Technique

The patient is placed in the Trendelenburg position, and three or four trocars are inserted. For establishment of pneumoperitoneum, CO2 is channeled through the infraumbilical trocar until the intraabdominal pressure reaches 10 mm Hg. Both the operating surgeon and camera holder stand on the patient's left side. After abdominal exploration, the operation table is rotated left side down so the small intestine falls toward the left upper quadrant.

The ascending colon is thoroughly mobilized from the base of the appendix (Figure 8.2.3) up to the hepatic flexure (Figure 8.2.4) by cutting the retroperitoneal attachments with electrosurgical scissors and laparoscopic coagulating shears, and bluntly dissecting the retro-peritoneal fusion fascia and loose connective tissue. With this procedure, the duodenum, Gerota's fascia, and sometimes more inferiorly the right ureter and the gonadal vessels become visible beneath the retroperitoneal fusion fascia (Figure 8.2.5). During dissection, the direct

Tissue Fusion Electrosurgery
Figure 8.2.3. The initial mobilization of the bowel commences with dissection at the cecal area.
Fusion Fascia Toldt Colon
Figure 8.2.4. Freeing up the lateral attachments of the right colon after some retroperitoneal dissection.

grasping and handling of diseased bowel loops should be avoided, to prevent incidental myotomies and enterotomies.

In Crohn's disease, intracorporeal inspection of the entire small bowel is performed carefully in a hand-over-hand manner using two

Bowel Hepatic Flexure
Figure 8.2.5. Freeing up the hepatic flexure so that the bowel may be drawn out through an umbilical incision. The duodenum and other retroperitoneal structures may become readily apparent.

bowel clamps following the laparoscopic colonic mobilization. In patients with ileovesical, ileorectal, and gastrocolic fistulas, division with an intracorporeal stapling device (one or two firings of the 45- or 60-mm stapler) can be done.

After mobilization of the entire ascending colon, meticulous hemo-stasis is made. Then, the patient is placed in a reversed Trendelenburg position temporarily and the abdomen is irrigated with warm sterile saline. The patient is placed in a flat supine position, and pneumoperi-toneum is released. A small laparotomy is performed through a 5-cm-long skin incision made at the umbilical trocar site or through a Pfannenstiel incision. A wound protector is inserted and the segments of the colon are delivered through this incision. Mesenteric division, ileocolic resection, and anastomosis by Gambee's procedure using 4-0 absorbable sutures such as Vicryl® or PDS®, or functional end-to-end anastomosis using linear staplers are performed extracorporeally (Figure 8.2.6A and B). After closure of the mesenteric defect, the entire residual small bowel is examined through the incision, and the stricture plasties (either Heineke-Mikulicz or Finney type) are performed on distant skip lesions, if necessary. The omentum is laid under the wound to prevent postoperative adhesions, and the peritoneum is closed with absorbable sutures. Closed silicone drain tube is left in cul-de-sac through the right lateral trocar site if necessary, and every trocar site incision is closed with skin staplers.

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