Technique

Once the preoperative diagnosis is confirmed and the laparoscopic procedure appears feasible, the pathology is located by running the entire length of the small bowel and placing a suture just upstream of the pathology.

Running the small bowel is accomplished from proximal to distal by placing the patient on the left side up, in slight reverse Trendelenburg position until the mid small bowel is reached, then adjusting the patient to the right side up with Trendelenburg position to run the distal half of the small intestine. The surgeon should start the "running" from between the legs then switch to the left side of the patient for the distal half (or permit the first assistant to run the distal half from left side of the patient). The technique of "running" should be "hand-over-hand" (Figure 8.1.3A and B) or "hand-to-hand" (Figure 8.1.4A-C) based on the degree of freedom present within the abdominal cavity.

If it will be advantageous to divide the mesenteric vessels before delivery of the specimen through the abdominal incision, this should be done using a LigaSure VTM instrument. We currently would just ligate the main vessel supplying the affected segment, and leave the other vessels of the mesentery to be divided through the incision. This may be especially helpful in a patient with a thick abdominal wall.

Once the specimen is fully mobilized, a cannula site is enlarged to 3-5 cm. For small incisions, a transverse incision is preferred. The anterior rectus sheath is transversely incised, the rectus muscles retracted, and the posterior sheath also transversely incised. If the incision has to be larger because of a bulky tumor, a longitudinal incision in the midline is accomplished above and below the umbilicus.

The wound is protected using a plastic sheath and the loop of intestine to be resected is drawn out through the enlarged incision. Wound protection is important to reduce any contamination by tumor cells or intestine and it may also facilitate the specimen extraction. The resection and anastomosis are then made in a standard manner extracorporeally, either by a hand-sewn or stapled method. The mesenteric defect is usually closed with a running absorbable suture through the incision.

After performing the anastomosis, the abdomen is copiously irrigated with warm sterile saline solution through the incision. The fluid is removed by placing the patient in the head-up position and passing a sump suction cannula into the pelvis. After irrigation of the peritoneal cavity, the abdominal wall is closed with a running suture or a series single suture.

Hand Sewn Bowel Anastomosis

Figure 8.1.3. Running the bowel using the "hand-over-hand" technique. A The right-handed grasper (1) releases the bowel and prepares to move from point A on the bowel to point C, while the left handed grasper (2), at point B, prepares to slide to the right of the illustration. B The instruments are crossed (handover-hand), and the left hand (2) now releases point B on the bowel and slides beneath the right-handed grasper (1) to regrasp at point D. Next the process repeats itself.

Figure 8.1.3. Running the bowel using the "hand-over-hand" technique. A The right-handed grasper (1) releases the bowel and prepares to move from point A on the bowel to point C, while the left handed grasper (2), at point B, prepares to slide to the right of the illustration. B The instruments are crossed (handover-hand), and the left hand (2) now releases point B on the bowel and slides beneath the right-handed grasper (1) to regrasp at point D. Next the process repeats itself.

The peritoneal cavity can then be finally inspected laparoscopically by leaving the wound protector in place, twisting it closed at the skin level, then clamping it with a Kocher clamp (Figure 8.1.5). This permits rapid reestablishment of the pneumoperitoneum, with a good seal of the specimen extraction site, for a final inspection inside the abdomen.

Lapriscopic Wounds HealthyLapriscopic Wounds Healthy
Figure 8.1.5. Twisting the wound protector and closing it with a clamp to quickly reestablish pneumoperitoneum after removing the specimen.

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Responses

  • diana
    What is "running the small bowel"?
    8 years ago

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