midline  and  so  have  made  a  larger  skin  incision  for  exposure.Use  two  Kelly  clamps  (or  hemostats)  to  elevate  the  peritoneum—hold  the  peritoneum  with  one  Kelly  clamp  and  lift  it  up  so  that  the  underlying  tissues  are  away  from  the  clamp,  hold  adjacent  to  it  with  another  Kelly  clamp  and  then  release  the  first  clamp  and  regrasp;  this  is  important  to  make  sure  no  underlying  tissue  gets  caught  in  the  clamp  when  you  take  the  first  grasp.  The  peritoneum  between  the  two  clamps  is  then  divided  with  a  pair  of  scissors  to  gain  entry  into  the  abdomen;  it  is  important  not  to  make  a  big  hole  in  the  peritoneum  because  this  can  cause  a  leak  in  the  pneumoperitoneum,  a  1-cm  cut  is  sufficient.  For  patients  with  a  thicker  abdominal  wall,  one  can  substitute  longer  instruments  like  a  Tonsil  clamp  or  Pean  clamp.  It  is  important  not  to  use  a  perforating  clamp  like  the  Kocher  clamp  for  this  step  because  it  can  damage  the  underlying  bowel  if  it  is  grasped  in  error  by  the  surgeon.To  make  sure  that  there  are  no  adhesions  before  you  place  the  port,  feel  the  peritoneal  cavity  with  your  little  or  index  finger  or  place  an  S-retractor  in  the  peritoneal  cavity.Place  two  stay  sutures  on  each  side  of  the  fascia  to  secure  the  Hasson  trocar.  Alternatively,  use  a  balloon-tipped  Hasson  trocar.  
SN  - 
PB  - McGraw Hill
CY  - New York, NY
Y2  - 2024/10/09
UR  - accesssurgery.mhmedical.com/content.aspx?aid=1204542364
ER  -