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The extent of exploration is somewhat dictated by the disease process. For example, in inflammatory bowel disease, it is critical to fully evaluate the entire intestine to confirm diagnosis and determine the extent of disease. Only after the small bowel has been thoroughly examined and cleared of disease can Crohn's disease be excluded and an ileal pouch fashioned for patients with presumed ulcerative colitis. Furthermore, in patients with Crohn's disease in whom skip lesions are not uncommon, the small bowel must be fully evaluated so all areas are adequately addressed. In cases of colorectal cancer, careful evaluation for peritoneal, retroperitoneal, and liver metastases is critical, and intraoperative findings can change the surgical plan.

Once all cannulae are placed, the abdomen is systematically evaluated. The upper abdomen is first explored with the patient in reverse Trendelenburg position, which allows the abdominal viscera to move downward with gravity. The flexible tip or 30°videoscope allows full evaluation of the dome of the liver and diaphragms. The lesser sac and retroperitoneum can be easily evaluated by opening the gastrohepatic ligament either with electrosurgery, ultrasonic scalpel, or LigaSure™ device. A fan retractor can be used to lift up on the left liver to allow visualization and evaluation of the retroperitoneum. Evaluation of the pancreas, celiac axis, and periportal adenopathy can be evaluated with the aid of the laparoscopic ultrasound. After visual inspection, the liver parenchyma is fully evaluated with ultrasound (Figure 10.1.3). Segments II-VIII can be well visualized by placing the ultrasound probes on the surface of the liver. Evaluation of segment I (caudate lobe) requires placing the probe beneath liver segments II and III and adjacent to the vena cava. Small visible lesions can easily be biopsied with a cupped forceps or excised with ultrasonic scalpel or cautery. Hemo-stasis is easily controlled with a 5-mm argon beam coagulator or elec-trosurgery. Deeper intraparenchymal lesions that are visualized on ultrasound can be biopsied using a trajectory guided TRU-cut needle under ultrasound guidance. The current laparoscopic ultrasound probe (Bruel & Kjaer, Naerum, Denmark) has an attachable needle guide that allows for ultrasound guided biopsy.

Ultrasound Laparoscopic Surgery

The mid abdomen is well visualized with the patient in the Trendelenburg position. The omentum is visualized and then placed over the liver, which brings the transverse colon superiorly for full evaluation. With the transverse colon in the upper abdomen, the small bowel and mid-abdominal retroperitoneum is easily visualized and evaluated. The patient is then tilted with the right side down, the small intestine is placed in the right abdomen, and the ligament of Treitz identified under the left transverse colon (Figure 10.1.4, with inset). The inferior mesenteric vein located adjacent to the ligament of Treitz and the left colon and its mesentery are easily identified including the origin of the inferior mesenteric artery. In this position, periaortic adenopathy can be evaluated and biopsied if necessary. Laparoscopic ultrasound with Doppler can be useful when evaluating retroperito-neal adenopathy. The origin of the inferior mesenteric artery and sigmoid mesentery are also well visualized. While keeping the patient in this position, the sigmoid colon and its mesentery are evaluated in the lower abdomen.

Attention is then placed back at the ligament of Treitz to begin evaluation of the small intestine. Using either a hand-over-hand or hand-to-hand technique (see Chapter 8.1), all surfaces of the small bowel are visualized as it is passed from one bowel grasper to the other (Figure 10.1.5). Once the distal jejunum/proximal ileum are reached, it is necessary to tilt the patient with the left side down - then the loops of intestine can be easily placed into the left side of the abdomen. This permits easy completion of the small bowel examination to the cecum. In cases of inflammatory bowel disease, sites of stricture can be marked with suture for later resection or stricturoplasty. In the left side down position, the second and third portions of duodenum are visualized as are

Crohn Disease StrictureRight Ileocolic Ligament

Figure 10.1.4. "Running" of the small bowel begins with appropriate positioning of the patient (inset: patient in left side up with intestines retracted to the right) and starting the evaluation at the ligament of Treitz. Note that the inferior mesenteric vein is readily seen even in moderately obese patients.

Figure 10.1.4. "Running" of the small bowel begins with appropriate positioning of the patient (inset: patient in left side up with intestines retracted to the right) and starting the evaluation at the ligament of Treitz. Note that the inferior mesenteric vein is readily seen even in moderately obese patients.

the ileocolic and middle colic pedicles. The appendix, cecum, right colon, and hepatic flexure are identified and evaluated with bowel graspers.

By next placing the patient in deep Trendelenburg position, the pelvic organs can be well visualized. The small bowel is placed in the mid and upper abdomen. The lower sigmoid colon and rectum can be inspected with bowel graspers and the peritoneal reflections including the cul-de-sac between rectum and the anterior organs are well visualized. In females, the ovaries, fallopian tubes, and uterus are inspected (Figure 10.1.6).

Rectal Grasper
Figure 10.1.5. Running the bowel using the "hand-over-hand" technique: The right-handed grasper (1) releases the bowel and prepares to move from point A on the bowel to point C, whereas the left-handed grasper (2), at point B, prepares to slide underneath the other grasper.
Laproscopy View Right Ovay And Tube
Figure 10.1.6. Diagnostic laparoscopy nearly always affords an excellent view of the uterus, Fallopian tubes, and ovaries.

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