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Fig. 8.2 Trocar  positions for right assisted hemicolectomy. A umbilical scope; B surgeon’s left 

hand; C surgeon’s right hand; D, E graspers of the first assistant. S surgeon; FA first assistant; 

CA camera assistant

The patient is positioned and the trocars are inserted (Figs. 8.3–8.5). Note that the trocar positions are moved down when a low anterior resection is performed.

As described previously, a medial to lateral or lateral to medial approach can be chosen. In the lateral to medial approach, the first step is to mobilize the sigmoid colon by applying traction and counter-traction during the dissection. At this point it is important to identify the rectosigmoid junction and the ureters. If a ureter is not clearly visible because of intense inflammation, it is possible to locate it by inserting a ureteral stent or even an ultraviolet stent. The left colon is then fully mobilized up to the left splenic flexure.

One trick is to move the camera to one of the left lower ports in order to get a direct view of the left fascia of Toldt. This will give an excellent view of the splenic flexure. Again, traction on the mesocolon of the transverse colon and traction on the adhesions of the splenic flexure will lead to safe division of the splenic flexure. The spleen should not be seen and one should stay as close as possible to the colon (Fig. 8.6).

When the whole colon has been mobilized, it is possible to go down into the pelvis and decide on the site for the anastomosis. The mesorectum is then carefully divided. Metallic clips are avoided as they may interfere with proper firing of the stapler.

Left

Hemicolectomy

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Fig. 8.3  Position  of  patient  for  left  colectomy  .  S  surgeon;  FA  first  assistant;  CA camera  assistant

The rectosigmoid junction is freed from its fatty surrounding tissues, after which a 60-mm stapler is introduced through the lowest trocar on the right side and fired appropriately. Sometimes, with a large rectum it is necessary to fire two shots to complete the transection. Before firing the stapler it is essential to make sure that no rectal tubes are in the rectum.

The fully mobilized left colon is exteriorized through a muscle splitting incision using one of the left lower quadrant ports or a Pfannenstiel, and the specimen is resected. An anvil is then placed in the proximal end after trimming the area appropriately, and a purse string suture applied. The anvil is reintroduced into the abdomen and the incision is closed. A circular stapler is then introduced into the rectum, with care being taken to perforate anterior to the staple line. Using a specific instrument that allows appropriate handling of the anvil, it is connected to the shaft of the stapler and fired (Fig. 8.7).

At its completion, the anastomosis is checked for leaks using intrarectal methylene blue, or by introducing air into the rectum through a rigid rectosigmoidoscope. The operation is completed by irrigation of the area. Drainage is not indicated. If there is a small leak, it can be located by using methylene blue and eliminated by inserting a stitch that is tied intracorporeally. As in open surgery, it is always imperative to check the

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Fig. 8.4  Port positions for left colectomy (note that all trocars are moved down for low anterior resection, as in Fig. 8.5). A surgeon’s left hand; B surgeon’s right hand, also used for the  introduction of the stapler; C camera; D, E graspers of the assistant. S surgeon; FA first assistant;  CA camera assistant

Fig. 8.5  Port positions for low anterior resection (Fig. 8.4). A surgeon’s left hand; B surgeon’s  right hand, also used for the introduction of the stapler; C camera; D, E graspers of the assistant. S surgeon; FA first assistant; CA camera assistant

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Fig. 8.6 Dissection of the splenic flexure of the colon. S  surgeon; CA camera assistant

resected tissue doughnuts to ensure that they are complete. An incomplete doughnut should prompt a laparoscopic suture repair of the anastomosis. If the area of the rupture is not recognized, the entire anastomosis should be revised and interrupted sutures placed around the circumference. Should this not be possible, the procedure is converted to an open operation.

In the medial to lateral approach, the sigmoid colon is grasped with the left hand and retracted until the superior hemorrhoidal arteries are under tension. A window is made around the vessels, and at this point the left ureter SHOULD be visualized before placement of the stapler. After the vessels are transected, the rest of the procedure is performed as described.

If a hand port is used, again it can be placed through a midline of a Pfannenstiel incision.