Patient Positioning and Operating Room Setup

After placement of an arterial and two intravenous lines as well as venous compression stockings on the legs, the patient is secured in the modified lithotomy position using adjustable stirrups. The thighs should be parallel to the abdomen. The use of a "bean bag" underneath the patient is advised. Both arms are tucked at the patient's side and

Laparoscopy Lithotomy Position

Figure 9.1.1. A Position of the equipment and the surgical team for the first phase of the HAL anterior resection. B Position of the equipment and the surgical team for the second phase (pelvic dissection) of the HAL anterior resection.

Figure 9.1.1. A Position of the equipment and the surgical team for the first phase of the HAL anterior resection. B Position of the equipment and the surgical team for the second phase (pelvic dissection) of the HAL anterior resection.

Patient Positioning Rectal
Figure 9.1.1. Continued

suction is applied to the bean bag. Tape is placed over a pad across the chest to the table at the level of the manubrium to further secure the patient. The monitor on the right side of the patient remains off the right foot throughout the laparoscopic portion of the case. The laparoscopic monitor on the left side is placed off the patient's left shoulder (Figure 9.1.1A). The surgeon stands between the patient's legs with left hand in the abdomen and right hand working via the cannula on the left side. The first assistant stands, with the camera person, on the patient's right side and utilizes the two right-sided cannulae.

Regardless of which specific hand-assisted approach is used, once the main vessels have been divided and the splenic flexure takedown

Table 9.1.1. Specific instruments recommended for HAL anterior rectal resection

1 Hand-assisted device

1 Dissecting device (i.e., LigaSure VTM or Ultrasonic Shears™ or electrosurgery)

1 Laparoscopic scissors

1 Laparoscopic dissector

2 Laparoscopic graspers 1 Endoscopic stapler completed, the proximal bowel and remaining mesentery are divided at the chosen level. At this point, if desired, the rectal dissection can be initiated laparoscopically or the minimally invasive part of the operation can be terminated and the open portion of the case begun. In the case of the former, the left-sided monitor must be moved to a position off the left leg or foot. The surgeon moves to the patient's right side whereas the first assistant moves to the left side. The camera person now stands cephalad to the surgeon on the right side (Figure 9.1.1B).

Once the decision has been made to terminate the minimally invasive portion of the operation, fascial sutures are placed to close the 10- and 12-mm cannula wounds and the cannulae are removed. The hand device is removed and a Bookwalter or similar retractor is used to expose the lower abdomen and pelvis. In the majority of cases, it is necessary to extend the skin incision several centimeters to allow open completion of the case. The Allen stirrups can be adjusted for the open part of the case so as to flex the hips and provide better access from below for transanal stapling.

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  • Conlan
    How to set up a bookwalter retractor stand?
    8 years ago

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