A good surgical exposure is always the key to success in any laparoscopic procedure. In general, this can be accomplished by the combination of:
1. adequate establishment and maintenance of pneumoperitoneum
2. appropriate positioning of the patient and the operating table to enhance gravity-induced displacement of the obstructing structures and
3. effective retraction and displacement of obstructing structures. Adequate Pneumoperitoneum
Adequate pneumoperitoneum can be obtained under sufficient muscle relaxants with an appropriate control of the intraabdominal CO2 insufflation. Usually, intraabdominal pressure of 10-12 mm Hg provides good laparoscopic visualization and sufficient working space. However, even after successful establishment of pneumoperitoneum, the insufflated gas can be lost from the peritoneal cavity during the instrument/ laparoscope exchange, by the aggressive evacuation of smoke, and because of spontaneous gas leakage. The intraabdominal pressure should therefore be continuously monitored, and the automatic reinsufflation function is mandatory. To keep steady and quick reinsufflation, each connection to the CO2 line should be maintained adequately through the procedure.
In principle, the operative site (i.e., target tissue) should be always positioned as "high" as possible in the peritoneal cavity to maximize gravitational retraction. The surrounding structures that may obstruct the exposure can be effectively displaced from the operative site with the aid of gravity. Collection of blood and tissue fluid can be also positioned away from the operative site. For this purpose, the patient should be placed adequately on the operating table so that the intraoperative rotation of the table can maximize the gravity-produced displacement. For example, to obtain good exposure of the hepatic flexure of right colon, the patient should be placed slightly in the reverse Trendelenburg position and the operating table should be turned with the right side tilted up (Figure 6.8). The operative table should be rotated appropriately as the operative site changes: In case of proctosigmoidectomy, the patient should be first placed flat or in the Trendelenburg position with the left side up to obtain good visualization of the inferior mesenteric artery pedicle, and then changed to the reverse Trendelenburg position to gain good exposure of the splenic flexure.
In addition to the gravity-produced displacement, aggressive retraction and displacement of obstructing structures are still necessary to optimize the exposure. In colorectal laparoscopy, most of the attention is directed to the small intestine and the greater omentum, because they normally spill into all quadrants of the abdomen. Using the atraumatic laparoscopic graspers, these structures should be retracted and displaced gently to the opposite site of the pathology: e.g., in right colectomy, the omentum is to be flipped up above the transverse colon, and the small bowel loops are to be positioned to the pelvis. The instrument shafts can be safely used for this purpose. Even after repeated efforts for manual retraction/displacement, the small bowel loops may still migrate into the operative site. On these occasions, additional cannula placement should be considered, to utilize a laparoscopic retractor for effective retraction.
For bowel retraction, a one-finger or a fan retractor is not recommended, because they are originally designed to retract the liver or other more fixed organs. Intestinal loops can be trapped between the fingers of the retractor, exposing the loop to potential injury. Although there are currently no optimal retractors available for rapidly retracting the small bowel, our current preference is a paddle-type retractor (Endo Paddle
Retract™; USSC-Tyco, Norwalk, CT).4 The device measures 12 mm in diameter and 47 cm in working length. It consists of a long, thin plastic tube, inside of which is housed a collapsible rectangular paddle-shaped instrument with a flat surface. Once the tube is passed inside the abdominal cavity, through a 12-mm cannula, deployment of a knob on the end of the instrument expands the paddle to a fully or partially deployed position, depending on the size of the retracting surface needed. A nylon cloth covering provides friction to the paddle, allowing for efficient retraction of the organ(s) to be moved. The Endo Paddle Retract™ is a useful tool in obese patients especially to retract the small bowel loops away from the pelvis or the inferior mesenteric artery.
Another simple technical alternative is the usage of gauze pads. A 4 x 8 inch gauze, marked with radioopaque tapes, is slightly soaked in warm saline solution then deployed through a 10- or 12-mm cannula. The gauze can be placed beneath and over loops of small bowel, especially useful in pelvic surgery or during the isolation of the inferior mesenteric artery pedicle in sigmoid colon or rectal cancer surgery (Figure 6.9).
We have also found valuable retraction using a large laparotomy pad during hand-assisted laparoscopic surgery (HALS). The hand access device, inserted through a Pfannenstiel incision, permits the insertion and handling of this large pad.5 Use of this method in morbidly obese
patients may allow minimally invasive surgical techniques to be used when they would otherwise be impossible.
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