Indications: We believe that patients with rectal lesions below the peritoneal reflection requiring circumferential mobilization completely down to the pelvic floor are potentially not good indications for even a HAL resection. This relates to the need for complex dissection deep in the pelvis and the need for a distal rectal washout. Otherwise, we agree that the indications are not different from open surgery. Patient positioning: We do not use a bean bag as described in this chapter. A gel-like pad beneath the patient, which adheres on its own to the operating table, is all we use. Instrumentation: We use similar instruments.
Cannula positioning: We use only 5-mm cannulae in addition to the hand device at the standard sites. Technique: We would emphasize the initial aspect of this procedure is a thorough evaluation of the entire abdomen, including the liver in cancer patients. We generally begin the dissection medially starting at the sacral promontory. Once we complete lymphovascular pedicle isolation, then we perform left colon mobilization and splenic flexure takedown. Peripheral mesenteric dissection and bowel diversion at the proximal resection line may be done using open technique through the hand port.
The laparoscopic approach to rectal mobilization is our preferred method. We sometimes use the hand port and draw the rectosigmoid up through this for strong countertraction (Figure 9.1.15, with inset). Once the rectum is fully dissected, we then perform distal rectal washout, bowel transection, and low anastomosis through the hand port incision.
We have found that using a disposable plastic wound retracting device (Alexis retractor, Applied Medical) is valuable.
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