Laparoscopic Colorectal Surgery

Prof. Dr. R. K. Mishra

INTRODUCTION vessels, mobilization and removal of a long floppy segment of

Laparoscopic colon resections are being performed with the colon, and restoration of intestinal continuity. Once the
increasing frequency all over the world. However, the colon segment has been thoroughly mobilized and its blood
use of minimal access surgery in colorectal surgery has supply divided, a small skin incision is made to exteriorize
lagged behind its application in other surgical fields. the colon, then resection and anastomosis are performed
Since the first laparoscopic colectomy was described in extracorporeally, and the rejoined colon is placed back into
1991, a great deal of controversy has surrounded its use, the abdomen.
particularly in the management of colorectal cancer. After The laparoscopic approach continues to gain popularity
the successful introduction of laparoscopic colectomy by and has evolved to include not just “pure” laparoscopic
Jacobs, laparoscopic surgery for the treatment of colorectal techniques but also hand-assist devices. Hand-assisted
cancer, especially laparoscopic rectal surgery, has been surgery can be used as a bridge for surgeons who are not
developed considerably. Several new important studies completely familiar or facile with laparoscopic techniques,
have demonstrated the benefits and safety of laparoscopic and even for the most experienced laparoscopic surgeons,
colorectal surgery, making it now the preferred approach in it is often the preferred technique for surgery involving
the surgical management of many colorectal diseases. left-sided pathology (Figs. 1A and B). The use of a hand-
The technique of laparoscopic colectomy has a long assist device provides tactile feedback for the surgeon and
learning curve because of the advanced laparoscopic skills shortens operating-room time while still preserving many
it entails. Unlike other laparoscopic procedures, such as of the advantages of laparoscopic surgery. By combining
the Nissen fundoplication or cholecystectomy, colorectal laparoscopic surgery with the tactile feedback of a hand-
procedures involve dissection and mobilization of intra- assisted device, surgeons can reduce operating-room time
abdominal organs in multiple quadrants. Tilting of the and have a lower procedure conversion rate. The technique
operating-room table in various positions during an operation involves making an incision the width of a hand and placing
uses gravity to allow intra-abdominal organs to fall away a hand-assist device to facilitate laparoscopic dissection.
from the area of dissection, providing necessary exposure that New handport devices make this technique possible
would normally be achieved through the use of retractors. without loss of pneumoperitoneum, which is essential for
Intestinal resection requires laparoscopic ligation of large performing laparoscopic procedures. Because an incision

A B
Figs. 1A and B: Hand-assisted colorectal surgery.
 CHAPTER 26: Laparoscopic Colorectal Surgery 341

(4–5 cm) is necessary to remove the colon specimen at the Intraoperative colonoscopy is a way of definitively localizing
end of a laparoscopic operation, the difference between a a lesion and should be available during all laparoscopic
pure laparoscopic procedure and a hand-assisted operation colectomies. A traditional colonoscopy uses room air as the
is generally a few additional centimeters (3–4 cm) of incision insufflating gas, which leads to significant bowel distension
length. Several clinical trials have demonstrated that there is and requires clamping of the proximal colon to minimize
no difference in patient recovery or discharge for laparoscopic this effect. Clamping the bowel can lead to injury, and even
versus hand-assisted techniques. Larger incisions are when it is successfully performed, the degree of distension
often needed, and because of the increased risk of wound often makes simultaneous laparoscopic visualization
infections and pulmonary complications, this technique has difficult. These problems can be circumvented with the use
particular advantages with overweight or obese patients. of CO2, rather than room air, as the insufflating gas. Because
Most patients are candidates for a laparoscopic approach. CO2 is absorbed much more rapidly than room air, bowel
When the surgeon is experienced, even patients with a history distension is minimized and dissipates quickly, making
of abdominal surgery can form possible candidates. Though proximal clamping unnecessary. The use of CO2 allows for
there are clear benefits, they have not been as compelling laparoscopic and endoscopic procedures to be performed
when compared to the clear advantages associated with simultaneously, and this technique has been shown to be
other laparoscopic procedures. The main reason is that safe and clinically useful. Besides tumor localization, CO2
a colectomy, whether open or laparoscopic, results in a colonoscopy may have other potential applications.
delayed return of bowel function. Though recovery of bowel
function is quicker after laparoscopic surgery, the difference PORT-SITE METASTASIS
is on the order of 1 or 2 days, resulting in a similar reduction In the early experience of laparoscopic colectomy for cancer,
in length of hospital stay. Also, the laparoscopic approach is a few reports described immediate tumor recurrence at
associated with longer operating-room times. Even if long- the laparoscopic incision sites, referred to as port site
term benefits are equivalent between open and laparoscopic recurrences (Figs. 2A and B). It was hypothesized that
techniques, the short-term benefits are real advantages for such early cancer recurrence happened after laparoscopy
patients. In practical terms, the laparoscopic approach is due to tumor shedding and/or accelerated tumor growth,
associated with less pain, a faster recovery, earlier return secondary to the presence of gas in the peritoneal cavity.
of bowel function, a shorter hospital stay, possible immune However, multiple reviews have indicated that this is not the
benefits, and smaller scars, making it the preferred method case. In one such study, which included over 2,600 cases, the
for intestinal resection. rate of port-site recurrence was approximately 1%, which
The lack of tactile feedback during laparoscopic surgery is similar to that noted in open colorectal surgery. It is not
can make tumor localization difficult, especially if the lesion currently believed that laparoscopic colectomy is associated
location has not been tattooed on the colon wall before with early wound recurrences.
surgery. It is imperative that the exact location of the tumor Port-site implantation was a concern in the early period,
is known prior to proceed with colectomy. Even when the but it has been shown now that it can be prevented by:
lesion location has been tattooed onto the colon, often the ■ Proper protection of port site while delivering the
mark can be challenging to see, or there may be confusion specimen. (Endobags® and pouches).
regarding the location of the tattoo in relation to the tumor ■ Avoid squeezing of the specimen by taking a liberal
(proximal or distal), which can affect surgical margins. incision.

A B
Figs. 2A and B: Port-site metastasis after laparoscopic surgery.
342 SECTION 2: Laparoscopic General Surgical Procedures

■ Thorough wash to the wound, 5FU solution irrigation of small intestine. Although, these results in low fecal bulk,
all ports satisfactory cleansing is obtained in only 17% of the patients.
■ Slow-release of pneumoperitoneum Nausea and vomiting can occur, and the evidence does not
■ Lap-lift technique favor elemental diets as a sole means of bowel preparation.
The cost can be brought down by either doing a hand-
sewn anastomosis through the specimen delivery site or use of Whole-gut Irrigation
conventional stapler for extracorporeal stapled anastomosis. Saline: Normal saline is instilled through a nasogastric tube
Minimal use of disposable ports and instruments can further at a constant rate of 50–70 mL/min in 4 hours, requiring a
cut down the cost. The use of ultrasonic energy sources in the total of 10–14 L of fluid. Cleansing effect is achieved in 90% of
form of harmonic shears (Ethicon® and USSC®) has added to the patients; however, the concentration of colonic bacteria
some of the cost of lap surgery. is not reduced unless antibiotics are added. Many patients
The two burning issues are port-site metastasis in complain of abdominal distension, nausea, and vomiting.
malignancies and cost factor due to the use of endo staplers. Other drawbacks of this method include the large volume
As mentioned earlier, for a benign condition such as rectal of irrigants, need of nasogastric tube, risk of electrolyte
prolapse, adenomas, rectal polyposis, and inflammatory disturbance and water retention, and nursing care required
condition such as tuberculosis, ulcerative colitis, and simple to assist the patient. It is contradicted in patients with
diverticulitis, laparoscopic surgery offers a patient-friendly gastrointestinal obstruction, perforation, and toxic colitis
technique. Crohn's disease, though not very common and has to be used with caution in patients with cardiac
in India, laparoscopy can be offered for the diagnosis, problems.
lymph node sampling, and curative resection. Ileocecal
Castor oil: It (30–60 mL) orally achieves good cleansing but
tuberculosis is commonly seen in our country, and it is an
requires a large volume of magnesium citrate purgative to
excellent option to provide the benefits of laparoscopy to
achieve the desired results and requires to be given 2 days
these patients whenever surgery is indicated. Incidental
before surgery followed by anal washouts a day prior which
colonic resection is unlikely to help the laparoscopic surgeon
entails preoperative admissions for 3–4 days. Unpalatabilty
team in mastering the techniques. The reduction of OT time
is another drawback.
due to better coordination and cost-benefit to patients can
only be offered by repetitive performances. A dedicated Mannitol: Mannitol is a nonabsorbable oligosaccharide
team effort will surely bring this specialty under the umbrella which acts as an osmotic agent by pulling fluid into the
of minimal access surgery as has happened in the western bowel and producing a purgative effect by irritating the
world. colon. Being a sugar, it is quite palatable and can be flavored
by mixing it with fruit juice. Usually, 4 L of 5% solution is
BOWEL PREPARATION IN consumed over 4 hours, which can be difficult and can result
COLORECTAL SURGERY in abdominal discomfort and nausea. To avoid these side
Though widely accepted as sensible and logical, it has never effects, hypertonic solutions (10–20%) can be used but these
been subjected to any stringent scrutiny. The ideal method predispose to dehydration and electrolyte losses. Overall,
of mechanical preparation should be simple, inexpensive, good cleansing is produced in about 80% of the patients,
without distress, and side effects to the patient. However, but leads to a high wound infection rate probably by acting
such an ideal method does not exist. It must be chosen with as a bacterial nutrient and production of explosive gases
respect to patient acceptability, efficiency and influence on as a result of fermentation into methane and hydrogen by
fluid and electrolyte imbalance and fecal microflora. The anaerobic bacteria is seen. The same can be overcome by
conventional method involves a 3-day regimen consisting of using of an antibiotic.
low residue and clear liquid diet combined with purgation Polyethylene glycol (PEG): To overcome the drawbacks of
using laxatives and enemas. Although satisfactory in bowel mannitol, PEG (PEGLEC) in a balanced electrolyte solution
cleansing in about 70% of patients, it is rather exhausting due was introduced which also acts as an osmotic purgative
to reduced calorie intake. It is time-consuming and may result (Fig. 3).
in dehydration if the patient drinks an inadequate amount To achieve satisfactory cleansing in >90% of the patients,
of fluids. These disadvantages stimulated the development an average of 2–4 L of PEGLEC solution must be ingested with
of more reliable, efficient, and quicker methods, which are tea and lemon. Studies using PEG have shown a significantly
given in the following text. lower incidence of fluid retention and lesser aerobic and
anaerobic fecal bacterial counts compared to other agents.
Elemental Diets It is nowadays used as an agent of choice for preparations
Low residue liquid or elemental diets were used with of the bowel before endoscopy and colonic surgery in a
the intention that nutrients could be absorbed in the nonobstructed patient.
 CHAPTER 26: Laparoscopic Colorectal Surgery 343

Fig. 3: Bowel preparation in colorectal surgery.

Picolax: It (sodium picosulfate and magnesium citrate) is a the surgeons would prefer parenteral antibiotics or with
stimulant purgative that acts mainly on the left colon after concomitant administration of oral antimicrobials together
activation by colonic bacteria and on osmotic laxative that with oral PEGLEC electrolyte solution as the method of
cleanses the proximal colon. Two sachets in 2 L of water choice of preoperative bowel preparation.
are administered with dietary restrictions to improve Though observational data suggest that mechanical bowel
effectiveness. Although acceptable cleansing is achieved in preparation before colorectal surgery reduces fecal mass
85% of patients undergoing barium enema and colonoscopy, and bacterial count in the lumen, but the practice has been
its efficacy for elective colorectal operations is poorly questioned because the bowel preparation liquefies feces,
documented. Picolax is well tolerated but does produces which could increase the risk for intraoperative spillage, and
fluid and electrolyte losses. may be associated with bacterial translocation and electrolyte
disturbance. Though commonly practiced without the
ANTIBIOTIC BOWEL PREPARATIONS benefit of evidence from randomized trials, and two of three
Mechanical cleansing alone has failed to achieve a significant meta-analyses suggest a higher rate of anastomotic leakage
reduction in the total bacterial load of the colon and, with mechanical bowel preparation thus calling for an end to
therefore, the associated septic complications. Addition of the practice of mechanical bowel preparation in view of the
antibiotics, oral as well as parenteral, to mechanical cleaning possible disadvantages of this practice, patient discomfort,
has resulted in a significant reduction of the infection rate and the absence of clinical value. There are others who
from 30 to 60% in an uncovered patient to as low as 2–10% in accept that though routine preoperative bowel cleansing is
otherwise patients covered with broad-spectrum antibiotics. no longer justified prior to colorectal surgery in general, they
call for further evaluation in cases such as total mesorectal
Oral Antibiotics resection with low anastomosis where it may still have a
Because the aerobic Escherichia coli and the anaerobic role and therefore to consider each case carefully, otherwise
Bacteroides fragilis are frequently involved organisms in the chance of making an inappropriate decision exists with
septic complications following colorectal operations; oral significant consequences for patients.
antibiotics active against both types of bacteria must be The majority of surgeons believe that patients should
given. Oral administration of erythromycin, neomycin, and have a standard bowel preparation 48 hours before the
metronidazole are popular. Several studies have documented operation and should receive a single-dose antibiotic dose
the efficacy of oral antibiotics; however, an antimicrobial immediately preoperatively. For the bowel preparation,
used alone without mechanical cleansing has little impact patients follow a strictly fiber-free diet eight days before
on the postoperative infection rate. surgery and take a sodium phosphate oral solution the day
before surgery. This method is very useful because it ensures
Parenteral Antibiotics an empty digestive tract and a flat small bowel, which
Since parenteral antibiotics are valid only when adequate facilitates the layering of intestinal loops, a crucial point for
tissue levels are present at the time of contamination, achieving adequate exposure. Alternatively, the PEG can be
systemic administration should start immediately before used. In this case, administration 2 days before surgery is
the surgery. A second- or third-generation cephalosporin preferable to avoid distension of small bowel loops that may
with metronidazole is the most commonly preferred agent. be difficult to handle during the surgery.
Studies had shown conflicting results when parenteral
antibiotics were compared with oral or both. Whether RIGHT COLECTOMY
antibiotics bowel preparation should be oral, systemic, A right colectomy or ileocolic resection is the removal of
or both are still a controversial issue. The majority of all or part of the right colon and part of the ileum (Fig. 4).
344 SECTION 2: Laparoscopic General Surgical Procedures

Equipment and Instruments

One can use the same basic equipment, such as light source,
insufflator, 30° angled laparoscope, and 5-mm graspers. To
this basic equipment, can be added reusable instruments
such as Babcock and alligator clamps, which should be at
least 38–40 cm in length to reach from the depths of the pelvis
to the upper abdomen using limited port sites. In developing
countries, these reusables can be used if necessary but
trying to keep disposable equipment to a minimum. Three
10 or 12 mm trocars with stability threads, plus reducers for
5-mm instruments should be used. Cannulas should allow
instruments to move through smoothly while maintaining
a good seal after multiple instrument passages. An energy
source device of one's choice can also be added, such
as bipolar, LigaSuretm, or harmonic scalpel. Additional
disposable equipment is kept readily available in the
Fig. 4: Section to be removed in right colectomy. operating room and used only as needed. These include a
clip applier, linear vascular stapler, suction irrigator, and fan
retractor.
These operations are performed for the removal of cancers,
certain non-cancerous growths as well as severe Crohn's
disease. If performed by an expert laparoscopic surgeon, Patient Positioning and
laparoscopic right colectomy and ileocolic resection are as Operating Room Setup
safe as “open” surgery in carefully selected cases. The patient is placed supine, and straps are used to secure
the patient during steep table position changes. The patient
Indications is fixed in a moldable “bean bag” form with both arms
The advanced laparoscopic skills required for laparoscopic tucked in, and placed in a modified lithotomy position using
resection of the colon and rectum have precluded wide levitator stirrups (Figs. 5 and 6). A urinary catheter is placed
dissemination of this procedure. By applying certain key in the bladder, and the stomach is decompressed with a
principles, laparoscopic right hemicolectomy can be made nasogastric tube. Identical operating room personnel is used
simple, reproducible, easy to teach, easy to learn, and for the laparoscopic case as for an open right hemicolectomy.
cost-effective. Although benign tumors not resectable by The nurse is on the patient’s right. This is also where
a colonoscopic procedure and structuring inflammatory the assistant stands, with the surgeon on the patient’s left
bowel disease may be good indications for laparoscopy, they side facing the right colon. Hasson (open) technique is
are not so common. The most common disease for right preferred to safely insert the first port through the umbilicus.
colectomy is right-sided colon cancer. Colon cancer seems After establishing pneumoperitoneum, the surgeon tries to
to be a good indication for laparoscopic surgery if performed expose the right mesocolon and to mark the lower border of
using proper oncologic methods, i.e., early proximal ligation the ileocolic vessels.
of the major mesenteric vessels and wide mesenteric and After initial exploration ensures no prohibitive adhesions,
intestinal resection with complete lymphadenectomy. For two additional 10–12 mm ports are placed under direct
right colectomy, either laparoscopic mobilization of the visualization, one in the left upper quadrant (in or lateral to
bowel and/or mesenteric resection, both are performed as the rectus, avoiding the epigastric vessels, approximately a
for open colectomy, and bowel division and creation of the handbreadth from the supraumbilical port) and one in the
anastomosis can be performed extracorporeally. suprapubic midline. Once all the trocars are in place, the
assistant moves to the patient's left side to direct the camera.
Contraindications To start the initial dissection, the surgeon moves between
the patient’s legs, the assistants position themselves on the
■ Patients with complete obstruction caused by the cancer patient’s left side, and the nurse stands near the patient’s
■ Cancer extensively invading adjacent organs right knee. The primary monitor is placed near the patient’s
■ Bulky cancer >10 cm in size should be excluded. right shoulder to give the surgeon and the assistant’s optimal
According to these concepts, a proper oncologic approach viewing (Fig. 7).
using laparoscopy for right colon cancer is described in this The second monitor is placed on the left side close to the
chapter. head, a location that gives the best view for the nurse.
 CHAPTER 26: Laparoscopic Colorectal Surgery 345

Fig. 5: Position of patient for colorectal surgery.

Fig. 6: Shoulder support to prevent sliding during colorectal surgery.

After completing the proximal vessel ligation with The patient is positioned in Trendelenburg with the
lymphadenectomy and mobilization of the terminal ileum right side inclined upward. This allows the small bowel and
and the cecum, the surgeon moves back to the patient’s left omentum to fall toward the left upper quadrant, exposing
side, and the first assistant stands between the patient’s legs the cecum and assisting in retraction. The omentum and
for take-down of right flexure and whole mobilization of the transverse colon are moved toward the upper abdomen, the
right colon (Fig. 8). ventral side of the right mesocolon is well visualized, and the
optimal operative field can be achieved. The small bowel is
Operative Technique mobilized out of the pelvis by grasping the peritoneum, not
Right colectomy can be broadly divided in the following bowel wall, near the base of the cecum and pulling cephalad
steps: and to the left. The appropriate plane along the base of the
■ Ligation of ileocolic vessels small bowel mesentery and around the cecum can be seen
■ Identification of right ureter and the peritoneum overlying it carefully opened, exposing
■ Dissection along the superior mesenteric vein the correct retroperitoneal plane.
■ Division of omentum The ureter is identified either before opening the
■ Division of right branch of middle colic vessels peritoneum in a thin patient or after, being visualized as
■ Transection of the transverse colon it courses over the right iliac vessels. Dissection is then
■ Mobilization of the right colon continued around the base of the cecum. Moving cephalad
■ Transection of the terminal ileum and laterally, the white line of Toldt is incised as the right
■ Ileocolic anastomosis colon is retracted medially and cephalad by grasping the cut
■ Delivery of specimen edge of the peritoneum, not the bowel.
346 SECTION 2: Laparoscopic General Surgical Procedures

Fig. 8: Mobilization of cecum and right colon.

through the suprapubic port. The medial side of the right

mesocolon is first incised, starting from the previously
marked region below the ileocolic pedicle, followed by the
incision of the peritoneum over to the superior mesenteric
vessels. This is done before mobilization of the right colon.
With adequate traction of mesocolon toward the right upper
quadrant, the ileocolic vessels are easily mobilized from
the subperitoneal fascia leading onto the duodenum. Their
Fig. 7: Position of surgical team during colorectal surgery.
origins are identified from the superior mesenteric vessels at
the lower border of the duodenum and divided.
Before starting the dissection, the ileocolic pedicle
The surgeon’s first step in the dissection is to mark the
must be definitively identified by retracting the right
inferior border of the ileocolic pedicle. From between the
mesocolon. Various approaches, such as lateral-to-medial
legs, the surgeon dissects the peritoneum overlying the
(lateral approach), medial-to-lateral (medial approach),
ileocolic vascular pedicle over to the superior mesenteric
and retroperitoneal approach, have been documented.
vessels.
The medial approach is quite effective for complete
lymphadenectomy with early proximal ligation, minimal After mobilization of the ileocolic pedicle from the
manipulation of the tumor-bearing segment, and ideal entry duodenum, the dissection of the ventral side of the superior
to proper retroperitoneal plane. mesenteric vein (SMV) leads to the dissection of the origin of
Various approaches to the right colon mobilization have the ileocolic artery. In type B, the ileocolic artery is running
been described. behind the superior mesenteric vein. After mobilization and
■ Lateral to medial (“classic” open approach) division of the ileocolic pedicle from the duodenum, the
■ Medial to lateral approach dissection of the ventral side of the SMV leads to a complete
■ Retroperitoneal approach dissection of the root of the middle colic artery and vein.
It is believed that the medial approach is optimal in order Careful dissection onto the duodenum and the caudad
to maintain conventional oncologic principles. First, the portion of the pancreas must be exercised in the exposure
mesocolon near the ileocecal junction is lifted to confirm of the middle colic vessels. Dissection around Henle’s trunk
the ileocolic pedicle. The root of the ileocolic pedicle is (the truck of mesenteric veins consisting of the gastroepiploic
usually located at the lower border of the duodenum. The vein fusing with the right branch of the middle colic vein
independent right colic vessels, if present, are located at or the main middle colic vein) may lead to the exposure
the upper border at the duodenum. However, the majority of an accessory right colic vein. Accessory right colic vein
of patients do not have the independent right colic vessels and right branches of middle colic vessels are clipped and
(vessels originating directly from the superior mesenteric divided. However, if an accessory right colic vein is difficult
artery and vein (Figs. 9A and B). The surgeon should to confirm in this situation, this vein may be easily detected
initially stand on the patient’s left side to confidently know later at the take-down of the right flexure.
the ileocolic pedicle from the superior mesenteric vessels, After securing the vessels, the operating table is tilted into
and to mark the lower border of the ileocolic pedicle. the steep Trendelenburg position with the right side down to
Once the ileocolic pedicle is identified, the surgeon move the small intestine toward the right upper quadrant.
moves between the patient’s legs and the scope is inserted After confirming the right ureter and gonadal vessels
 CHAPTER 26: Laparoscopic Colorectal Surgery 347

A B
Figs. 9A and B: (A) Position of major blood vessels at the time of surgery; (B) Important vessels supplying right side of colon.

A B
Figs. 10A and B: Specimen of right side of colon after right colectomy.

through the subperitoneal fascia at the right pelvic brim, the this situation and should be divided before extracting the
peritoneum is incised along the base of the ileal mesentery right colon to avoid its injury. Up to this point, the primary
upward to the duodenum, and the ileocecal region is tumor has been minimally manipulated using medial to
mobilized medially to lateral. After this mobilization, the lateral approach. Finally, the right flexure and right colon,
surgeon moves back to the patient’s left side, and the scope including the tumor-bearing segment, are detached laterally,
is inserted through the umbilical port. The right mesocolon which completes the mobilization of the entire right colon
is mobilized from medial to lateral. Again, this approach (Figs. 10A and B).
allows dissection into the proper retroperitoneal plane. The Once the entire right colon is freed, it is withdrawn
right gonadal vessels and ureter are safe from injury in this through an enlargement of the port site at the umbilicus. The
plane, so exposing them is not necessary. This approach also wound must be covered with a wound protector to prevent
allows the surgeon to work in a straight path from medial to contamination or metastasis. The resection of ileum and
lateral, without tissue to obstruct the vision that can occur transverse colon, and the anastomosis are accomplished
while working from lateral to medial. This plane connects extracorporeally by the functional end-to-end anastomotic
the previous dissection plane from the caudad side. method using conventional staplers or by a hand-sewn
The anatomy around the right flexure is essential to method (Figs. 11A and B). The anastomotic site is returned
avoid inadvertent bleeding, especially from around Henle's to the peritoneal cavity. Wounds and peritoneal cavity are
(gastrocolic) trunk. However, if the previous mesenteric copiously irrigated. All wounds are closed, and operation is
dissection is fully performed from the caudad side and the completed.
accessory right colic vein is divided, the right flexure is easily The identification of a small tumor in the colon may be
taken down only by dividing the hepatotoxic ligament. If the difficult even in conventional open surgery. In laparoscopic
accessory right colic vein is difficult to detect at the previous surgery, where there is no tactile sensation, pre- or
dissection, it can be easily confirmed from Henle’s trunk at intraoperative marking of the tumor is frequently needed.
348 SECTION 2: Laparoscopic General Surgical Procedures

A B
Figs. 11A and B: Transaction of ileum by the stapler.

Various kinds of marking methods are available, e.g., dye vein compression and traction injuries to the brachial plexus.
injection and mucosal clip placement by preoperative The patient is placed supine, in the modified lithotomy
colonoscopy, which has been reported for the tumor position, with legs abducted and slightly flexed at the knees.
localization. Several reports demonstrated the usefulness of The patient’s right arm is alongside the body, whereas the
tattooing the colonic wall adjacent to the tumor with India left arm is usually placed at a 90° angle. Adequate padding is
ink in four quadrants using preoperative colonoscopy. used to avoid compression on bone prominences.
However, effective injection in all four points of the bowel A nasogastric or orogastric tube and a urinary catheter
is sometimes challenging to achieve. In some cases, surgeons are placed. Adequate thromboembolism prophylaxis should
failed to achieve serosal staining visible at laparoscopy, be used, as preferred by the surgeon, and intermittent leg
which forced them to use intraoperative colonoscopy. This compression stockings can be used as well. The procedure
complicated the laparoscopic colonic resection because of the is usually performed with two assistants and a scrub nurse
distended bowel related to air insufflation during colonoscopy. (Fig. 12). The surgeon is on the right side of the patient,
and the second assistant is also on the right side. The first
Conclusion assistant stands between the patient's legs and the scrub
Right-sided colon cancer can be adequately treated by nurse at the lower right side of the table. The team remains
proper laparoscopic procedures adherent to the oncologic in the same position throughout the entire procedure. It is
principles. Port-site metastasis after laparoscopic colon advisable to use a table that can be easily tilted laterally and
cancer surgery is unlikely to be a major risk factor when the placed into steep Trendelenburg and reverse Trendelenburg
procedure is performed according to oncologic principles. position in order to facilitate exposure of the pelvic space and
It is believed that laparoscopic right colectomy for cancer of the splenic flexure. The laparoscopic unit with the main
performed by expert surgeons is accepted as less invasive monitor is located on the left side of the table. It is useful to
surgery without sacrificing the survival benefit compared use a second monitor placed above the patient’s head.
with conventional open right colectomy.
Cannula Positioning
SIGMOIDECTOMY Standardize cannula placements are five or six cannulae for
Laparoscopic sigmoid colon resection is indicated for both left-sided colectomies. This allows us to achieve excellent
benign (diverticulitis, segmental Crohn's disease, polyp exposure, which may be particularly valuable at the
unresectable by colonoscopy) and malignant (primary colon beginning of a surgeon’s learning curve. Using six cannulae
cancer) etiologies, and is one of the most common operations allows the use of more instruments in the abdominal cavity
done by laparoscopic methods. In chronic diverticular for retraction of bowel and structures, especially in the
disease, the indications for laparoscopic sigmoid resection presence of abundant intra-abdominal fat or the dilated
are the same as for open surgery. Sigmoid colectomy for small bowel, as well as during mobilization of the splenic
diverticulitis can be technically challenging because of flexure.
severe inflammation in the left lower quadrant and pelvis. Cannula fixation to the abdominal wall is essential, to
avoid CO2 leakage, and in cases of malignancy, to minimize
Patient Positioning and Operating Room Setup the passage of tumor cells and help reduce the incidence
A proper patient position is key to both facilitating operative of port-site metastases. This is mainly achieved by fitting
maneuvers and preventing complications such as nerve and the size of the incision to the cannula size or by fixing the
 CHAPTER 26: Laparoscopic Colorectal Surgery 349

Fig. 12: Position of surgical team in colorectal surgery.

Fig. 13: Port position for sigmoidectomy for benign disease. Fig. 14: Alternating port position for sigmoidectomy
for malignant disease.

cannula to the abdomen with a suture placed around the to allow the introduction of a linear stapler at the time of
stopcock of the cannula. Use of screw-like cannulae has bowel resection. This cannula accommodates the following:
drawbacks that it increases the parietal trauma. Generally, scissors (monopolar, high-frequency hemostasis device,
it is better to perform an “open” technique for the insertion clip, staplers), a monopolar hook, surgical loops, a suction-
of the first cannula, which is placed at the midline, above the irrigation device, and an atraumatic grasper. A fourth cannula
umbilicus, to reduce the risk of injury of abdominal organs. is placed on the left midclavicular line at the level of the
With some experience, the task becomes easy and very rapid. umbilicus. This is a 5-mm cannula, which accommodates
However, in the case of previous abdominal surgery, we an atraumatic grasper used for retraction and exposure
usually inflate the abdominal cavity using the Veress needle during the medial approach for the dissection of the left
in the left subcostal area, in order to insert the first cannula mesocolon. When performing mobilization of the splenic
as far lateral as possible, in the right hypochondrium, to flexure, this cannula becomes an operating cannula. A fifth
avoid potential areas of adhesions. 5-mm cannula is placed 8–10 cm above the pubic bone, on
The first cannula (12 mm), which is used for the optical the midline, and is used for retraction (Figs. 13 and 14).
device, is positioned on the midline 3–4 cm above the For most of the procedure, it accommodates a grasper
umbilicus. The two operating cannulae are introduced, used to expose the sigmoid and descending mesocolon. At
one at the junction between the umbilical line and the the end of the procedure, the incision at this cannula's site
right midclavicular line, and the other 8–10 cm inferiorly, is lengthened to allow extraction of the specimen. Some
on the same line. The latter is a 12 mm operating cannula surgeons sometimes use an additional cannula, which is a
350 SECTION 2: Laparoscopic General Surgical Procedures

A B
Figs. 15A and B: Exposure of sigmoid colon after shifting the omentum upward.

5 mm cannula situated on the right midclavicular line in the

subcostal area and accommodates an atraumatic grasper used
to retract the terminal portion of the small intestine laterally
at the beginning of the dissection and to retract the transverse
colon during the mobilization of the splenic flexure.

Operative Technique
Exposure
To complete exposure of the operative field, active
positioning of the bowel is usually necessary in addition to
the passive action of gravity, especially in the presence of
obesity or bowel dilatation. The greater omentum and the
transverse colon are placed in the left subphrenic region and
maintained in this position by the Trendelenburg tilt. An
atraumatic retractor, introduced through the cannula on the Fig. 16: Securing the uterus by suture for proper exposure of rectum.
left side, may also be used. Subsequently, the proximal small
bowel loops are placed in the right upper quadrant using retractor passed through the suprapubic cannula. Very often,
gentle grasping (Figs. 15A and B). conversion to open surgery is caused by difficulty in exposure,
The distal small bowel loops are placed in the right lower not only at the beginning but also throughout the procedure.
quadrant with the cecum and maintained there with gravity. To perform a medial approach, time is dedicated to the
If gravity is not sufficient, as occurs mainly in the presence of perfect achievement of this exposure, which will serve not
abundant intra-abdominal fat or dilated bowel, an additional only for the initial vascular approach, but also for about half
maneuver is used. An instrument passed through the right of the remaining operative time. After adequate exposure has
subcostal cannula is passed at the root of the mesentery and been achieved, the following steps of the technique include
grasps the parietal peritoneum of the right iliac fossa; the the vascular approach, the medial posterior mobilization
shaft of the grasper thus provides an autostatic retraction of the sigmoid, the extraction of the specimen, and the
of the bowel loops, keeping them away from the midline anastomosis. Additional steps include the mobilization of
and the pelvic space. This technique of exposure offers an the splenic flexure, performed when further lengthening of
excellent view of the sacral promontory and the aortoiliac the bowel is needed to perform a tension-free anastomosis.
axis. This particular view on the operative field is essential This step of the exposure is preliminary, and it is done
for the medial-to-lateral vascular approach. in a similar manner, regardless of the type of disease. The
The uterus may be an obstacle to adequate exposure in remainder of the procedure is different if the indication for
the pelvis. In postmenopausal women, the uterus can be surgery is cancer or benign disease.
suspended to the abdominal wall by a suture (Fig. 16). This
suture is introduced halfway between the umbilicus and the Sigmoid Colon Resection for Cancer
pubis and opens the rectovaginal space. In younger women, In laparoscopic colorectal sigmoidectomy for cancer
the uterus can be retracted using a similar suspension or for benign disease, the vascular approach is the first
by a suture around the round ligaments or using a 5-mm step of the dissection. It is believed that it allows us
 CHAPTER 26: Laparoscopic Colorectal Surgery 351

to avoid unnecessary manipulation of the colon and Primary Vascular Approach (Medial Approach)
tumor, which may cause tumor cell exfoliation, and to
perform a good lymphadenectomy following the vascular
Peritoneal Incision
anatomy. The vessels are gradually exposed once the The sigmoid mesocolon is retracted anteriorly, using a
peritoneum at the base of the sigmoid mesocolon is incised grasper introduced through the suprapubic cannula:
(Figs. 17A and B). The medial-to-lateral view allows us This exposes the base of the sigmoid mesocolon. The visceral
to see the sympathetic nerve plexus trunks, the left ureter, peritoneum is incised at the level of the sacral promontory
and gonadal vessels, avoiding ureteral injuries and possibly (Figs. 18A to D). The incision is continued upward along
preserving genital function. the right anterior border of the aorta up to the ligament of

A B
Figs. 17A and B: Vascular supply of left side of colon.
(SRA: superior rectal artery; LCA: left colic artery; IMA: inferior mesenteric artery)

A B

C D
Figs. 18A to D: Incision of peritoneum over sacral promontory.
352 SECTION 2: Laparoscopic General Surgical Procedures

Treitz. The pressure of the pneumoperitoneum facilitates the junction (Fig. 21). The vein is divided below the inferior
dissection, as the diffusion of CO2 opens the avascular planes. border of the pancreas or above the left colic vein. Once
again, clips are sure options to ligate and divide this vessel
Identification of the Inferior (Figs. 22A to D).
Mesenteric Artery
The dissection of the cellular adipose tissue is continued Mobilization of the Sigmoid and
upward by gradually dividing the sigmoid branches of Descending Colon
the right sympathetic trunk. The dissection behind the The mobilization of the sigmoid colon follows the division
inferior mesenteric artery (IMA) involves preservation of of the vessels. This step includes the freeing of posterior and
the main hypogastric nerve trunks but also division of the lateral attachments of the sigmoid colon and mesocolon
small branches traveling to the colon to expose the origin and the division of the rectal and sigmoid mesenteries. The
of the IMA (Figs. 19A and B). To ensure an adequate approach is either medial or lateral. It is wise to routinely
lymphadenectomy, the first 2 cm of the IMA are dissected perform this medial-to-lateral laparoscopic dissection
free, and the artery is skeletonized before it is divided. for all indications. The medial approach is well adapted
This dissection at the origin of the IMA involves a risk of for laparoscopy because it preserves the working space
injury to the left sympathetic trunk situated on the left border and demands the least handling of the sigmoid colon.
of the inferior mesenteric artery. A meticulous dissection of In a randomized trial comparing the medial-to-lateral
the artery (skeletonization) helps to avoid this risk, because laparoscopic dissection with the classical lateral-to-medial
only the vessel will be divided, and not the surrounding approach for resection of rectosigmoid cancer, Liang et al.
tissues. Dissection performed close to the artery also showed that the medial approach reduces operative time and
minimizes the risk of ureteral injury during the ligation of the postoperative proinflammatory response. Besides the
the inferior mesenteric artery. The IMA can then be divided potential oncologic advantages of early vessel division and
between clips, or by using a linear stapler (vascular 2.5 or “no-touch” dissection, it is believed that he longer the lateral
2.0-mm cartridges. The artery is divided at 1–2 cm distal to abdominal wall attachments of the colon are preserved, the
its origin from the aorta ideally after the take-off of the left easier are the exposure and dissection.
colic artery (Figs. 20A to H).
Posterior Detachment
Identification of the Inferior Mesenteric Vein The sigmoid mesocolon is retracted anteriorly using the
The inferior mesenteric vein (IMV) terminates when suprapubic cannula to expose the posterior space. The plane
reaching the splenic vein, which goes on to form the portal between Toldt's fascia and the sigmoid mesocolon can then
vein with the SMV. Anatomical variations include the IMV be identified. This plane is avascular and easily divided.
draining into the confluence of the SMV and splenic vein The dissection continues posteriorly to the sigmoid
and the IMV draining in the SMV. mesocolon going laterally toward Toldt's line. The sigmoid
The IMV is identified to the left of the IMA or in case colon is then completely free, and the lateral attachments
of difficulty, higher, just to the left of the ligament of Treitz can then be divided using a lateral approach.

A B
Figs. 19A and B: Arterial supply of sigmoid colon.
 CHAPTER 26: Laparoscopic Colorectal Surgery 353

A B

C D

E F

G H
Figs. 20A to H: Dissection of inferior mesenteric artery

Lateral Mobilization
The extent of the dissection is superiorly formed by the
inferior border of the pancreas, laterally following Gerota's
fascia and inferiorly the psoas muscle where the ureter
crosses the iliac vessels. The sigmoid loop is pulled toward
the right upper quadrant (grasper in right subcostal cannula)
to exert traction on the line of Toldt (Fig. 23). The peritoneal
fold is opened cephalad and caudad, and the dissection joins
the one previously performed medially. During this step, care
must be taken to avoid the gonadal vessels and the left ureter
because they can be attracted by the traction exerted on the Fig. 21: Venous supply of sigmoid colon.
354 SECTION 2: Laparoscopic General Surgical Procedures

A B

C D
Figs. 22A to D: Dissection of inferior mesenteric vein.

mesentery. Ureteral stenting (infrared stents) can be useful

in cases in which inflammation, tumoral tissue, or adhesions
and endometriosis make planes difficult to recognize.

Dissection of the Upper Mesorectum

This area of dissection should be approached with
caution, especially on the left side: The mesorectum
there is closely attached to the parietal fascia where
the superior hypogastric nerve and the left ureter are
situated. The upper portion of the rectum is mobilized
posteriorly following the avascular plane described before,
then laterally, until a sufficient distal margin is achieved
(Figs. 24A to D).

Resection of the Specimen

Division of the Rectum Fig. 23: Lateral approach.

Once the upper rectum is freed, the area of distal resection

is chosen, allowing a distal margin of at least 5 cm. The fat useful, although they are usually unnecessary at the level of
surrounding this area is cleared, using monopolar cautery, the upper rectum (Figs. 26A and B).
ultrasonic dissection, or the LigaSuretm device. Doing so, the
superior hemorrhoidal arteries are divided in the posterior Proximal Division
upper mesorectum. The distal division is performed using a The proximal division site should be located at least 10 cm
linear stapler. proximal to the tumor. It is performed by first dividing the
The stapler is introduced through the right lower mesocolon and, subsequently, the bowel (Fig. 27).
quadrant cannula. It is wise to use stapler loads 3.5 mm, The division of the mesocolon is more easily performed
45 mm blue cartridges, which are applied perpendicular to with the harmonic scalpel, or the LigaSuretm, although linear
the bowel (Figs. 25A to F). Articulated staplers can also be staplers can also be used. The distal portion of the divided
 CHAPTER 26: Laparoscopic Colorectal Surgery 355

A B

C D
Figs. 24A to D: Dissection of upper mesorectum.

A B

C D

E F
Figs. 25A to F: Division of rectum using stapler.
356 SECTION 2: Laparoscopic General Surgical Procedures

B
Figs. 26A and B: Disposable circular staplers used
in colorectal surgery. Fig. 27: Division 10 cm proximal and 5 cm distal to tumor.

IMA is identified, and the division of the mesocolon starts introduced through this cannula. Retraction of the
right at this level and continues toward the chosen proximal descending colon and the splenic flexure toward the right
section site at a 90° angle. A linear stapler is then fired across lower quadrant using graspers introduced through the
the bowel. The stapler (blue load) is introduced through the right lower and suprapubic cannulae helps to expose the
right lower quadrant cannula. The specimen is placed in a correct plane (Figs. 28A and B). The attachments between
plastic retrieval sac introduced through the same cannula. the transverse colon and the omentum are divided close
This permits the continuation of the procedure without to the colon until the lesser sac is opened. The division of
manipulation of the bowel and tumor. If the resected these attachments is continued as needed to facilitate the
specimen is large and obscures the operative fields, the mobilization of the colon into the pelvis.
extraction can be done before completing the mobilization
of the left colon. Medial Mobilization
This approach dissects the posterior attachments of the
Mobilization of the Splenic Flexure transverse and descending colon first. The dissection plane
In the frequent event that a long segment of the sigmoid naturally follows the plane of the previous sigmoid colon
colon has been resected, mobilization of the splenic flexure mobilization, cephalad, and anterior to Toldt’s fascia. The
is required. This can be achieved in different ways. It is transverse colon is retracted anteriorly to expose the inferior
important for the surgeon to be familiar with all approaches border of the pancreas, and the root of the transverse
in order to select the most suitable approach. Sufficient mesocolon is divided anterior to the pancreas and at a
mobilization of the splenic flexure may be achieved by distance from it, to enter the lesser sac. The dissection
simply freeing the posterior and lateral attachments of the then follows toward the base of the descending colon and
descending colon. This is begun by a medial approach to distal transverse colon, dividing the posterior attachments
free the posterior attachments of the descending and distal of these structures. The division of the lateral attachments,
transverse colon, followed by the dissection of the lateral as described above, then follows the full mobilization of the
attachments, or by doing the same task in the reverse order. splenic flexure. If the mobilized colon reaches the pelvis
Lateral mobilization is sometimes sufficient in cases of easily, it may be safely assumed the anastomosis will be
sigmoid cancer, where the posterior mobilization can be tension free as well.
omitted.
Extraction of Colon
Lateral Mobilization of the Splenic Flexure The extraction of the specimen is performed using
This approach is often used in open surgery and can also double protection: A wound protector as well as a retrieval
be used in simple laparoscopic colectomies. The first step sac (Figs. 29 and 30). The wound protector is also helpful
is the section of the lateral attachments of the descending to ensure that there is no CO2 leak during the intracorporeal
colon. An ascending incision is made along the line of colorectal anastomosis, which follows the extraction. This
Toldt using scissors introduced via the left-sided cannula. allows a reduction of the size of the incision and potentially
The phrenicocolic ligament is then divided using scissors minimizes the risk of tumor cell seeding.
 CHAPTER 26: Laparoscopic Colorectal Surgery 357

A B
Figs. 28A and B: Mobilization of the splenic flexure of the colon.
(IMV: inferior mesenteric vein)

The Incision to Extract the Specimen

The size of the incision, its location, and the extraction
technique take into account the volume of the specimen,
the patient's body habitus, cosmetic concerns, and the
type of disease. The incision is generally performed in the
suprapubic region. The proximal division is performed
intracorporeally, as described above, and the specimen
placed into a thick plastic bag before being extracted through
the incision at the suprapubic area.

Anastomosis
For anastomosis, a mechanical circular stapling device
passed transanally to perform the anastomosis is used.
Performing the anastomosis includes an extra-abdominal
preparatory step, and an intra-abdominal step performed Fig. 29: Extraction of colon.
laparoscopically.
The extra-abdominal step takes place after the extraction colon and the mesentery should be checked. The stapler
of the specimen. The instrument holding the proximal bowel is then fired after ensuring that the neighboring organs are
presents it at the incision where it can easily be grasped with away from the stapling line. The stapler is then twisted open
a Babcock clamp and pulled out. If necessary, the colon and withdrawn. The anastomosis is checked for leaks by
is divided again in a healthy and well-vascularized zone verifying the integrity of the proximal and distal rings, as well
(Figs. 31A and B). as performing an air test (Figs. 35 and 36).
The anvil (at least 28 mm in diameter) is then introduced
into the bowel lumen and closed with a purse-string; Wound Closure
then, the colon is reintroduced into the abdominal cavity The cannula sites are checked internally for possible
(Fig. 32). The abdominal incision is closed to re-establish the hemorrhage. To do so, a grasper is passed through the
pneumoperitoneum. For an air-tight closure, it is sufficient cannula, and the cannula is removed, leaving the grasper in
to twist the wound protector at the level of the incision the abdomen. Because of the smaller diameter of the grasper
using a large clamp (Figs. 33A and B). The circular stapler is compared with the cannula, if the bleeding was so far
introduced into the rectum through the gently dilated anus. concealed by the tamponade effect of the cannula, it would
The rectal stump is then transfixed with the tip of the head be revealed promptly. The cannula is then reintroduced
of the circular stapler. In women, the posterior vaginal wall to allow maintenance of the pneumoperitoneum while
should be retracted anteriorly by the assistant passing the performing the same check at all cannula sites.
stapler (Fig. 34). Once the center rod and anvil are clicked When the check is completed, the CO2 is desufflated
into the distal part of the circular stapler, twisting of the through the cannulae, and cannulae are removed. No routine
358 SECTION 2: Laparoscopic General Surgical Procedures

A B
Figs. 30A and B: Extraction of specimen through wound protector.

A B
Figs. 31A and B: Preparation of the proximal loop of the colon for anastomosis.

drainage of the anastomotic area is performed. The suprapubic

incision is closed in layers using running absorbable sutures,
and all fascial defects of 10 mm and more are closed. The skin
is closed with a subcuticular absorbable suture.

Sigmoidectomy for Diverticular Disease

The outcomes after laparoscopic sigmoidectomy for
diverticulitis are similar or even better to those seen in
the open method, with faster recovery and decreased
postoperative pain. Hand-assisted laparoscopic sigmoid
resection for diverticulitis is also an attractive alternative to a
“pure” laparoscopic method in complicated cases.
The vascular approach for patients with benign diseases
Fig. 32: Fixing the anvil on the proximal loop of colon.
of the sigmoid colon is performed with the following steps.

Peritoneal Incision in this approach. The branches of the sigmoid arterial trunk
can be divided separately anteriorly to inferior mesenteric
The peritoneal incision can be similar to the cancer
technique, particularly in difficult cases (obesity, vessels or together after creating windows in the mesentery
inflammatory mesocolon). In most cases, the surgeon to divide the various branches. A linear stapler or, better, the
should try to preserve the vascularization of the rectum and LigaSuretm Atlas 10-mm device can be used for this task.
the left colic vessels. The opening of the peritoneum can
be limited to the mesosigmoid parallel to the colon at mid- Resection of the Specimen
distance between the colon and the root of the mesosigmoid. In diverticular disease, one should perform the distal
An initial lateral mobilization of the sigmoid can be useful resection of the bowel below the rectosigmoid junction.
 CHAPTER 26: Laparoscopic Colorectal Surgery 359

A B
Figs. 33A and B: Clamping and twisting of wound protector to prevent gas leak.

Fig. 34: Anvil and stapler ready for anastomosis. Fig. 35: End-to-end anastomosis done with the help of circular stapler.

The rectosigmoid junction is located just above the anatomy of the region and render the identification of the
peritoneal reflection at the pouch of Douglas (Fig. 37). It is ureter troublesome. In these special cases, prevention of
preferred to perform the mobilization of the splenic flexure ureteral injury may be facilitated by the use of infrared wires
at this moment, before resection at the proximal limit, using inserted in ureteral stents. The infrared light is cold and safe
the same principles as described above. for use in close contact with the ureteral tissue, and, on the
other side, makes it easy to recognize the structure under the
Extraction of the Specimen light of an adequate laparoscope.
Before extracting the colon, it is important to divide the
mesocolon at the level of the proximal side of the division. LOW ANTERIOR RESECTION
After adequate mobilization is achieved, the colon is Two surgical procedures with curative intent are available to
extracted through a suprapubic incision, protected by patients with rectal cancer:
the plastic drape described above, and proximal division 1. Lower anterior resection
performed externally on a compliant and well-vascularized 2. Abdominoperineal resection
part of the colon. The anastomosis is performed as described Lower anterior resection may improve quality of life and
above for cancer. functional status. Lower anterior resection, formally known
as anterior resection of the rectum and anterior excision of
Special Considerations the rectum or simply anterior resection, is a common surgery
Ureteral injuries are one of the most important for rectal cancer. It is commonly abbreviated as LAR. LAR is
complications, which can be avoided by a perfect exposure generally the preferred treatment for rectal cancer insofar as
and the respect of the correct plane of dissection. Indeed, a this is surgically feasible. Laparoscopic low anterior resection
dissection properly performed above the Toldt's fascia does for rectal cancer has gained full acceptance among general
not expose the ureter to accidental injury. Difficult cases, surgeons. Hand-assisted laparoscopic surgery (HALS) LAR
such as important inflammatory reaction, cancer invasion also has equal recognition, mainly due to the technical
or adhesions, and, sometimes, endometriosis, may alter the difficulties encountered during pelvic dissection.
360 SECTION 2: Laparoscopic General Surgical Procedures

A B

C D

E F

G H

I J

K L
Figs. 36A to L: Anastomosis by the help of a circular stapler.
 CHAPTER 26: Laparoscopic Colorectal Surgery 361

Fig. 37: Before and after sigmoidectomy. Fig. 38: Patient position for low anterior resection.

Patient Positioning
The patient is placed supine on the operating table
(Fig. 38). After induction of general anesthesia and insertion
of an orogastric tube and Foley catheter, the legs are placed
in stirrups. The arms are tucked at the patient's side, and
the beanbag is aspirated. The abdomen is prepared with an
antiseptic solution and draped routinely.

Position of Surgical Team

The primary monitor is placed on the left side of the
patient at approximately the level of the hip. The operating
nurse is placed between the patient’s legs. There should
be sufficient space to allow the surgeon to move from
either side of the patient to between the patient’s legs,
if necessary. The primary operating surgeon stands on
the right side of the patient with the assistant standing
on the patient’s left and moving to the right side, caudad
to the surgeon, once ports have been inserted (Fig. 39). Fig. 39: Position of the surgical team for LAR.
A 30-degree telescope is used. (LAR: low anterior resection)

Port Position upper quadrant port is also inserted to aid splenic flexure
The primary optical port is introduced subumbilical using a mobilization. Again, all of these remaining ports are kept
modified Hasson approach. Having confirmed entry into the lateral to the epigastric vessels. This may be ensured by
peritoneal cavity, a purse-string suture is placed around the diligence to anatomic port site selection and using the
subumbilical fascial defect, the abdomen to be insufflated laparoscope to transilluminate the abdominal wall before
with CO2 to a pressure of 12 mm Hg. making the port-site incision to identify any obvious
The telescope is inserted into the abdomen and an initial superficial vessels.
diagnostic laparoscopy is performed, carefully evaluating The assistant now moves to the patient’s left side, standing
the liver, small bowel, and peritoneal surfaces. A 12-mm caudad to the surgeon. The patient is rotated with the left
port is inserted in the right lower quadrant approximately side up and right side down, to approximately 15–20° tilt, and
2–3 cm medial and superior to the anterior superior iliac often as far as the table can go. This helps to move the small
spine. It is carefully inserted lateral to the inferior epigastric bowel over to the right side of the abdomen. The patient is
vessels, paying attention to keep track of the port going as then placed in the Trendelenburg position. This again helps
perpendicular as possible through the abdominal wall. A gravitational migration of the small bowel away from the
5-mm port is then inserted in the right upper quadrant at operative field. The surgeon then inserts two atraumatic
least a hand’s breadth superior to the lower quadrant port. bowel clamps through the two right-sided abdominal ports.
A left lower quadrant 5-mm port is inserted. A 5-mm left The greater omentum is reflected over the transverse colon
362 SECTION 2: Laparoscopic General Surgical Procedures

so that it comes to lie on the stomach. If there is no space in the bowel off the anterior surface of the Gerota's fascia up
the upper part of the abdomen, one must confirm that the toward the splenic flexure. This makes the inferior vein quite
orogastric tube is adequately decompressing the stomach. obvious, and this vessel can also be divided just inferior to
The small bowel is moved to the patient’s right side, allowing the pancreas. This allows increased reach for a coloanal
visualization of the medial aspect of the rectosigmoid anastomosis with or without neorectal reservoir.
mesentery. This may necessitate the use of the assistant’s
5-mm atraumatic bowel clamp through the left lower Mobilization of the Lateral Attachments
quadrant to tent the sigmoid mesentery cephalad. of the Rectosigmoid and Descending Colon
The surgeon now grasps the rectosigmoid junction with his
Defining and Dividing the left-hand instrument and draws it to the patient's right side.
Inferior Mesenteric Pedicle This allows the lateral attachments of the sigmoid colon to
An atraumatic bowel clamp is placed on the rectosigmoid be seen and divided using electrosurgery or harmonic.
mesentery at the level of the sacral promontory, Bruising from the prior retroperitoneal mobilization of
approximately halfway between the bowel wall and the the colon can usually be seen in this area. Once this layer
promontory itself. This area is then stretched up toward the of peritoneum has been opened, one immediately enters
left lower quadrant port, stretching the inferior mesenteric into the space opened by the retroperitoneal dissection.
vessels away from the retroperitoneum. In most cases, this Dissection now continues up along the white line of Toldt,
demonstrates a groove between the right or medial side of toward the splenic flexure. As the dissection continues, the
the inferior mesenteric pedicle and the retroperitoneum. surgeon’s left-hand instrument needs to be gradually moved
Electrosurgery or harmonic is used to open the peritoneum up along the descending colon to keep the lateral attachments
along this line, opening the plane cranially up to the origin under tension. In this way, the lateral and any remaining
of the inferior mesenteric artery, and caudally up to the posterior attachments are freed, making the left colon and
sacral promontory. Blunt dissection is then used to lift sigmoid a midline structure. Elevating the descending
the vessels away from the retroperitoneum and presacral colon and drawing it medially is useful, as this keeps small
autonomic nerves. The ureter is then looked for under the bowel loops out of the way of the dissecting instrument
inferior mesenteric artery. If the ureter cannot be seen, and and facilitates the dissection. In some patients, particularly
the dissection is in the correct plane, the ureter should be very obese or otherwise large patients, it is difficult to reach
just deep to the parietal peritoneum, and just medial to the high enough through the right lower quadrant port. For this
gonadal vessels. Care must be taken not to dissect too deep reason, the surgeon’s right-hand instrument is moved to
and injure the iliac vessels. the left lower quadrant port site. This permits greater reach
If the ureter cannot be found, it has usually been elevated along the descending colon.
on the back of the inferior mesenteric pedicle, and one needs
to stay very close to the vessel not only to find the ureter but Mobilization of the Splenic Flexure
also to protect the autonomic nerves. If the ureter still cannot Complete lateral mobilization of the left colon up to the
be found, the dissection needs to come in a cranial direction, splenic flexure is performed as an initial step. The descending
which is usually into clean tissue allowing it to be found. If colon is pulled medially using an atraumatic bowel clamp in
this fails, a lateral approach can be performed. This usually the right lower quadrant port, and the scissors are placed in
gives a fresh perspective to the tissues, and the ureter can the left iliac fossa port. A 5-mm left upper quadrant port may
often be found quite easily. In very rare cases, the ureter still be necessary, particularly in those with a very high splenic
may not be found. The ureteric stent should be used, and flexure, or in very tall or obese individuals. The lateral
it helps in easy identification of ureter and prevents it from attachments of the left colon are divided, and the colon is
getting injured. It is good not to proceed if the ureter cannot dissected off the Gerota's fascia over the left kidney.
be defined. The dissection is continued up to the origin of Once the lateral attachments of the colon have been
the inferior mesenteric artery, which is carefully defined freed, it is necessary to move medially and enter the lesser
and divided using a high ligation, above the left colic artery. sac. Some surgeons prefer to perform this as an initial step
A clamp is placed on the origin of the vessel to control it if before lateral mobilization. To enter the lesser sac, the
clips or other energy sources do not adequately control the patient is tilted to a slight reverse Trendelenburg position. An
vessel. Endo Gia stapler can also be used for easy division of atraumatic bowel clamp is inserted through the right upper
the vessel. quadrant port. If the left upper quadrant port is available,
Having divided the vessels at the origin of the artery, this can also be used. The assistant holds up the greater
the plane between the descending colon mesentery and omentum, toward its left side, like a cape. The surgeon grasps
the retroperitoneum is developed laterally, out toward the the transverse colon toward the left side using a grasper in
lateral attachment of the colon, and superiorly, dissecting the right lower quadrant port to aid the identification of
 CHAPTER 26: Laparoscopic Colorectal Surgery 363

the avascular plane between the greater omentum and the

transverse mesocolon. Harmonic scalpel or monopolar
scissors can be used through the left lower quadrant port
to dissect this plane and enter the lesser sac. The surgeon
usually moves to stand between the patient’s legs for this
part of the procedure. This dissection is continued toward
the splenic flexure.
Following separation of the omentum off the left side of
the transverse colon, connection to the lateral dissection
allows the splenic flexure to be fully mobilized. The colon
at the flexure is retracted caudally and medially, and any
remaining restraining attachments are divided.
Fig. 40: Low anterior resection.
Rectal Mobilization
The patient is returned to the Trendelenburg position, and Division of Rectum
the small bowel is reflected cranially. Atraumatic bowel The lower rectum may be divided with a stapler either
clamps inserted through the left-sided ports are used to laparoscopically or by open surgery, depending on the ease of
elevate the rectosigmoid colon out of the pelvis and away access related to the size of the pelvis (Fig. 40). A rotaculator
from the retroperitoneum and sacral promontory, to enable laparoscopic stapler may be used to divide the muscle tube
entry into the presacral space. The posterior aspect of the of the rectum below the level of the mesorectum. The stapler
mesorectum can be identified and the mesorectal plane is inserted through the right lower quadrant incision, and
dissected with diathermy, preserving the hypogastric nerves two firings of the stapler are usually required to divide the
as they pass down into the pelvis, anterior to the sacrum. rectum. There is no residual mesorectum to divide at this
Dissection continues down the presacral space in this level. A digital examination is performed to confirm the
avascular plane toward the pelvic floor. location of the distal staple line. If there is any doubt about
Attention is now switched to the peritoneum on the the adequacy of the distal margin, a rigid proctoscopy is
right side of the rectum. This is divided into the level of the performed.
seminal vesicles or rectovaginal septum. This is repeated on It is sometimes impossible to divide the rectum
the peritoneum on the left side of the rectum. This facilitates laparoscopically as the angulation of the endovascular
further posterior dissection along the back of the mesorectum stapler is limited to 45°, necessitating the open division of
to the pelvic floor, to a level inferior to the lower edge of the the rectum. In some patients, getting an assistant to push
mesorectum, just posterior to the anal canal. For an LAR, it is up on the perineum with their hand may lift the pelvic floor
necessary to perform a total mesorectal excision and hence enough to get the first cartridge of the stapler low enough. In
the rectum must be dissected down to the muscle tube of some cases, placing a suprapubic port allows easier access
the rectum below the inferior extent of the mesorectum. with the stapler to allow the division of the rectum.
In many cases, particularly in those who are obese or men Some patients are either too obese or have a very narrow
with a narrow pelvis, some or all of the anterior and lateral pelvis or a long anal canal, and the stapler cannot be passed
dissection must be completed to get adequate visualization, low enough. Two options exist. One is to perform a transanal
to complete the posterior dissection. intersphincteric dissection, remove the specimen, and then
An atraumatic bowel clamp through the left iliac fossa perform a handsewn coloanal anastomosis. The second is to
port is used to retract the peritoneum anterior to the rectum perform a short Pfannenstiel incision, which allows a linear
forward. The peritoneal dissection is continued from the free 30-mm stapler to be positioned and the rectum divided.
edge of the lateral peritoneal dissection, anteriorly. Lateral
dissection is continued on both sides of the rectum and is Extraction and Anastomosis
extended anterior to the rectum, posterior to Denonvilliers’ The specimen can be extracted either through a Pfannenstiel
fascia, separating the posterior vaginal wall from the anterior incision or a left iliac fossa incision; in both incisions, a
wall of the rectum or down to the level of the prostate in men. wound protector is used in cases with a polyp or cancer to
The difficulty of dissection will vary depending on the body reduce the risk of tumor implantation in the wound. The left
habitus of the patient, the diameter of the pelvis, and the size colon mesentery is divided with cautery. The left colon is
of the tumor. Occasionally, rectal mobilization can be very divided, and the specimen is removed. Pulsatile mesenteric
difficult to perform laparoscopically. In some cases, it may bleeding is confirmed and the vessels ligated with 0
need to be completed in an open manner through a small polyglycolate suture ties. Depending on the preference of
Pfannenstiel incision. the operating surgeon, a colonic pouch or coloplasty may
364 SECTION 2: Laparoscopic General Surgical Procedures

Fig. 41: Anus, rectum, and sigmoid colon removed in APR.

(APR: abdominoperineal resection)

be performed. A 2/0 Prolene purse-string suture is inserted oncological safety is not only dependant on the abdominal
into the distal end of the left colon or pouch, the anvil of a procedure but also the adequacy of the perineal part of
circular stapling gun inserted, and the purse-string suture the operation. Besides, should tumor injury be detected
is tied tightly. If a Pfannenstiel incision has been made, the intraoperatively, it is advisable to convert to open surgery to
coloanal anastomosis can be performed under direct vision control the amount of contamination and complete the rest
and open manipulation following the insertion of a circular of the procedure.
stapling gun into the rectal stump. If a left iliac fossa incision
has been used, the colon is returned to the abdomen, and the Patient Position
incision closed, the pneumoperitoneum recreated, and the
The patient is placed supine on the operating table on a
anastomosis is formed laparoscopically. The anastomosis
beanbag. After induction of general anesthesia and insertion
can be leak-tested by filling the pelvis with saline and
of an orogastric tube and Foley catheter, the legs are placed
inflating the neorectum using a proctoscope or bulb syringe.
stirrups. The arms are tucked at the patient’s side. The abdomen
is prepared with an antiseptic solution and draped routinely.
ABDOMINOPERINEAL RESECTION
Laparoscopic abdominoperineal resection is an operation Position of Surgical Team
in which the anus, rectum, and sigmoid colon are removed
The primary monitor is placed on the left side of the patient
(Fig. 41). It is used to treat cancer located very low in the
up toward the patient’s feet. The secondary monitor is
rectum or in the anus, close to the sphincter muscles.
placed on the right side of the patient at the same level and
Laparoscopic surgery for anorectal carcinoma is steadily
is primarily for the assistant during the early phase of the
gaining acceptance. The advantage offered by laparoscopy
surgery and port insertion. The operating nurse’s instrument
has always centered on improved vision. This advantage
table is placed between the patient’s legs. There should be
seems to be put to best use in the case of rectal cancer
sufficient space to allow the surgeon to move from either
surgery, where logistic impediments, viz., narrow pelvis and
side of the patient to between the patient’s legs, if necessary.
impaired visibility as the dissection proceeds caudad, have
The primary operating surgeon stands on the right side of
proved to be obstacles to colorectal surgeons during open
the patient with the assistant standing on the patient’s left
surgery. Recent studies have shown that the size of the tumor
and moving to the right side, caudad to the surgeon, once
does not hamper the feasibility of performing laparoscopic
ports have been inserted.
abdominoperineal resection. We need to consider the
possibility of an increased circumferential margin rate for
large-size tumors. This may be addressed by preoperative Port Position
radiotherapy and chemotherapy before undertaking surgery This is performed using a Hasson approach. A 10-mm smiling
on these large tumors. It is important to note, though, that the subumbilical incision is made. This is deepened down to the
 CHAPTER 26: Laparoscopic Colorectal Surgery 365

linea alba, which is then grasped on each side of the midline Division of the Left Colon
using Kocher clamps. A scalpel (No. 15 blades) is used to open The mesentery of the left colon is divided from the free
the fascia between the Kocher clamps, and a Kelly forceps edge, cranial to the previously divided inferior mesenteric
is used to open the peritoneum bluntly. Having confirmed artery, toward the left sigmoid colon. The mesentery can
entry into the peritoneal cavity, a purse-string suture of 0 be divided with diathermy, and the marginal artery can be
polyglycolic acids is placed around the subumbilical fascial clipped and then divided. Alternatively, an energy source
defect. A 10-mm reusable port is inserted through this port such as a LigaSuretm may be used to divide the mesentery up
wound, allowing the abdomen to be insufflated with CO2 to to the edge of the bowel. This may be done before freeing the
a pressure of 12 mm Hg. The laparoscope is inserted into the lateral attachments of the sigmoid and left colon as it aids in
abdomen and an initial laparoscopy is performed, carefully retraction.
evaluating the liver, small bowel, and peritoneal surfaces. After the division of the mesentery, the lateral
A 12-mm port is inserted in the right lower quadrant attachments of the sigmoid to the abdominal wall are divided
approximately 2–3 cm medial and superior to the anterior along the white line. Care is taken to avoid damage to the
superior iliac spine. This is carefully inserted lateral to the retroperitoneal structures. The colon is then divided using
inferior epigastric vessels, paying attention to keep track a linear endoscopic stapler at the site where the colonic
of the port going as perpendicular as possible through the mesentery has been divided.
abdominal wall. A 5-mm port is then inserted in the right
upper quadrant at least a hand’s breadth superior to the Rectal Mobilization
lower quadrant port. A left lower quadrant 5-mm port is also In women, the uterus may be hitched out of the area of
inserted. dissection with a suture. Atraumatic bowel clamps that are
inserted through the left-sided ports are used to elevate
Exposure and Dissection of Retroperitoneum the rectosigmoid colon out of the pelvis and away from the
retroperitoneum and sacral promontory, to enable entry into
The assistant now moves to the patient’s left side, standing
the presacral space. The posterior aspect of the mesorectum
caudad to the surgeon. The patient is rotated with the left
can be identified and the mesorectal plane dissected with
side up and right side down, to approximately 15–20° tilt, and
diathermy, preserving the hypogastric nerves passing down
often as far as the table can go. This helps to move the small
into the pelvis anterior to the sacrum. Dissection continues
bowel over to the right side of the abdomen. The patient is
down the presacral space in this avascular plane toward the
then placed in the Trendelenburg position. This again helps
pelvic floor. Attention is now switched to the peritoneum on
gravitational migration of the small bowel away from the the right side of the rectum. This is divided to the level of the
operative field. The surgeon then inserts two atraumatic seminal vesicles or rectovaginal septum. This is repeated
bowel clamps through the two right-sided abdominal ports. on the peritoneum on the left side of the rectum. This
The greater omentum is reflected over the transverse colon facilitates further posterior dissection along the back of the
so that it comes to lie on the stomach. If there is no space in mesorectum to the pelvic floor, to a level inferior to the lower
the upper part of the abdomen, one must confirm that the edge of the mesorectum. Usually, when the approach is
orogastric tube is adequately decompressing the stomach. low on the posterior surface of the mesorectum, it becomes
The small bowel is moved to the patient’s right side, allowing necessary to perform a lateral and anterior dissection.
visualization of the medial aspect of the rectosigmoid A bowel grasper inserted through the left iliac fossa port
mesentery pedicle. This may necessitate the use of the is used to retract the peritoneum anterior to the rectum
assistant’s 5-mm atraumatic bowel clamp through the left forward. The peritoneal dissection is continued from the free
lower quadrant to tent the sigmoid mesentery cephalad. edge of the lateral peritoneal dissection, anteriorly. Lateral
Complete mobilization of the left colon is not required. dissection is continued on both sides of the rectum. It is
Adequate mobilization must allow the formation of a left extended anteriorly to the rectum in front of Denonvilliers’
iliac fossa colostomy without tension. Following the division fascia, separating the posterior vaginal wall from the anterior
of the inferior mesenteric artery, the left mesocolon is wall of the rectum or down past the level of the prostate in
separated from the retroperitoneum in a medial-to-lateral men. The most inferior rectal dissection can be completed
direction using a spreading movement. An atraumatic from the perineal approach. For anterior tumors, the
bowel clamp inserted through a right-sided port is placed dissection may be performed anterior to Denonvilliers’
under the left colonic mesentery, which is elevated away fascia, or by taking one side of the fascia to protect the
from the retroperitoneum, and using a scissors inserted anterolateral nerve bundle.
through the other right-sided port, the attachments to the It is necessary to perform a total mesorectal excision
retroperitoneum are swept down, until the lateral abdominal and hence the rectum must be dissected down close to the
wall is reached. muscle tube of the rectum below the level of the mesorectum.
366 SECTION 2: Laparoscopic General Surgical Procedures

The levators may then be divided from above, staying with 0 nylon, and an elliptical skin incision is made. The
well wide of any potential tumor, or the division may be incision is deepened using diathermy, and the ischiorectal
performed from below after making the perineal incision. fossae are entered on either side, well lateral to the external
sphincter muscle. The dissection continues laterally and
Formation of Trephine Left Iliac posteriorly to expose the levator ani muscles (Fig. 43). The
Fossa Colostomy tip of the coccyx is used as the posterior landmark, and the
pelvic cavity is entered by dividing the levator ani muscle just
The divided distal end of the left sigmoid colon is grasped
anterior to the tip of the coccyx. A finger can be placed into
with atraumatic bowel clamps, which are locked. A trephine
the pelvis onto the upper border of the levator ani, which is
colostomy is made in the left iliac fossa at a site that has
divided with diathermy onto the underlying finger. Care is
been marked by an enterostomal therapist before surgery.
taken anteriorly to divide the remaining levator ani while
A skin disk is excised, and a longitudinal incision is made in
protecting the posterior surface of the vagina or prostate/
the anterior rectus sheath, and the left rectus muscle is split.
urethra. The specimen may then be delivered out of the
The peritoneum is held with two hemostats and incised. The
pelvis, which facilitates the division of the remaining anterior
stapled colon is delivered to the trephine and grasped with
attachments of the rectum, reducing the risk of damage to
Babcock forceps and delivered through the trephine.
the prostate or posterior wall of the vagina. The specimen is
The staple line is excised, and the end colostomy is
removed, the pelvic cavity irrigated of blood or debris, and the
matured using 3/0 chromic catgut sutures.
perineal tissue closed in layers using polydioxanone sutures.

Perineal Dissection HARTMANN REVERSAL

The perineal dissection is performed with a conventional The Hartmann procedure is a standard life-saving operation
open approach (Figs. 42A and B). The anus is sutured closed for acute left colonic complications. It is usually performed

A B
Figs. 42A and B: Perineal dissection.

Fig. 43: Perineal anatomy.

 CHAPTER 26: Laparoscopic Colorectal Surgery 367

as a temporary procedure with the intent to reverse it later The bowel is trimmed as necessary, and a purse-string
on. This reversal is associated with considerable morbidity suture is positioned before insertion of the anvil of a curved
and mortality by the open method. The laparoscopic EEA stapling device. The bowel is returned to the abdomen,
reestablishment of intestinal continuity after Hartmann the fascia is closed with a monofilament suture, but before
procedure has shown better results in terms of a decrease in tying the suture a 12-mm port is inserted at this site, and the
morbidity and mortality. abdomen is insufflated.
There are several laparoscopic techniques of the reversal The laparoscope is inserted into the abdomen through the
of the Hartmann procedure. The principle common to stoma port to assess adhesions and allow direct visualization
all techniques is a tension-free intracorporeal stapler for subsequent port insertion, and an initial laparoscopy
anastomosis. The introduction of a circular stapler in the is performed, carefully evaluating the liver, small bowel,
rectal stump helps in the identification and mobilization of and peritoneal surfaces. A 10-mm port is inserted in the
the rectal stump. Others have mobilized the colostomy first umbilicus for camera location. A 5-mm right lower quadrant
and have used the colostomy site as a first port or used a trocar is placed approximately 2–3 cm medial to the anterior
standard umbilical port. superior iliac spine. This is carefully inserted lateral to the
It is technically challenging and requires an experienced inferior epigastric vessels, paying attention to keep track
laparoscopic surgeon but offers clear advantages to patients. of the port going as perpendicular as possible through the
Main reasons reported for conversion to open were dense abdominal wall. A 5-mm port is then inserted in the right
abdominal–pelvic adhesions secondary to diffuse peritonitis upper quadrant at least a hand’s breadth superior to the
at the primary operation, the short delay before the lower quadrant port. A left upper quadrant 5-mm port is
reconstruction, difficulty in finding the rectal stump, and inserted. Again all of these remaining ports are kept lateral
rectal scarring. Leaving long, nonabsorbable suture ends to the epigastric vessels. This may be ensured by diligence
at the rectal stump or suturing it to the anterior abdominal to anatomic port site selection and using the laparoscope to
wall helps in its localization. Other relative limitation transilluminate the abdominal wall before making the port-
factors could be a large incisional hernia from the previous site incision to identify any obvious superficial vessels.
laparotomy and contraindications to general anesthesia and The assistant now moves to the patient’s right side,
laparoscopy. standing caudad to the surgeon. The patient is rotated with
the left side up and right side down, to approximately 15–20°
Patient Position degrees tilt, and often as far as the table can go. This helps to
The patient is placed supine on the operating table, on a move the small bowel over to the right side of the abdomen.
beanbag. After induction of general anesthesia and insertion The patient is then placed in the Trendelenburg position.
of an orogastric tube and Foley catheter, the legs are placed This again helps gravitational migration of the small bowel
in a lithotomy stirrup position. The arms are tucked at the away from the operative field. The surgeon then inserts
patient’s side, and the beanbag is aspirated. two atraumatic bowel clamps through the two right-sided
The abdomen is prepared with an antiseptic solution and abdominal ports. The greater omentum is reflected over the
draped routinely. transverse colon so that it comes to lie on the stomach. If
there is no space in the upper part of the abdomen, one must
Position of Surgical Team confirm that the orogastric tube is adequately decompressing
the stomach. The small bowel is moved to the patient’s
The primary monitor is placed on the left side of the patient
right side, allowing visualization of the proximal rectum.
at approximately the level of the hip. The secondary monitor
Variable degrees of adhesiolysis may be required. This may
is placed on the right side of the patient at the same level and
necessitate the use of the assistant’s 5-mm atraumatic bowel
is primarily for the assistant during the early phase of the
clamp through the stoma trocar or left upper quadrant.
surgery and port insertion. The operating nurse’s instrument
table is placed between the patient’s legs. There should be
sufficient space to allow the surgeon to move from either Left Colon Mobilization
side of the patient to between the patient’s legs, if necessary. An atraumatic bowel clamp is placed on the descending colon
The primary operating surgeon stands on the right side of to take down the inflammatory and native attachments to
the patient with the assistant standing on the patient’s left free it laterally. The omentum is dissected off the transverse
and moving to the right side, caudad to the surgeon once colon, and the lesser sac is entered. The splenic flexure
ports have been inserted. A 30-degree camera lens is better is released to allow a tension-free reach to the proximal
to be used. rectum. The colonic mesentery should be mobilized off the
The colostomy is mobilized and all adhesions dissected Gerota's fascia. The left ureter is identified at the pelvic brim
through the fascial opening until an adequate segment and freed from the proximal rectum to avoid injury. The
of bowel has been freed from the surrounding tissues. ureter should be just deep to the parietal peritoneum, and
368 SECTION 2: Laparoscopic General Surgical Procedures

just medial and posterior to the gonadal vessels. Care must prolapse. Rectopexy with or without bowel resection is the
be taken not to dissect too deep or caudad, leading to injury most frequent surgical procedure, with 0–9% recurrence
of the iliac vessels. rates in many years. Laparoscopic resection rectopexy is
safely feasible as a minimally invasive treatment option for
Mobilization of Rectum rectal prolapse.
An atraumatic bowel clamp inserted through the left lower
quadrant port is used to elevate the proximal rectum out of Patient Position
the pelvis and away from the retroperitoneum and sacral The patient is placed supine on the operating table, on a
promontory, to enable entry into the presacral space. The beanbag. After induction of general anesthesia and insertion
posterior aspect of the mesorectum can be identified and the of an orogastric tube and Foley catheter, the legs are placed
mesorectal plane dissected with diathermy, preserving the in Dan Allen stirrups. The arms are tucked at the patient’s
hypogastric nerves as they pass down into the pelvis anterior side. The abdomen is prepared with an antiseptic solution
to the sacrum. Dissection needs to progress only to allow the and draped routinely.
advancement of the circular stapler to the end of the rectum
and assure that all the sigmoid has been resected. If residual Position of Surgical Team
sigmoid is present, the linear endoscopic stapler should be
The primary monitor is placed on the left side of the patient
used to divide the bowel at the level of the proximal rectum.
at approximately the level of the hip. The secondary monitor
A site for rectal division should be chosen in proximal,
is placed on the right side of the patient at the same level and
peritonealized rectum, which assures that the anastomosis
is primarily for the assistant during the early phase of the
will be distal to the sacral promontory. The rectum is divided
surgery and port insertion. The operating nurse’s instrument
laparoscopically with a linear endoscopic stapler through the
table is placed between the patient’s legs. There should be
right lower quadrant trocar. One or two firings of the stapler
sufficient space to allow the surgeon to move from either
may be required to divide the rectum. The mesorectum is
side of the patient to between the patient’s legs, if necessary.
divided using monopolar and bipolar cautery at this level.
The primary operating surgeon stands on the right side of
the patient with the assistant standing on the patient’s left
Specimen Extraction and Anastomosis and moving to the right side, caudad to the surgeon once
If residual sigmoid is required, the specimen is extracted ports have been inserted. A 0-degree camera lens is used.
through the stoma site port. Pneumoperitoneum is recreated,
and the circular stapled anastomosis is formed under Port Position
laparoscopic guidance. The anastomosis can be leak-tested
This is performed using a Hasson approach. A smiling
by filling the pelvis with saline and inflating the neorectum
10-mm subumbilical incision is made. This is deepened
using a proctoscope or bulb syringe, and the orientation
down to the linea alba, which is then grasped on each side of
and lack of tension confirmed. The fascia of all the 10 mm
the midline using Kocher clamps. A scalpel (No. 15 blades)
or above port is closed, and the usual manner is followed for
is used to open the fascia between the Kocher clamps, and
skin dressing.
a Kelly forceps is used to open the peritoneum bluntly.
The telescope is inserted into the abdomen, and an initial
Conclusion laparoscopy is performed, carefully evaluating the liver, small
The reversal of the Hartmann procedure can be difficult bowel, and peritoneal surfaces. A 12-mm port is inserted in
due tendency of the Hartmann segment to become densely the right lower quadrant approximately 2–3 cm medial and
adherent deep in the pelvis. The laparoscopic reversal has superior to the anterior superior iliac spine. This is carefully
made this major operation easier, safe, and practical. As a inserted lateral to the inferior epigastric vessels, paying
majority of these patients is in the elderly age group, it has attention to keep track of the port going as perpendicular as
the advantage of early mobilization, less pain, short hospital possible through the abdominal wall. A 5-mm port is then
stay, and returns to normal life. inserted in the right upper quadrant at least a hand’s breadth
superior to the lower quadrant port. A left lower quadrant
RESECTION RECTOPEXY 5-mm port is inserted. All the ports are more or less obeying
the baseball diamond concept.
Total rectal prolapse with chronic constipation and anal
incontinence is a devastating disorder. It is more common
in the elderly, especially women, although why it happens Dissection
is unclear. Rectal prolapse can cause complications (such The patient is rotated with the left side up and right side
as pain, ulcers, and bleeding), and cause fecal incontinence down, to approximately 15–20° tilt, and often as far as the
(Figs. 44A to C). Surgery is commonly used to repair the table can go. This helps to move the small bowel over to
 CHAPTER 26: Laparoscopic Colorectal Surgery 369

B C
Figs. 44A to C: Rectal prolapse

the right side of the abdomen. The patient is then placed in peritoneum along this line, opening the plane cranially up
the Trendelenburg position. This again helps gravitational to the origin of the inferior mesenteric artery, and caudally
migration of the small bowel away from the operative field. The past the sacral promontory. Blunt dissection is then used to
surgeon then inserts two atraumatic bowel clamps through lift the vessels away from the retroperitoneum and presacral
the two right-sided abdominal ports. The greater omentum autonomic nerves. The ureter is then looked for under the
is reflected over the transverse colon so that it comes to lie inferior mesenteric artery. If the ureter cannot be seen, and
on the stomach. If there is no space in the upper part of the dissection is in the correct plane, the ureter should be
the abdomen, one must confirm that the orogastric tube is just deep to the parietal peritoneum, and just medial to the
adequately decompressing the stomach. The small bowel is gonadal vessels. Care must be taken not to dissect too deep
moved to the patient’s right side, allowing visualization of or caudad, leading to injury of the iliac vessels.
the medial aspect of the rectosigmoid mesentery. This may If the ureter cannot be found, it has usually been elevated
necessitate the use of the assistant’s 5-mm atraumatic bowel on the back of the inferior mesenteric pedicle, and one needs
clamp through the left lower quadrant to tent the sigmoid to stay very close to the vessel not only to find the ureter
mesentery cephalad. but also to protect the autonomic nerves. If the ureter still
cannot be found, the dissection needs to come in as a cranial
Division of Inferior Mesenteric Vessel dissection, which is usually into clean tissue allowing it to be
An atraumatic bowel clamp is placed on the rectosigmoid found. If this fails, a lateral approach can be performed. This
mesentery at the level of the sacral promontory, approximately usually gives a fresh perspective to the tissues, and the ureter
halfway between the bowel wall and the promontory itself. can often be found quite easily. In very rare cases, the ureter
This area is then stretched up toward the left lower quadrant still may not be found.
port, stretching the inferior mesenteric vessels away from the The dissection should allow sufficient mobilization of
retroperitoneum. In most cases, this demonstrates a groove the IMA so that the origin of the left colic artery is seen. The
between the right or medial side of the inferior mesenteric vessel is carefully defined and divided just distal to the left
pedicle and the retroperitoneum. Cautery is used to open the colic artery. A clamp is placed on the origin of the vessel to
370 SECTION 2: Laparoscopic General Surgical Procedures

control it if clips or other energy sources do not adequately

control the vessel. In general, a cartridge of the endoscopic
linear stapler is used to divide the vessel. Having divided the
pedicle, the plane between the sigmoid colon mesentery and
the retroperitoneum is developed laterally, out toward the
lateral attachment of the colon. Limited mobilization of the
mesentery of the anterior surface of Gerota’s fascia and of
the left colon should be performed to enhance the fixation
of the rectum.

Mobilization of the Lateral Attachments

of the Rectosigmoid
A B
The surgeon now grasps the rectosigmoid junction with his
left-hand instrument and draws it to the patient’s right side. Figs. 45A and B: Resection rectopexy.
This allows the lateral attachments of the sigmoid colon to the rectum. The mesorectum is divided using monopolar
be seen and divided using cautery. Bruising from the prior and bipolar cautery at this level.
retroperitoneal mobilization of the colon can usually be
seen in this area. Once this layer of peritoneum has been Specimen Extraction and Anastomosis
opened, one immediately enters into the space opened
The specimen is extracted through a left iliac fossa incision.
by the retroperitoneal dissection. No dissection should be
Before making the incision, the proximal colonic transaction
performed more proximally along the white line of Toldt,
point should be grasped with a locking atraumatic bowel
toward the splenic flexure.
grasper. This site should allow a colorectal anastomosis
that will provide a safe amount of tension on the rectum to
Mobilization of Rectum maintain prolapse reduction. After extracorporeal bowel
An atraumatic bowel clamp inserted through the left lower transaction, adequate vascularity of the colon should be
quadrant port is used to elevate the rectosigmoid colon out assured. A 2/0 Prolene purse-string suture is inserted into
of the pelvis and away from the retroperitoneum and sacral the distal end of the left colon; the anvil of a circular stapling
promontory, to enable entry into the presacral space. The gun is inserted, and the purse-string suture is tied tightly.
posterior aspect of the mesorectum can be identified, and the The colon is returned to the abdomen, and the left iliac fossa
mesorectal plane dissected with diathermy, preserving the incision is closed in layers with 0 polyglycolic acid suture.
hypogastric nerves as they pass down into the pelvis anterior Pneumoperitoneum is recreated, and the circular stapled
to the sacrum. Dissection continues down the presacral anastomosis is formed under laparoscopic guidance. The
space in this avascular plane toward the pelvic floor. Only the anastomosis can be leak-tested by filling the pelvis with
posterior 60% of the rectum needs to be mobilized; however, saline and inflating the neorectum using a proctoscope or
dissection should be continued all the way to the levator ani bulb syringe.
muscles. A transanal examining finger should be used to
confirm the distal extent of the dissection. The lateral stalks Rectopexy (Figs. 45A and B)
should be preserved. The peritoneum on either side of the The rectum is retracted rostrally to the desired tension to
rectum should be incised to the level of the lateral stalks. The allow complete reduction of the prolapse. The rectopexy is
lateral stalks should generally be preserved, the exception then performed from the right side using the two remaining
being when further dissection must completely reduce a ports. Two or three nonabsorbable sutures are used to attach
very distal prolapsing segment. the mesorectum distal to the anastomosis to the sacral
promontory. Alternatively, nitinol or titanium tackers may
Rectal Division be employed using one of the mechanical fixation devices
The fully mobilized rectum should be elevated out of the pelvis used for mesh hernia repairs.
and a site selected for optimal rectal tension to maintain a
full reduction of the prolapse. A site for rectal division should WELLS OR MARLEX RECTOPEXY
be chosen in proximal, peritonealized rectum, which assures Rectal prolapse is a distressing condition, especially when
that the anastomosis will be rostral to the sacral promontory. associated with fecal incontinence and constipation. It usually
The rectum is divided laparoscopically with a linear occurs in children or the elderly. Presently laparoscopic
endoscopic stapler through the right lower quadrant trocar. approach is favored as it has better results, especially in
One or two firings of the stapler may be required to divide terms of less postoperative pain, shorter hospital stay, and
 CHAPTER 26: Laparoscopic Colorectal Surgery 371

lower cost. The pelvic sympathetic and parasympathetic This suggests an alternate mechanism of improvement in
nerves run along with the rectum; if dissection is not carried patients with rectal intussusception.
out in the proper plane, injury can occur, leading to bladder
dysfunction, impotence, and retrograde ejaculation. This Mobilization of the Lateral Attachments
is an important consideration when trying to decide which of the Rectosigmoid
procedure to perform, especially in men, although the risk For rectal prolapse surgery lateral mobilization, the
of injury should be <1–2%. Perineal procedures and anterior surgeon grasps the rectosigmoid junction with his left-
resection have a low risk of outlet obstruction. Abdominal hand instrument and draws it to the patient's right side.
procedures of rectopexy that tack the rectum to the sacrum This allows the lateral attachments of the sigmoid colon to
can cause outlet obstruction if the rectum is wrapped be seen and divided using cautery. Bruising from the prior
circumferentially, often requiring the release of the fixation retroperitoneal mobilization of the colon can usually be
to treat the problem. seen in this area. Once this layer of peritoneum has been
In a Marlex rectopexy (Ripstein procedure), the entire opened, one immediately enters into the space opened
rectum is mobilized down to the coccyx posteriorly, the by the retroperitoneal dissection. No dissection should be
lateral ligaments laterally, and the anterior cul-de-sac performed more proximally along the white line of Toldt,
anteriorly. A nonabsorbable material, such as Marlex mesh toward the splenic flexure.
or an Ivalon sponge, is then fixed to the presacral fascia. The
rectum is then placed on tension, and the material is partially Rectal Mobilization
wrapped around the rectum to keep it in position. The
An atraumatic bowel clamp inserted through the left lower
anterior wall of the rectum is not covered with the sponge or
quadrant port is used to elevate the rectosigmoid colon out
mesh in order to prevent a circumferential obstruction. The
of the pelvis and away from the retroperitoneum and sacral
peritoneal reflections are then closed to cover the foreign
promontory, to enable entry into the presacral space. The
body. The Marlex mesh or sponge causes an inflammatory
posterior aspect of the mesorectum can be identified, and the
reaction that scars and fixes the rectum into place.
mesorectal plane dissected with diathermy, preserving the
The Wells procedure was followed by rectal dysfunction
hypogastric nerves as they pass down into the pelvis anterior
accompanied by increased constipation and evacuation
to the sacrum. Dissection continues down the presacral
problems. The Ripstein procedure, preserving the lateral
space in this avascular plane toward the pelvic floor. Only the
ligaments, appears not to affect such symptoms adversely.
Modified mesh rectopexy aligns the rectum, avoids posterior 60% of the rectum needs to be mobilized; however,
excessive mobilization and division of lateral ligaments, dissection should be continued all the way to the levator ani
thus preventing constipation and preserving potency. We muscles. A transanal examining finger should be used to
recommend this technique for patients with complete rectal confirm the distal extent of the dissection. The peritoneum
prolapse with up to grades 1, 2, and 3 incontinence based on on either side of the rectum should be incised to the level
Browning and Parks classification. of the lateral stalks. The lateral stalks should generally be
During wells rectopexy, the dissection should allow preserved, the exception being when further dissection must
sufficient mobilization of the IMA so that the origin of the completely reduce a very distal prolapsing segment. The
left colic artery is seen. The pedicle is not divided. rectum is not divided in the case of Wells rectopexy.
The plane between the sigmoid colon mesentery and
the retroperitoneum is developed laterally, out toward the Rectopexy
lateral attachment of the colon. Limited mobilization of the A 2–4 cm portion of polypropylene mesh is rolled and inserted
mesentery of the anterior surface of Gerota's fascia and of through the umbilical trocar. The camera is reinserted,
the left colon should be performed to enhance the fixation and the mesh is positioned at the sacral promontory. A
of the rectum. mechanical device used for hernia mesh fixation is used to fix
Ripstein operation often improved anal continence in the mesh to the promontory. This may be inserted through
patients with rectal prolapse and rectal intussusception. This the right lower quadrant port, but if adequate access cannot
improvement was accompanied by increased maximum be obtained, a 5-mm suprapubic port may be inserted. Great
resting pressure (MRP) in patients with rectal prolapse, care must be taken not to tear or strip off the presacral fascia
indicating recovery of internal anal sphincter function. In when stapling the mesh in place.
one of the studies at the Department of Surgery, Karolinska The rectum is retracted rostrally to the desired tension
Institute at Danderyd Hospital, Stockholm, Sweden, to allow complete reduction of the prolapse, which is
MRP (52+/– 23 mm Hg) was found in patients with rectal confirmed by digital rectal examination. The rectopexy is
prolapse who underwent Ripstein operation than in patients then performed from the right side using the two right-sided
with rectal intussusception. No postoperative increase trocars. Two or three nonabsorbable sutures are used to
in MRP was found in patients with rectal intussusception. attach the distal mesorectum to the mesh at the promontory,
372 SECTION 2: Laparoscopic General Surgical Procedures

sufficient to maintain adequate tension. Alternatively, the When suspected, the wound should be carefully inspected,
mechanical fixation device used for mesh fixation may be and when a collection is detected, it is drained by reopening
employed. the wound. Gram stain can assist in the management and
antibiotic selection.
The Complications of Colorectal Surgery
The exact frequency and severity of complications are Anastomotic Leak
difficult to determine due to heterogeneous definitions, During laparoscopic colorectal surgery, the anastomotic
patient populations, procedures, comorbidities, and leak is a common, potentially life-threatening complication
intensity of follow-up. One perspective of the incidence of associated with significant morbidity, increased risk of
complications can be gleaned from four recent randomized local recurrence of cancer, decreased functional outcomes,
controlled trials comparing laparoscopic to open colon increased length of stay, high risk of (permanent) ostomy,
resections for cancer (Table 1). and death. Leaks are variably defined in the literature, but in
general, regarded as perianastomotic stool, gas, or abscess,
The risk factors related to colorectal surgery include:
■ Perioperative blood transfusion peritonitis, or a fecal fistula. The incidence of an anastomotic
■ American Society of Anesthesiology (ASA) score grade
leak following colectomy is generally reported between 2
and 6%. Anastomotic leaks present in one of three ways:
2 or 3
1. Asymptomatic leak
■ Male gender
2. Subtle, insidious leak
■ Surgeons
3. Dramatic early leak
■ Types of operation
After surgery, the asymptomatic leak is incidentally found
■ Creation of an ostomy
during endoscopic or radiographic studies. The incidence
■ Contaminated wound
of radiographically detected leaks is 4–6 times higher than
■ Use of a drain
clinically detected leaks. These leaks, which often present
■ Obesity
weeks or months later, are typically walled off sinuses, and
■ Long duration of operation
are, as a general rule, harmless. Treatment is rarely necessary.
The subtle, insidious leak can present perioperatively
Wound Infection with nonspecific signs and symptoms common in the
Superficial wound infections are the most common postoperative period. Such signs include low-grade fevers,
complication of colorectal surgery. The previously held mild leukocytosis, protracted ileus, and failure to thrive
belief that preoperative cathartic and oral antibiotic bowel and occur 5–14 days following surgery. Management of the
preparation was mandatory to prevent postoperative stable patient without signs of peritonitis usually begins with
infections has recently been debunked by multiple imaging to identify and localize the process. Traditionally,
randomized controlled trials. Superficial wound infections water-soluble contrast enema has been the primary study to
are recognized by any combination of erythema, induration, identify leaks. Drawbacks include lower sensitivity for right-
tenderness, or drainage at the wound site. Systemic signs of sided anastomosis as the contrast dilutes out before reaching
fever and tachycardia may also be present. The infection may the proximal bowel. It also provides little information
manifest as an abscess, cellulitis, or a combination of the two. on extracolonic conditions such as ileus and collections.

TABLE 1: Complication rates following laparoscopic and open colon resections.

Barcelona trial Cost trial Classic trial Color trial
Wound infection 11.9% 2.5 8.7 3.3%
Persistent ileus 5.5% 2.8
Evisceration 0.9% 0.8%
Bleeding 0.5% 1.2% 4.8% 1.9%
Anastomotic leak 0.9% 6.0% 2.3%
Pneumonia 0% 6.5% 1.9%
UTI 0.5% 1.2% 2.3%
ARF 1.4%
DVT 1%
Cardiac 2.6% 1.2%
(ARF: acute renal failure; DVT: deep venous thrombosis; URI: urinary tract infection)
 CHAPTER 26: Laparoscopic Colorectal Surgery 373

Abdominopelvic CT scan with triple contrast (oral, located above the transverse colon. Signs and symptoms of
intravenous, and rectal) has become the imaging modality of early postoperative small bowel obstruction are similar to
choice to evaluate suspected postoperative intra-abdominal and hard to differentiate from the more common paralytic
infection. Specificity during the first 5 days postoperative, ileus. Patients typically develop abdominal distention,
however, is reduced. During this period, infectious processes nausea, and vomiting, but cannot tolerate nasogastric tube
may be challenging to differentiate from acute postoperative clamping or removal. Most patients have a slow, smoldering
inflammation and fluid collections. Sensitivity is much course, with emergencies being the exception.
improved beyond 5–7 days. CT scan and contrast enema can The surgeon should try to manage obstruction
also be used as complementary studies. conservatively initially. There is a fine balance between
If there are large collections, it can often be amenable waiting for the obstruction to resolve and rushing a patient
to percutaneous, transgluteal, or transanal image-guided to the operating room. In the first week following surgery,
catheter drainage. The images should be reviewed with an obstruction is hard to differentiate from ileus. Between
interventional radiologist to identify a safe window of access 2 weeks and 2 months, postoperative adhesions become
that avoids vascular structures and other organs. Abscesses thick, vascular, and obliterate natural planes, making surgery
<3–4 cm are too small for most pigtail catheters and will often much more difficult and prone to complications. The decision
resolve with a course of antibiotics. In the era of modern to operate should, therefore, occur between 7 and 14 days.
CT scanning and interventional radiology, the routine If the patient has symptoms of obstruction, plain films
practice of repeat laparotomy, abdominal washouts, large readily diagnose most small bowel obstructions. Oral
sump drains, and open abdominal wound management is administration of water-soluble contrast followed by a plain
rarely necessary and can be reserved for patients who fail to abdominal film or CT scan 4 hours later is a good predictor
respond to, deteriorate following, or are not candidates for of the resolution of a small bowel obstruction. The contrast
percutaneous drainage. in the colon indicates the obstruction is likely to resolve with
Sometimes the management of the patient with nonoperative means. CT scan may be useful in identifying
progressive generalized peritonitis with or without signs of ischemia, other intra-abdominal processes and in
septic shock requires resuscitation in ICU with broad localizing the site of obstruction for operative planning.
spectrum antibiotics and urgent laparotomy. Laparoscopic Initial management of the stable patient involves fluid
management may be considered if the surgeon has sufficient and electrolyte replacement, bowel rest, nasogastric tube
laparoscopic skills and operative experience. At the time of drainage, and nutritional evaluation. Total parenteral
surgery, the anastomosis should be scrutinized for signs, nutrition should be started as soon as the detected
which led to its failure. This can guide the appropriate leak. Operation is advised for high-grade or complete
method of repair. bowel obstruction, concern for strangulated bowel, or
After laparoscopic colorectal surgery, if the findings at unresolved small bowel obstruction despite prolonged NGT
operation show ischemia and necrosis of greater than one decompression.
third of the anastomosis, the anastomosis should be resected If proper care is ensured, most patients resolve with
with the creation of a stoma. If the mucous fistula can be nonoperative management. If surgery becomes necessary,
brought up to the skin, it should ideally be fashioned through it should occur prior to the 2 weeks mark, after which the
the same site as the proximal ostomy. When performed in acute adhesions become dense, vascular, and problematic.
this fashion, subsequent ostomy reversal can be done via Surgery involves careful re-exploration and lysis of
a circumstomal incision, obviating the need for formal adhesions. Operative findings usually reveal either a single
laparotomy and its associated morbidity. If the findings at adhesive band or multiple matted adhesions, each occurring
operation identify a smaller leak with healthy bowel, the with similar frequency.
anastomosis can usually be salvaged with suture repair, After colorectal surgery, if obstruction develops,
proximal diversion, and washout of the distal segment. Our laparoscopic exploration and adhesiolysis is being
preferred diversion is a loop ileostomy. increasingly utilized for small bowel obstructions. Advanced
laparoscopic skills and experience are a prerequisite
Early Postoperative Small Bowel Obstruction because access is difficult in these patients. Poor candidates
After colorectal laparoscopic surgery, early postoperative for laparoscopic management include patients with signs
bowel obstruction is rare, occurring in 1% of patients. of peritonitis, multiple previous operations for small bowel
This time period accounts for 5–29% of all small bowel obstruction, small bowel diameter >4 cm, or other medical
obstructions. Most obstructions are caused by adhesions contraindication to laparoscopy. Pneumoperitoneum
which form within 72 hours of surgery and then become should be established with an open technique at a site
very dense and vascular after 2–3 weeks. Obstructions are remote from the previous incision. Atraumatic graspers are
more common following colorectal and gynecological used to explore the bowel in a retrograde fashion beginning
procedures than following appendectomy or procedures with decompressed bowel at the ileocecal valve. Distended
374 SECTION 2: Laparoscopic General Surgical Procedures

bowel is fragile and should not be grasped: grasping the ■ Before dividing any tissues, identify the ureter and
adjacent mesentery reduces the risk of inadvertent bowel gonadal vessels one more time.
perforation. Adhesiolysis is best performed with scissors or ■ During all procedure steps, clear communication with
bipolar cautery devices to reduce the risk of adjacent bowel the patient-side assistant is essential.
injury. Conversion rates range from 7 to 43%. Proactive
reasons to convert include poor visualization, nonviable CONCLUSION
intestine, multiple dense adhesions, deep pelvic adhesions, The laparoscopic technique reduces parietal aggression and
and failure to progress in a reasonable time. achieves the same results as traditional surgery. Patients
recover faster and experience less pain, with fewer wound
Sexual Dysfunction infections, postoperative hernias, less time in the hospital,
Sexual dysfunction following rectal surgery is related to the and reduced costs. But laparoscopic colonic surgery requires
extent of pelvic nerve dissection and occurs in both men and extensive and highly specialized training, with few surgeons
women. In men, damage to the sympathetic nerves during qualified to perform these procedures. The recent conclusion
high ligation of the IMA or posterior dissection at the sacral of the oncologic debate, together with the rapid development
promontory can lead to retrograde ejaculation. In addition, of technological means and the increase in public awareness,
damage to the parasympathetic plexus (nerve erigentes) will probably result in a substantial increase in the number
during lateral and anterior dissection can lead to erectile of surgeons performing laparoscopic colorectal surgery. The
dysfunction. The pathophysiology of sexual dysfunction laparoscopic technique is an excellent approach, though not
in women is likely multifactorial and includes damage to yet the gold standard. Smooth performance of this technique
the parasympathetic nerves during deep pelvic dissection depends on the quality of the equipment, perfect knowledge
as well as postoperative mechanical changes in the pelvis, of the operative steps, exposure of operative field, and the
which contribute to loss of sexual desire, vaginal dryness, experience of the surgical team. Operative times are somewhat
altered orgasm, and dyspareunia. Sexual dysfunction is more longer than open procedures but become shorter along the
difficult to diagnose in women, in part because the presence learning curve. Right colectomies are shorter and easier to
of incontinence often discourages women from engaging in perform than left-sided and rectal resections and should be
sexual activity. employed for teaching residents. The conversion rate would
not necessarily drop after the first 50 cases and should reflect
TIPS AND TRICKS good surgical judgment rather than a surgical failure.
To avoid intraoperative complications:
■ Create adequate exposure.
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