A standardized approach to cannula size and placement for all colorec-tal resections has reduced operative times. Five cannulae are generally required with the camera port placed in the supraumbilical position utilizing an open technique. After a diagnostic laparoscopy to assess feasibility, right-sided cannulae are placed. A 12-mm cannula is placed two fingerbreadths above and medial (2 + 2) to the right anterior superior iliac spine (Figure 8.8.2). This should always be lateral to the rectus sheath to avoid potential injury to the epigastric vessels. The large cannula can accommodate a laparoscopic clip applier, a laparoscopic
stapler, or a laparoscopic Babcock clamp. Before placing this cannula, lay a standard laparoscopic instrument from the right lower quadrant site to the left upper quadrant to ensure the instrument can reach the splenic flexure. For taller patients, the cannula will need to be shifted upward. For wider patients, the cannula will need to shift inward. The cannula should still lie outside the rectus sheath. I do not recommend placing the cannula in the site for a right lower quadrant ileostomy in the rectus sheath. This instrument will "sword fight" with the camera and there is potential for an epigastric vessel injury. A 5-mm cannula is placed four fingerbreadths above the lower cannula. One can easily remember this (2 + 2 then 4) measurement. The same approach to cannula placement is performed on the left side. With these five can-nulae the entire colon can be devascularized and mobilized.
A 10-mm laparoscope is recommended for the majority of cases. With the advent of high-resolution 5-mm laparoscopes, this may change. I have found using the EndoEYE Deflectable Tip Video Laparoscope by Olympus (Olympus America Inc., Melville, NY), with its flexible tip, has greatly enhanced the performance of laparoscopic colon resection. A 30' laparoscope is not necessary and may hinder orientation of the field. The camera is often in constant motion during the performance of a laparoscopic colectomy. Overviews and close magnification views are routinely required in vascular pedicle ligation and colon mobilization. The skill of the camera person can enhance or deter the flow of the procedure and may greatly alter the operative times. Because the individual running the camera tends to be the least experienced laparo-scopist, I prefer a 0' laparoscope to limit confusion in orienting the field. The camera person may already be overwhelmed with instructions by the operating surgeon, without the added complexity of a 30' lens.
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