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The laparoscopic portion of the procedure is broken into two segments, an extended right colectomy followed by left colectomy. Once the colon is fully mobilized and devascularized, it is brought over the small intestine to the right lower quadrant and all the small intestine is brought to the left of the midline in the left upper quadrant. A 6- to 8-cm muscle-splitting Pfannenstiel incision is created to mobilize and transect the distal rectum from the top of the anal canal, create the pouch, and complete the double-stapled anastomosis in a standard manner. For patients with ulcerative colitis, a loop ileostomy is routinely created through the right rectus muscle, separate from the right lower quadrant cannula site.

The operation begins with the isolation and division of the major vascular pedicles before lateral mobilization of the right colon. The patient is tilted left side down and Trendelenburg position so that the small intestine falls to the left side. The surgeon uses the left-sided cannulae, and the assistant, the right-sided cannulae (Figure 8.8.1a). The assistant, through the right-sided cannulae grasps the cecum and terminal ileum and retracts laterally. This is at a reverse angle to the camera and takes time to master. The ileocolic pedicle is identified as the first vessels crossing over the duodenal sweep. The assistant then grasps the pedicle and elevates the vessels and mesentery (Figure 8.8.3). The surgeon using the left-sided cannulae scores the mesentery just inferior and underneath the pedicle near its origin from the superior mesenteric vessels. A plane is developed underneath the ileocolic pedicle until the duodenum is identified and this structure is swept posteriorly. The pedicle is then isolated from surrounding structures. The ileocolic pedicle is traced distally to the cecum before division to correctly distinguish it from the superior mesenteric artery and vein. Once identification is confirmed, the pedicle is ligated and divided either using the Endo GIA stapler or a LigaSureTM device.

Once the pedicle is divided, the assistant grasps the pedicle and the cut edge of the mesocolon, and the surgeon, using a dissector and bowel grasper, begins a medial to lateral mobilization of the right colon mesentery (Figure 8.8.4). The right ureter and gonadal vessels may be seen in the retroperitoneum of a thin patient. The dissection of the mesocolon from the retroperitoneum continues laterally to the right sidewall, under the colon, then cephalad to the hepatic flexure, and medially to free the mesocolon from the duodenum. Most of the dissection is performed bluntly with minimal sharp or electrocautery dissection except over the duodenum. Here, sharp dissection is often needed to break the fine fibrous attachment between the right mesoco-

Ileocolic Pedicle
Figure 8.8.3. The initial phase involves an incision just below the ileocolic pedicle, gently placed under tension by the assistant from the right side.
Mesentery Pedicle
Figure 8.8.4. Once the ileocolic pedicle is divided, a medial to lateral dissection posterior to the right colon mesentery is performed.

lon and duodenum. With this "medial" approach, there is excellent visualization of the dissection from the midline camera port, without the struggle of looking over the colon.

The procedure then shifts to the division of the transverse mesocolon and middle colic vessels. The assistant has an important role in maintaining proper tension and angulation of the transverse mesocolon, to allow the surgeon to correctly identify and ligate the middle colic vessels (Figure 8.8.5). The assistant will elevate the transverse mesocolon in a vertical plane at a 90' angle to the small bowel mesentery and superior mesenteric artery. This maneuver (called the "Ole maneuver," like the bullfighter's cape) is accomplished by passing a grasper from the right upper quadrant to hold the left side of the transverse mesocolon and another from the right lower quadrant cannula to the right side of the mesocolon. The camera person will often shift to a position between the legs at this time. The surgeon, still on the left side, may then work without the assistant's instruments crossing into the field. The surgeon incises transversely the transverse mesocolon to the left of the middle colic vessels. Here there is usually a well-defined lesser sac opening and the posterior wall of the stomach is visualized (Figure 8.8.6). The surgeon then works across the mesocolon toward the patient's right side and isolates the individual middle colic vessels. Two to three separate branches are identified, isolated, and ligated either with large clips or the LigaSure™ device. The main trunk of the

Middle Colic

Figure 8.8.5. The middle colic vessels are placed under tension using the "Ole maneuver" by the assistant (arrows), from the right side of the patient.

Figure 8.8.5. The middle colic vessels are placed under tension using the "Ole maneuver" by the assistant (arrows), from the right side of the patient.

Middle Colic Branches
Figure 8.8.6. By incising the mesocolon to the left of the left colic branch of the middle colic vessel, a free space usually emerges into the lesser sac. This expedites the freeing of the pedicle.

middle colic artery is short and rarely visualized either in open or laparoscopic surgery. If the surgeon attempts to divide this main trunk, near the superior mesenteric artery, there is the potential to injure the superior mesenteric artery either directly or indirectly and, therefore, the branches of the middle colic artery should be the target, not the main trunk. Once the middle colic branches are divided, the surgeon continues to work toward the patient's right side, freeing any filmy adhesions between the mesocolon and dorsal side of the omentum. The surgeon may then encounter a right colic pedicle or potentially a large venous trunk called the "gastrocolic trunk." This area over the first portion of the duodenum can often be confusing. It is possible to identify from this approach the gastroepiploic vessels and omental vessels after the mesocolon has been divided.

The surgeon needs to maintain proper orientation of the field. If unsure of the origin of a vessel in this area, the surgeon should proceed with lateral mobilization and return to this once the omentum has been separated from the colon edge. At this junction, the entire right and proximal transverse mesocolon has been divided. One can now visualize the major pedicles, duodenum, and pancreatic head (Figure 8.8.7).

The procedure then turns to the lateral mobilization of the right colon. The appendix and cecum are elevated and the peritoneum is incised to free these structures (Figure 8.8.8). This continues until the point of medial mobilization of the right mesocolon is met. Here the

Surgery Right ColonSurgery Right Colon
Figure 8.8.7. View after the complete right colon mobilization permits clear view of the head of the pancreas and duodenum.
Appendix During Laparoscopy
Figure 8.8.8. Lateral mobilization of the right colon starts by incising peritoneum at the base of appendix and cecum.

surgeon will enter an open space, which had been dissected previously during the medial mobilization of the right colon mesentery. The attachments of the terminal ileal mesentery are then divided up to the duodenum. If an ileoanal pouch is to be constructed, the terminal ileal mesentery is further mobilized over the duodenum. This is done with the assistant elevating the ileal mesentery and the surgeon still on the left side freeing the attachments (Figure 8.8.9). The camera is almost vertical during this portion of the procedure, which can be quite disorienting.

The dissection then continues laterally up the right colic gutter where now there remains only a fine line of attachment of the colon to the lateral side wall. The surgeon switches to two graspers to reflect the colon medially as the assistant, through the right lower quadrant cannula, uses a hook cautery to divide the lateral attachments (Figure 8.8.10). At the hepatic flexure, the surgeon separates the omentum from the colon and the assistant, again with the hook cautery, divides the planes. This reproduces the same technique as open surgery with the surgeon providing traction and countertraction and the assistant using the cautery. Once the omentum is freed from the colon edge, it is then separated from the cephalad side of the mesentery until the lesser sac is entered. This can be a very tedious portion of the procedure depending on how fused the mesocolon and omentum are to each other. I will often separate the omentum and colon to the left of midline where the

Omentum Surgery
Figure 8.8.10. The lateral attachments of the right colon are divided using a hook cautery instrument.

lesser sac is usually well developed and work back to the hepatic flexure. The entire right colon and terminal ileum are now fully mobilized to a point beyond the midline, completing this portion of the procedure. The colon and terminal ileum should be placed back in anatomic position before beginning the next step to prevent the ileal mesentery from twisting.

The procedure then shifts to the left colon. Monitors and the surgical team are repositioned (Figure 8.8.1B). The patient is placed in steep Trendelenburg and is tilted right side down so the small intestine falls into the right upper quadrant. If the small bowel will not stay out of the pelvis, a sponge can be passed through the 12-mm cannula to help hold the small bowel away. The assistant elevates the inferior mesen-teric pedicle and the surgeon makes an incision along the right peritoneal fold of the rectosigmoid mesentery beginning at the sacral promontory (Figure 8.8.11). The incision parallels the course of the inferior mesenteric pedicle and should be opened widely. Using blunt dissection, the inferior mesenteric artery and vein are swept ventrally away from the preaortic hypogastric nerve plexus. Small nerve fibers, which directly enter the mesocolon, are sacrificed and the main nerve plexus is swept dorsally. As dissection is continued medially beneath the inferior mesenteric artery and vein, the left ureter and gonadal vessels are identified and swept posteriorly (Figure 8.8.12). The assistant should grasp the inferior mesenteric artery and mesentery to facilitate exposure underneath the pedicle. If the ureter cannot be readily and easily identified at this point in the dissection, the lateral attach-

Sacral Promontory
Figure 8.8.11. Dissection of the left colon begins with dissection of the inferior mesenteric artery at the sacral promontory.

ments of the sigmoid colon are incised, the sigmoid colon is mobilized left to right, and the gonadal vessels and left ureter are identified laterally and dissected free of the mesentery.

Once the origin of the inferior mesenteric artery is identified, the peritoneum is incised anteriorly over this pedicle and across the inferior mesenteric vein. The surgeon then uses blunt dissection under the pedicle to create a window lateral to the inferior mesenteric artery and vein below the left colic vessels. A high ligation of the pedicle is not necessary for benign disease. The inferior mesenteric pedicle is ligated and divided either using the Endo GIA stapler or LigaSure™ device. Before firing the stapler or LigaSure™ device, the tips should be clearly visible and the location of the left ureter confirmed (Figure 8.8.13). The proximal and distal sides of the pedicle are grasped so any bleeding can be easily controlled. We prefer to leave the pedicle 1.5-2.0 cm long so if any bleeding occurs, an additional clip or LigaSure™ application can be applied to the pedicle. Once the pedicle is divided, the left colon mesentery then opens and the left colon mesentery is mobilized form medial to lateral in a similar manner as was done for the right colon. The assistant holds the divided distal end of the inferior mesenteric pedicle through the lower port and the cut edge of the left colon mesentery above the pedicle and the surgeon uses blunt dissection with appropriate traction and countertraction to dissect the left colon mes-

Retroperitoneal Laparoscopic
Figure 8.8.12. With dissection of the inferior mesenteric artery, the retroperitoneal attachments are swept posteriorly, and the ureter and gonadal vessels are clearly identified.

Figure 8.8.13. Once the hypogastric vessels are identified and dissected away from the inferior mes-enteric artery, the vessel is ligated with a bipolar device below the left colic artery.

entery from the retroperitoneum. This remains a relatively avascular plane with the exception of a few small vessels on the surface of Gerota's fascia.

The dissection from medial to lateral proceeds out under the sigmoid colon to the lateral side wall, inferiorly into the upper retrorectal space, and superiorly under the splenic flexure. The left-sided monitor is moved from the left foot to the left shoulder. The surgeon then continues dissecting in a cephalad manner, sweeping Gerota's fascia away from the posterior surface of the colonic mesentery. All medial mesen-teric attachments should be divided as far cephalad, in a line parallel to and just lateral to the inferior mesenteric vein. The left colic pedicle is identified, isolated, ligated, and divided (Figure 8.8.14). As the dissection continues cephalad, the small bowel will tend to obscure the view. To handle this, the table is repositioned with a slight reverse Trendelenburg and steep left side upward position. If the head is elevated too much above the feet, the transverse colon may hinder the exposure. Once the left colon mesentery is mobilized medially up to the transverse colon, the dissection continues laterally.

The team repositions for the final phase of the colectomy (Figure 8.8.1C). The senior surgeon remains on the patient's right side and will provide medial traction on the colon as the lateral attachments are divided by the assistant standing between the legs. The white line of Toldt is incised with the hook cautery and the point of medial mobiliza-

White Line Toldt

Figure 8.8.13. Once the hypogastric vessels are identified and dissected away from the inferior mes-enteric artery, the vessel is ligated with a bipolar device below the left colic artery.

White Line Toldt

tion is quickly reached. The colon is retracted medially as the dissection continues cephalad toward the splenic flexure. If the colon has been adequately mobilized from the medial approach, there should only be one or two layers of thin attachments laterally. During this dissection, the surgeon constantly must remain in the proper planes (Figure 8.8.15) - generally close to the bowel edge laterally, between Gerota's fascia and the bowel mesentery.

In the region of the splenic flexure, the greater omentum gradually appears and is distinguishable from the epiploic appendices by its finer lobulated fatty texture. Separation of the omentum from the colon and these appendices is essential for accurate mobilization of the flexure (Figure 8.8.16). Once the first layer of omental attachments is freed (Figure 8.8.17), there is often a secondary attachment of the omentum to the ventral aspect of the distal transverse mesocolon that must be divided. If the splenic flexure proves to be difficult to dissect, the dissection can be continued right to left from the distal transverse colon toward the splenic flexure. The remaining omental attachments can be divided beginning in the mid-transverse colon where they had been previously divided during the right colon mobilization. In our experience, it is important to mobilize the left colon and left mesocolon as far cephalad as possible in the dorsal mesenteric plane adjacent to Gerota's fascia. This greatly simplifies the mobilization of the splenic flexure, and may simplify dissection of the greater omentum and the lateral adhesions close to the colonic wall. Once the splenic flexure is mobilized, the only remaining attachment of the colon is a small segment of

Splenic Marsupialization Steps

freed from the splenic flexure attachments using a bipolar device.

freed from the splenic flexure attachments using a bipolar device.

Take Down Splenic Flexure
Figure 8.8.17. If dissection is difficult from the lateral side, splenic flexure takedown may be expedited using a medial to lateral approach starting in the middle portion of the transverse colon.

the distal transverse mesocolon. There may be a large venous branch to the inferior mesenteric vein in this segment, which requires ligation and division if identified.

Once these final attachments have been dissected, the entire colon is free and must be placed over the small intestine to prepare for extraction. The patient is typically in a slight reverse Trendelenburg position with the left side upward. To facilitate placement of the colon over the small intestine, the table will be gently shifted to a Trendelenburg and right side upward position. The surgeon, who is now standing between the patient's legs, coordinates the change in table positioning. The surgeon uses the two left-sided cannulae and elevates the splenic flexure and starts to bring this over the small intestine to the right lower quadrant. As this is done, the table is shifted and the small intestine should pass under the colon to the left upper quadrant (Figure 8.8.18). The surgeon continues to pass the colon over the small intestine and follows the mesenteric edge of the colon proximally. Eventually all of the small intestine will lie in the left upper quadrant and the surgeon can trace the mesenteric edge of the small intestine up and over the duodenum (Figure 8.8.19). If this is not performed correctly, the mesentery to the small intestine may twist and not allow the colon to be extracted through the Pfannenstiel incision.

With the colon now in the right lower quadrant, the surgeon has two options. One option is to begin and complete the rectal mobilization laparoscopically and then create the Pfannenstiel incision for rectal transection and pouch construction. If the surgeon has extensive laparo-scopic experience, or the patient is moderately obese, this may be the

Pfannenstiel Cut

Figure 8.8.18. Once the colon is completely freed, the colon is passed over the small intestines and placed into the right lower quadrant.

Pfannenstiel Cut
Figure 8.8.19. The surgeon must trace the cut edge of the small intestine mesentery on the right side to be sure that there is no twisting.

preferred approach. The other option is to create the Pfannenstiel incision now and proceed with open rectal mobilization, transection, and pouch construction. This is my preferred approach. Because an incision is needed eventually for pouch construction, one can more easily accomplish rectal mobilization through the open wound. This reduces both the operative time and the technical complexity of the procedure because most surgeons are not skilled in laparoscopic rectal mobilization. If the rectal mobilization is to be performed open, the three 12-mm cannula sites are closed in a transcorporeal manner with absorbable suture before discontinuation of pneumoperitoneum.

An 8-cm Pfannenstiel incision is made two fingerbreadths above the pubic symphysis. The anterior rectus sheath is incised transversely and curved upward at the lateral edges to remain out of the inguinal canal. Superior and inferior flaps are created over the rectus muscle and the peritoneum is incised vertically between the rectus muscles. The peritoneum is incised either to the left or right of the midline inferiorly with care to avoid injury to the bladder wall. A wound protector is placed and a Balfour retractor is used to facilitate the view into the pelvis.

If a loop ileostomy is planned, the incision both in the skin and the anterior rectus sheath for the ileostomy should be made before the Pfannenstiel incision. This is required to prevent a shutter effect at the fascial level of the ileostomy. This can occur if the opening for the ileostomy is made after the Pfannenstiel incision is created and the fascia of the ileostomy is pulled caudally when the fascia of the Pfannenstiel incision is closed transversely (Figure 8.8.20). This may lead to early intestinal obstruction. To avoid this potential complication, the skin and fascial opening for the ileostomy should be made before Pfannenstiel incision. If the ileostomy is created after the Pfannenstiel incision, the fascia of the Pfannenstiel should be pulled caudally as the ileostomy aperture is created. The fascia of the ileostomy should be opened more widely than usual to prevent this complication. If the patient develops evidence of an early bowel obstruction after surgery, narrowing of the ileostomy at the fascial level may be the cause. This can be readily diagnosed by retrograde ileostomy injection or by simply passing a red rubber tube through the ileostomy several inches, which will alleviate the relative obstruction.

Before rectal mobilization, the colon is extracted and divided from the terminal ileum. It is important to maintain proper orientation of the small bowel mesentery during colon extraction. The patient is placed in Trendelenburg position with the right side up to keep the small intestine to the left of midline. A lighted Deaver retractor is used to illuminate the field as the colon is extracted. If performed correctly, one can follow the cut edge of the mesentery up and over the duodenum with all the small bowel remaining to the left of midline. This orientation is maintained for eventual ileoanal pouch construction and anastomosis. The terminal ileum and its mesentery are divided in the usual manner. A tagging suture is placed beneath the staple line of the terminal ileum, and the small bowel is protected with moist laparotomy sponges, in preparation for the rectal dissection.

Pfannenstiel Skin Incision
Figure 8.8.20. The incision in the skin and the fascia (both anterior and posterior sheaths) must be carefully aligned so that a "shutter" effect (arrow) does not occur after fascial closure of the suprapubic incision. This could cause an ileostomy obstruction in the postoperative period.

Rectal mobilization through the Pfannenstiel incision can be quite challenging especially in the male pelvis. We use a lighted pelvic retractor and long instruments because often the hand cannot fit through the wound. If necessary, the skin incision can be enlarged to complete the dissection. The rate-limiting factor in viewing the pelvis through the Pfannenstiel is often the skin and not the rectus muscle. Once the rectum is completely mobilized from the abdomen, it may be either divided with a linear stapler or a rectal mucosectomy from the perineal approach may be performed depending on surgeon's preference and patient diagnosis.

Once the colon and rectum are removed, the small intestine is brought through the Pfannenstiel incision and pouch construction and anastomosis is performed according to the surgeon's preference. Before completing the anastomosis, the surgeon should check the orientation of the small bowel mesentery one last time through the Pfannenstiel incision using the lighted retractors. Once the anastomosis is completed, the abdomen is lavaged and a drain may be placed through the left lower cannula site. A loop ileostomy is created in the majority of cases with special care to the opening in the anterior sheath as mentioned above. It is our preference to wrap the ileostomy with Seprafilm (Genzyme Corporation, Cambridge, MA) to facilitate eventual ileostomy closure. The peritoneum of the Pfannenstiel incision is closed vertically and the rectus muscle is loosely reapproximated in the midline with several interrupted sutures to prevent diastases of the rectus. The anterior rectus sheath is closed transversely with two sutures, one coming from each corner to prevent the possible development of a lateral hernia near the internal inguinal ring. The skin incisions are closed and the ileostomy is matured.

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