The patient is placed supine on the operating table on a bean bag. After induction of general anesthesia, an oral gastric tube and a Foley catheter are placed. The legs are then placed in yellow fin stirrups in modified lithotomy. Care is taken to ensure the perineum is at the edge of the table to ensure easy passage of the EEA stapler. The legs need to be positioned such that the stirrups can be dropped so that the thighs are at the level of the abdominal wall. If they lay higher, the operator may conflict with the
patient’s thighs while working between the legs taking down the splenic flexure. The arms are tucked. If the patient is too obese to tuck both arms, the left arm is left out as most of the dissection will be on the patient’s right side. The bean bag is aspirated after wrapping it about the shoulders and the patient’s arms.

The primary monitor is placed on the patient’s left side at the level of the shoulder or mid-chest. A secondary monitor is placed near the patient’s right lower abdomen, primarily for the assistant during port placement. The instrument table is placed below the left leg. The nurse stands adjacent to the left leg. The operating surgeon is in the right lower quadrant, with the first assistant to his left, except during port placement. The operating surgeon may move between the legs during splenic flexure mobilization. A second assistant, if available, would stand on the patient’s left side (Fig. 16.1). A 30-degree, 5-mm laparoscope is used.

The applied medical gelport is the preferred handport. A midline incision is made through the umbilicus, and the gelport is inserted (Fig. 16.2). Positioning the incision higher in the abdomen facilitates takedown of the splenic flexure and high
ligation of the inferior mesenteric artery (IMA). Generally, the handport incision length in centimeter corresponds to the surgeon’s glove size or a size smaller. The author wears a size 8 glove, but typically makes a 7-cm handport incision. Any adhesions in the midline are lysed via the port incision. A port is placed through the gelport, and the abdomen is insufflated. A 5-mm suprapubic port is placed. The hand is then placed in the abdomen and a 12-mm right lower quadrant port is placed to allow stapling. An optional 5-mm port is placed in the left lower quadrant to facilitate splenic flexure mobilization. An optional additional 5-mm port in the right midabdomen can be helpful with IMA ligation (Fig. 16.3).

The abdomen is insufflated to a pressure of 12 to 15 mmHg and is explored. The liver is examined with the laparoscope and palpated with the hand. The primary tumor is looked at and palpated to determine its location and assess resectability. The remaining abdomen is examined for nodal or peritoneal metastases.

The surgeon begins in the right lower quadrant with the assistant to his left. The camera is in the right lower quadrant port. The surgeon’s left hand is in the abdomen and dissection is initially begun via the suprapubic port. The patient is placed in the steep Trendelenburg position and rotated right side down. The small bowel is swept from the pelvis. The omentum is placed in the upper abdomen cephalad to the transverse colon, overlying the stomach. The orogastric tube placement is confirmed at this time. The hand greatly facilitates these maneuvers. A laparotomy pad can be placed in the abdomen via the gelport. This facilitates packing the small bowel cephalad in obese patients and can also be used to clean the laparoscope periodically without removing the scope from the abdomen.