Tissue triangulation is one of the most essential techniques in colorectal laparoscopy. The tissue is triangulated between three grasping instruments, two held by the assistant and one by the surgeon (Figure 6.10). This tension allows for precise initial incision of the peritoneum and guidance in the direction of the dissection using the third grasper. Thereafter, mesenteric vessels can be palpated and isolated with a gentle, blunt sweeping maneuver of the dissecting instrument and then coagulated or clipped. With this technique, the mesentery can be divided quickly with only minor bleeding.
Separating the greater omentum from the transverse colon should also be accomplished using tissue triangulation. Any adhesions of greater omentum to the colon/mesocolon can be divided under tension using a scissor with electrosurgery, the ultrasonic scalpel, or the LigaSure™ vessel sealer. In some patients with colitis, the greater omentum may develop vascular attachments to the colon, and dissection may be difficult and require extensive coagulation. Because the greater omentum itself is usually quite flaccid, coagulation with ultrasonic scalpel is difficult. The LigaSure™ device seems preferable to us in these cases (Figure 6.11).
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