Peritoneal Reflexion

Exposure

To complete exposure of the operative field, active positioning of the bowel is usually necessary in addition to the passive action of gravity, especially in the presence of obesity or bowel dilatation (Figure 8.4.3). The greater omentum and the transverse colon are placed in the left subphrenic region and maintained in this position by the Trendelenburg tilt. An atraumatic retractor, introduced through the cannula on the left side, may also be used. Subsequently, the proximal small bowel loops are placed in the right upper quadrant using gentle grasping (Figure 8.4.3, inset). The distal small bowel loops are placed in the right lower quadrant with the cecum, and maintained there with gravity. If gravity is not sufficient, as occurs especially in the presence of abundant intraabdominal fat or dilated bowel, an additional maneuver is used. An instrument passed through the right subcostal cannula is passed at the root of the mesentery and grasps the parietal perito-

Laparoscopic Colectomy Gravity

Figure 8.4.3. Active positioning using gravity produces optimum exposure. The greater omentum and the transverse colon are placed in the left subphrenic region and maintained in this position by the Trendelenburg tilt (inset). Subsequently, the proximal small bowel loops are placed in the right upper quadrant.

neum of the right iliac fossa; the shaft of the grasper thus provides an auto static retraction of the bowel loops, keeping them away from the midline and from the pelvic space. This technique of exposure provides an excellent view of the sacral promontory and of the aortoiliac axis. This particular view on the operative field is essential for the medial to lateral vascular approach that we perform routinely and will describe in the following paragraphs.

The uterus may be an obstacle to adequate exposure in the pelvis. In postmenopausal women, the uterus can be suspended to the abdominal wall by a suture (Figure 8.4.4). This suture is introduced halfway between the umbilicus and the pubis, and opens the rectovaginal space. In younger women, the uterus can be retracted using a similar suspension by a suture around the round ligaments or using a 5-mm retractor passed through the suprapubic cannula.

Very often, conversion to open surgery is caused by difficulty in exposure, not only at the beginning, but also throughout the procedure. Because we choose to perform a medial approach, time is dedicated to the perfect achievement of this exposure, which will serve not only for the initial vascular approach, but also for about half of the remaining operative time. After adequate exposure has been achieved, the following steps of the technique include the vascular approach, the medial posterior mobilization of the sigmoid, the extraction of the specimen, and the anastomosis. Additional steps include the mobilization of the splenic flexure, performed when further lengthening of the bowel is needed to perform a tension-free anastomosis.

The step of the exposure is preliminary, and it is done in a similar manner, regardless of the type of disease. The remainder of the procedure is different if the indication for surgery is a cancer or a benign disease. We will describe the two variants of the technique separately.

Comment Suturer Colon
Figure 8.4.4. The uterus can be suspended to the abdominal wall using a suture placed through its fundus.

Sigmoid Colon Resection for Cancer

In laparoscopic colorectal sigmoidectomy for cancer or for benign disease, the vascular approach is the first step of the dissection. We believe that it allows us to avoid unnecessary manipulation of the colon and tumor (which may cause tumor cell exfoliation), and to perform a good lymphadenectomy following the vascular anatomy. The vessels are gradually exposed once the peritoneum at the base of the sigmoid mesocolon is incised. The medial to lateral view allows us to see the sympathetic nerve plexus trunks, the left ureter, and gonadal vessels, avoiding ureteral injuries and possibly preserving genital function.

Primary Vascular Approach (Medial Approach) Peritoneal Incision

The sigmoid mesocolon is retracted anteriorly, using a grasper introduced through the suprapubic cannula: This exposes the base of the sigmoid mesocolon. The visceral peritoneum is incised at the level of the sacral promontory. The incision is continued upward along the right anterior border of the aorta up to the ligament of Treitz (Figure 8.4.5). The pressure of the pneumoperitoneum facilitates the dissection, as the diffusion of CO2 opens the avascular planes.

Identification of the Inferior Mesenteric Artery

The dissection of the cellular adipose tissue is continued upward by gradually dividing the sigmoid branches of the right sympathetic trunk

Sigmoid Mesentery Anatomy
Figure 8.4.5. Initial dissection starts with an incision of the sigmoid mesentery at the sacral promontory with dissection cephalad posterior to the IMA.
Hypogastric Nerve
Figure 8.4.6. The dissection behind the IMA involves preservation of the main hypogastric nerve trunks, but also division of the small branches traveling to the colon.

to expose the origin of the inferior mesenteric artery (IMA) (Figures 8.4.6 and 8.4.7). To ensure an adequate lymphadenectomy, the first 2 cm of the IMA are dissected free and the artery is skeletonized before it is divided. This dissection at the origin of the IMA involves a risk of injury to the left sympathetic trunk situated on the left border of the IMA. A meticulous dissection of the artery (skeletonization) helps to avoid this risk, because only the vessel will be divided, and not the surrounding tissues. Dissection performed close to the artery also minimizes the risk of ureteral injury during the ligation of the IMA. The IMA can then be divided between clips, or by using a linear stapler (vascular 2.5- or 2.0-mm cartridges) or the LigaSure Atlas™ (Figure 8.4.8). The artery is divided at 1-2 cm distal to its origin from the aorta or after the take off of the left colic artery.

Identification of the Inferior Mesenteric Vein

The inferior mesenteric vein (IMV) is identified to the left of the IMA or in case of difficulty, higher, just to the left of the ligament of Treitz junction. The vein is divided below the inferior border of the pancreas or above the left colic vein (Figure 8.4.9). Once again, clips, or the LigaSure Atlas™ are both sure options to ligate and divide this vessel.

Mobilization of the Sigmoid and Descending Colon

The mobilization of the sigmoid colon follows the division of the vessels. This step includes the freeing of posterior and lateral attachments

Radical Lymphadenectomy
Figure 8.4.7. Radical lymphadenectomy involves exposure of the main trunk of the IMA and skeletonization, but preservation of the hypogastric nerve trunks.
Sigmoid Colon Mobilisation Steps
Figure 8.4.8. The IMA is divided 1-2 cm distal to its origin, or just distal to the left colic branch. 154
Colic Vessels
Figure 8.4.9. The IMV is divided in a safe area between the pancreas and the left colic vessels.

of the sigmoid colon and mesocolon and the division of the rectal and sigmoid mesenteries. The approach is either medial or lateral.

We routinely perform this medial-to-lateral laparoscopic dissection for all indications. The medial approach is well adapted for laparos-copy because it preserves the working space and demands the least handling of the sigmoid colon. In a randomized trial comparing the medial-to-lateral laparoscopic dissection with the classical lateral-to-medial approach for resection of rectosigmoid cancer, Liang et al.5 showed that the medial approach reduces operative time and the postoperative proinflammatory response. Besides the potential oncologic advantages of early vessel division and "no-touch" dissection, we believe that the longer the lateral abdominal wall attachments of the colon are preserved, the easier are the exposure and dissection.

Posterior Detachment

The sigmoid mesocolon is retracted anteriorly (using the suprapubic cannula) to expose the posterior space. The plane between Toldt's fascia and the sigmoid mesocolon can then be identified. This plane is avas-cular and easily divided (Figure 8.4.10, including inset). The dissection continues posterior to the sigmoid mesocolon going laterally toward Toldt's line. The sigmoid colon is then completely free, and the lateral attachments can then be divided using a lateral approach.

Lateral Mobilization

The sigmoid loop is pulled toward the right upper quadrant (grasper in right subcostal cannula) to exert traction on the line of Toldt (Figure

Toldt Plane

Figure 8.4.10. An avascular plane exists between Toldt's fascia and the mesocolon, which is bluntly dissected medial to lateral after IMA and IMV ligation. (Inset: Cross-sectional drawing illustrating the correct surgical plane indicated by arrow.)

Gonadal vessels

Ureter

Gonadal vessels

Ureter

Figure 8.4.10. An avascular plane exists between Toldt's fascia and the mesocolon, which is bluntly dissected medial to lateral after IMA and IMV ligation. (Inset: Cross-sectional drawing illustrating the correct surgical plane indicated by arrow.)

8.4.11). The peritoneal fold is opened cephalad and caudad, and the dissection joins the one previously performed medially. During this step, care must be taken to avoid the gonadal vessels and the left ureter because they can be attracted by the traction exerted on the mesentery. Ureteral stenting (infrared stents) can be useful in cases in which inflammation, tumoral tissue, or adhesions and endometriosis make planes difficult to recognize.

Dissection of the Upper Mesorectum

This area of dissection should be approached with caution, especially on the left side: The mesorectum there is closely attached to the parietal fascia where the superior hypogastric nerve and the left ureter are situated (Figure 8.4.12). The upper portion of the rectum is mobilized posteriorly following the avascular plane described before, then laterally, until a sufficient distal margin is achieved.

Resection of the Specimen Division of the Rectum

Once the upper rectum is freed, the area of distal resection is chosen, allowing a distal margin of at least 5 cm. The fat surrounding this area is cleared, using monopolar cautery, ultrasonic dissection, or the LigaSure AtlasTM. Doing so, the superior hemorrhoidal arteries are divided in the posterior upper mesorectum (Figure 8.4.13). Although we do not routinely perform it, the colon may then be closed using an umbilical tape before a rectal washout is performed, which aims at reducing tumor cell implantation at the staple line. The distal division is performed using a linear stapler. The stapler is introduced through the right lower quadrant cannula. We use stapler loads (3.5 mm, 45-mm blue cartridges), which are applied perpendicular to the bowel. Articulated staplers can also be useful, although they are usually unnecessary at the level of the upper rectum (Figure 8.4.14).

Proximal Division

The proximal division site should be located at least 10 cm proximal to the tumor. It is performed by first dividing the mesocolon and subsequently the bowel (Figure 8.4.15). The division of the mesocolon is

Bowel Staplers
Figure 8.4.11. Lateral dissection then proceeds after the previous medical dissection.
Colectomie Selon Technique Babcock
Figure 8.4.12. The dissection of the upper rectum should proceed with caution because the hypogastric nerves are tented upward and may be inadvertently injured. These nerves may be swept posteriorly before dividing the soft tissues in the area.
Divisions The Hypogastric
Figure 8.4.13. After upper rectal mobilization, the area of mesorectal division is chosen.
Endoscopic Linear Stapler
Figure 8.4.14. Distal bowel division is performed through the right lower quadrant cannula using an endoscopic stapler.
Lower Quadrant Anatomy Organs
Figure 8.4.15. Proximal bowel division is performed after dividing the mesocolon up to the chosen site.

more easily performed with the Harmonic ScalpelTM, or the LigaSure AtlasTM, although linear staplers can also be used. The distal portion of the divided IMA is identified, and the division of the mesocolon starts right at this level and continues toward the chosen proximal section site at a 90° angle. A linear stapler is then fired across the bowel. The stapler (blue load) is introduced through the right lower quadrant cannula. The specimen is placed in a plastic retrieval sac introduced through the same cannula. This permits continuation of the procedure without manipulation of the bowel and tumor. If the resected specimen is large and obscures the operative fields, the extraction can be done before completing mobilization of the left colon.

Mobilization of the Splenic Flexure

In the frequent event that a long segment of sigmoid colon has been resected, mobilization of the splenic flexure is required. This can be achieved in different ways. It is important for the surgeon to be familiar with all approaches in order to select the most suitable approach.

Sufficient mobilization of the splenic flexure may be achieved by simply freeing the posterior and lateral attachments of the descending colon. This is begun by a medial approach to free the posterior attachments of the descending and distal transverse colon, followed by the dissection of the lateral attachments, or by doing the same task in the reverse order. A lateral mobilization is sometimes sufficient in cases of sigmoid cancer, where the posterior mobilization can be omitted.

The medial mobilization is perfectly suited to our laparoscopic approach as the surgeon, situated to the patient's right, may have an excellent view of the anterior surface of the pancreas and the base of the left transverse mesocolon, especially in obese patients (Figure 8.4.16).

In addition, division of colocolic adhesions or sometimes careful mesenteric division must be performed to achieve full mobilization and to allow adequate bowel length for a tension-free anastomosis.

Lateral Mobilization of the Splenic Flexure

This approach is often used in open surgery and can also be used in simple laparoscopic colectomies. The first step is the section of the lateral attachments of the descending colon. An ascending incision is made along the line of Toldt using scissors introduced via the left-sided cannula. The phrenocolic ligament is then divided using scissors introduced through this cannula. Retraction of the descending colon and the splenic flexure toward the right lower quadrant using graspers introduced through the right lower and suprapubic cannulae helps to expose the correct plane. The attachments between the transverse colon and the omentum are divided close to the colon until the lesser sac is opened. Division of these attachments is continued as needed, to facilitate the mobilization of the colon into the pelvis.

Medial Mobilization

This approach dissects the posterior attachments of the transverse and descending colon first (Figure 8.4.16). The dissection plane naturally

Transverse Mesocolon
Figure 8.4.16. Medial to lateral dissection beneath the left mesocolon provides excellent views of the distal pancreas, the base of the left transverse mesocolon, and retroperitoneum.

follows the plane of the previous sigmoid colon mobilization, cephalad and anterior to Toldt's fascia. The transverse colon is retracted anteriorly to expose the inferior border of the pancreas, and the root of the transverse mesocolon is divided anterior to the pancreas and at a distance from it; we thus enter the lesser sac. The dissection then follows toward the base of the descending colon and distal transverse colon, dividing the posterior attachments of these structures. The division of the lateral attachments, as described above, then follows the full mobilization of the splenic flexure. If the mobilized colon reaches the pelvis easily, it may be safely assumed the anastomosis will be tension free as well.

Extraction

The extraction of the specimen is performed using a double protection: A wound protector as well as a retrieval sac (Figure 8.4.17). The wound protector is also helpful to ensure that there is no CO2 leak during the intracorporeal colorectal anastomosis, which follows the extraction. This allows reduction of the size of incision and potentially minimizes the risk of tumor cell seeding.

Incision to Extract the Specimen

The size of the incision, its location, and the extraction technique take into account the volume of the specimen, the patient's body habitus, cosmetic concerns, and the type of disease. The incision is generally performed in the suprapubic region. The proximal division is per-

Rectoscopy Endometriosis

Figure 8.4.17. Specimen extraction at the suprapubic site involves double protection: 1) a wound protector; and 2) an impermeable retrieval sac.

formed intracorporeally, as described above, and the specimen placed into a thick plastic bag before being extracted through the incision at the suprapubic area.

Anastomosis

We always use a mechanical circular stapling device passed transanally to perform the anastomosis. Performing the anastomosis includes an extraabdominal preparatory step and an intraabdominal step performed laparoscopically. The extraabdominal step takes place after the extraction of the specimen. The instrument holding the proximal bowel presents it at the incision where it can easily be grasped with a Babcock clamp and pulled out (Figure 8.4.18). If necessary, the colon is divided again in a healthy and well-vascularized zone. The anvil (at least 28 mm in diameter) is then introduced into the bowel lumen and closed with a purse string (Figure 8.4.19); then the colon is reintroduced into the abdominal cavity (Figure 8.4.20). The abdominal incision is closed to reestablish the pneumoperitoneum. For an air-tight closure, it is sufficient to twist the wound protector at the level of the incision using a large clamp (Figure 8.4.21). The circular stapler is introduced into the rectum through the gently dilated anus. The rectal stump is then trans fixed with the tip of the head of the circular stapler (Figure 8.4.22). In women, the posterior vaginal wall should be retracted anteriorly by the assistant passing the stapler. Once the center rod and anvil are clicked into the distal part of the circular stapler, we check for twisting of the colon and the mesentery. The stapler is then fired after ensuring that the neighboring organs are away from the stapling line. The stapler is then twisted open and withdrawn. The anastomosis is checked for leaks by verifying the integrity of the proximal and distal rings, as well as performing an air test (Figure 8.4.23). Some authors complete the evaluation of the anastomosis with a rectoscopy.

Wound Closure

The cannula sites are checked internally for possible hemorrhage. To do so, a grasper is passed through the cannula and the cannula is removed leaving the grasper in the abdomen. Because of the smaller diameter of the grasper compared with the cannula, if a bleeding was so far concealed by the tamponade effect of the cannula, it would be revealed promptly. The cannula is then reintroduced to allow maintenance of the pneumoperitoneum while performing the same check at all cannula sites.

Pace Proximal Colon
Figure 8.4.18. After specimen extraction, the proximal colon is drawn out through this site, keeping the wound protector in place.
Laparoscopy Harmonic Scissor
Figure 8.4.19. The anvil and center rod of the circular stapler are introduced into the bowel lumen and secured with a purse string suture.

Figure 8.4.20. The bowel is reintroduced into the abdominal cavity, checking for adequate length for anastomosis. The bowel should comfortably reach the pelvis without tension.

Figure 8.4.21.

Reestablishment of the pneumoperitoneum can be achieved quickly by twisting the wound protector, then clamping it at the skin level with a Kocher clamp.

Figure 8.4.21.

Reestablishment of the pneumoperitoneum can be achieved quickly by twisting the wound protector, then clamping it at the skin level with a Kocher clamp.

Plastic Wound Drapes Laparoscopy

Figure 8.4.22. The anastomosis is then done under laparoscopic guidance, perforating the proximal rectal stump with the sharp spike of the circular stapler, then performing a standard double-stapled anastomosis.

Figure 8.4.22. The anastomosis is then done under laparoscopic guidance, perforating the proximal rectal stump with the sharp spike of the circular stapler, then performing a standard double-stapled anastomosis.

Double Stapled AnastomosisPeritoneal Reflexion
Figure 8.4.23. After firing the stapler, the anastomosis is checked by filling the pelvis with saline, then insufflating the rectum with air using a rectoscope. The bowel upstream of the anastomosis is gently occluded during this test.

When the check is completed, the CO2 is desufflated through the cannulae and cannulae are removed. No routine drainage of the anas-tomotic area is performed. The suprapubic incision is closed in layers using running absorbable sutures, and all fascial defects of 10 mm and more are closed. The skin is closed with a subcuticular absorbable suture.

Sigmoidectomy for Diverticular Disease

The vascular approach for patients with benign diseases of the sigmoid colon is performed with the following steps.

Peritoneal Incision

The peritoneal incision can be similar to the cancer technique particularly in difficult cases (obesity, inflammatory mesocolon). In most cases, we try to preserve the vascularization of the rectum and the left colic vessels. The opening of the peritoneum can be limited to the mesosig-moid parallel to colon at mid distance between the colon and the root of the mesosigmoid. An initial lateral mobilization of the sigmoid can be useful in this approach. The branches of the sigmoid arterial trunk can be divided separately anteriorly to inferior mesenteric vessels (Figure 8.4.24) or together after creating windows in the mesentery to divide the various branches. A linear stapler or, better, the LigaSure Atlas™ 10-mm device can be used for this task.

Resection of the Specimen

In diverticular disease, we usually perform the distal resection of the bowel below the rectosigmoid junction. The rectosigmoid junction is located just above the peritoneal reflexion, at the pouch of Douglas. We prefer to perform the mobilization of the splenic flexure at this moment, before resection at the proximal limit, using the same principles as described above.

Extraction of the Specimen

Before extracting the colon, it is important to divide the mesocolon at the level of the proximal site of division. After adequate mobilization is achieved, the colon is extracted through a suprapubic incision, protected by the plastic drape described above, and proximal division performed externally on a compliant and well-vascularized part of the colon. The anastomosis is performed as described above for cancer (Figure 8.4.23).

Image Suprapubic Drape
Figure 8.4.24. In sigmoidectomy for benign disease, the mesenteric division may proceed anterior to the IMA/IMV, because a less radical resection is required. This preserves more blood flow to the bowel and leaves the hypogastric nerves less subject to surgical trauma.
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