Crohn S Disease Indication To Total Abdominal Colectomy

Except for cancer, the indications for laparoscopic total abdominal colectomy are basically the same as in open surgery. For less experienced laparoscopic surgeons, however, further restrictions may apply such as previous operations with formation of intraabdominal adhesions, obesity, or fistula formation, because these conditions may make laparoscopic orientation and accessibility difficult.1,2 This is especially true for the anatomic regions of the omentum, transverse colon, and meso-colon...

Pfannenstiel Incision Using 28 Mm Device To Transect Bowel

Gerota Fascia

The procedure begins with the patient in Trendelenburg position. A Pfannenstiel or vertical suprapubic incision is created, usually 6-9 cm in size, just large enough to insert one's gloved hand. The general rule is to make the incision as large as the surgeon's glove size for example, size 7 glove 7-cm incision . Superior and inferior flaps are created of the anterior rectus fascia, and the rectus abdominus is split in the midline and the peritoneum opened. Before inserting the hand-assist...

Ilocolic Pedical

White Line Toldt

The laparoscopic portion of the procedure is broken into two segments, an extended right colectomy followed by left colectomy. Once the colon is fully mobilized and devascularized, it is brought over the small intestine to the right lower quadrant and all the small intestine is brought to the left of the midline in the left upper quadrant. A 6- to 8-cm muscle-splitting Pfannenstiel incision is created to mobilize and transect the distal rectum from the top of the anal canal, create the pouch,...

Cannula Positioning

Splenic Flexure

The cannulae are placed as shown in Figure 8.7.2. Technique Phase I Transection of the Inferior Mesenteric Artery and Vein, Medial Dissection of the Left Mesocolon, Pelvic Dissection, Left Lateral Mobilization of the Sigmoid Colon, and Transection of the Upper Rectum The procedure begins as in proctosigmoidectomy. The patient is placed in a steep Trendelenburg position and is tilted right side down so the small intestine falls into the right upper quadrant. All small intestinal loops are...

Peritoneal Reflexion

Transverse Mesocolon

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 Figure 8.4.3 . 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 left side, may also be used. Subsequently, the proximal small bowel loops...

Establishing Pneumoperitoneum

Gas Insufflation Laparoscopic Surgery

Pneumoperitoneum is most often established using a Veress needle. The needle is usually inserted at the site where the primary cannula for the laparoscope will be placed. Our preference is a vertical infra-umbilical incision because it overlies the location where the skin, fascia, and parietal peritoneum converge and fuse. If the patient has had prior abdominal surgery, we generally avoid the old incision scars and enter from a remote site in the upper abdomen. After the skin is incised, the...

Dissection and Detachment of the Rectosigmoid Colon

White Line Toldt

The initial step in this technique is dissection and detachment of the distal sigmoid colon and the rectum. This can be performed from either the lateral side or the medial side of the rectosigmoid Figure 8.5.3 . When the lateral approach is used, the dissection plane can be naturally exposed while the descending colon is being dissected if the operating table is tilted with the right side down. Ureter and gonadal arteries veins are dissected without any damage if Toldt's fusion fascia, con-...

Diverting Loop Ileostomy

Laparoscopic Diverting Stoma

The peritoneal access is achieved through the preoperatively chosen ostomy site, nearly always planned inside the rectus sheath Figure 10.2.2 . For loop ileostomy formation, the right lower quadrant site is generally preferred. A 3-cm disk of skin is excised at the site. Subcutaneous tissue is divided longitudinally onto the abdominal fascia. The anterior leaf of the rectus sheath is divided longitudinally using a Bovie and the rectus muscle is spread in the direction of the muscle exposing the...

Gastrocolic Trunk Of Henle

Suprapubic Area Anatomy

The patient is placed in the modified lithotomy position to allow the surgeon to stand between the patient's legs for one portion of the operation. After establishing the pneumoperitoneum through an umbilical port, an additional four ports are placed in the left and right lower quadrant, left upper abdomen, and suprapubic area. The operating table is tilted into the slight Trendelenburg position with the left side down to move the small intestine toward the left upper quadrant. The omentum and...

Lienocolic Ligament

Mobilisation Rectum

There are two basic approaches to mobilize the left colon and ligate the vessel, medial to lateral and lateral to medial. The medial to lateral approaches allow prompt mobilization and division of the main vessels proximally which is recommended by many experts in the cancer setting. There are two ways to do the medial to lateral mobilization The first initiates dissection at the level of the sacral promontory whereas the second starts at the level of the inferior mesenteric vein IMV . A brief...

Pulmonary

Apical Alveoli

Changes in respiratory physiology during laparoscopy are from the combined effects of pneumoperitoneum, positioning, ongoing CO2 absorption, and patient body weight. The basic principles of respiratory physiology that apply to a routine general anesthetic remain pertinent under laparoscopy Figure 5.1 . In the awake state with spontaneous ventilation, a gravitational gradient promotes greater blood flow, and greater intrapleural pressure surrounding the basilar alveoli. The alveoli at the lung...

The Operating Room Setup

Modified Lithotomy Position Surgery

A clearly defined setup for all laparoscopic colorectal procedures is recommended. Because laparoscopic surgery requires complex equipment, it is advisable to organize the operating room to facilitate each step of the procedure, increase efficiency, and shorten anesthesia time. A laparoscopic surgical procedure should be initiated only if all equipment is functional and has been calibrated immediately before the scheduled operation. There should also always be backup instruments to replace a...

Trocar Insertion and Stabilization

Endotip Storz

In general, we place four to five cannulae for most colorectal procedures one for the laparoscopic camera, two for the operating surgeon, and one or two for the assistant surgeon. This technique provides best surgical flexibility in all four quadrants, allowing operating and assistant surgeons to cooperate. In most instances, the operating surgeon will place the cannula opposite to the site of the pathology, which allows the greatest room to work and to visualize the pathology site. Because any...