Standard mechanical bowel preparation with a polyethylene glycol solution and the addition of oral metronidazole and erythromycin is the author’s preference, because it is easier to handle an empty colon and the addition of oral antibiotics has been shown to decrease the incidence of surgical site infections. The patients are maintained on clear liquids up to 2 hours before surgery. We ensure that standard intravenous (IV) broad-spectrum antibiotics are given within 1 hour of skin incision. Because the patients will be in a modified lithotomy position for several hours, venous thromboembolic prophylaxis is mandatory. The author utilizes both subcutaneous heparin and sequential compression device (SCD) stockings, commencing immediately before surgery and continued after surgery. In an attempt to minimize narcotics use, patients receive IV ibuprofen and acetaminophen within 1 hour of surgery. All patients have an informed consent that includes the potential for conversion to an open procedure.

The patient is placed on a self-securing pad with a chest strap to prevent slippage. After induction of general anesthesia, an orogastric tube and indwelling urinary bladder catheter are placed. The patient is placed in a modified lithotomy position using Yellowfin Stirrups (Allen Medical, Batesville, IN) with the thighs even with the hips and all potential pressure points appropriately padded. Care is taken to ensure that there is no pressure on the peroneal nerves and that the patient’s knees are in line with contralateral shoulder. Both arms are tucked in the adducted position to facilitate securing the patients for the extremes of positioning used during laparoscopy. Rectal irrigation is performed and the skin is prepped with a 2% chlorhexidine-based solution and draped in a standard manner. Before draping, the table is rotated in all directions to ensure that the patient is secure.

Two monitors are utilized during the procedure. One is on the patient’s right side at the level of the shoulder. The other monitor is placed on the patient’s left side at the level of the hip. At the author’s institution, the monitors are mounted on booms from the ceiling allowing easy repositioning for optimal visualization. In the author’s institution, the insufflation tubing, suction tubing, cautery power cord, laparoscopy camera wiring, and a laparoscope light cord are brought off the patient’s left side at the foot of the table. The author routinely uses a 10-mm laparoscope with a 30-degree lens. However, with the increased availability of high-definition cameras and monitors, a 5-mm laparoscope may be an acceptable alternative.

Before placing any ports, the outline of the hand-assist device is marked on the patient’s abdomen. The author uses the Applied Medical GelPort (Applied Medical, Ranch Santa Margarita, CA). By tracing the outline of the device we ensure that all of our ports are outside the outline to function throughout the procedure. The author places the inferior edge of the device 2-3 cm from the pubic symphysis in the midline. Once this marking is done, a modified Hasson technique is employed to enter the abdomen above the umbilicus and obtain pneumoperitoneum. A vertical skin incision is made with a scalpel followed by dissection down to the linea alba. A Kocher clamp is used to elevate the fascia in the midline at the level of the umbilical stump and the linea alba is then incised. S-shaped retractors are helpful in exposing the midline. Entry into the peritoneal cavity is accomplished sharply. Once entry into the peritoneal cavity is obtained, a 10-mm blunt-tip balloon trocar is placed and inflated. A total of four additional ports are used. We use two 5-mm ports in the left and right upper quadrants and a 5-mm port in the left lower quadrant. A 12-mm port is employed in the right lower quadrant to allow placement of an endoscopic stapler if necessary; the hand port is placed later in the procedure (Fig. 24-1).

After establishing pneumoperitoneum and placing the necessary ports, the abdominal cavity is laparoscopically explored. To help with postoperative pain, we a place a transversus abdominis plane (TAP) block with bupivacaine. The TAP block is performed at the anterior axillary line midway between the
costal margin and the iliac crest. A 20-gauge needle is passed through the skin and continued until two distinct “pops” are felt, signifying passage through the oblique layers and into the TAP. Here, boluses of bupivacaine are placed at 2-cm intervals. The entire process is visualized laparoscopically.

The patient is then placed in slight reverse Trendelenburg position and is rotated to the patient’s right. We initially begin the operation with both splenic flexure and right colon mobilization before placement of the hand port. Unlike other authors, we find that placing the hand port before mobilizing these steps actually slows down the operation. With the patient rotated to the right, the small bowel is swept to the right and inferior. This exposes the ligament of Treitz. Looking laterally the inferior mesenteric vein (IMV) is clearly visible. The vein is carefully elevated and dissection is carried out laterally, posterior to the IMV and anterior to Gerota’s fascia to the abdominal sidewall posterior to the colon. Once the plane is developed, the IMV is divided using a vessel-sealing device such as the Ethicon EnSeal (Ethicon Endosurgery, Cincinnati, OH), although the choice of the alternate energy source is left to the surgeons’ discretion. The dissection is carried out superiorly to the inferior border of the pancreas and inferiorly to the inferior mesenteric artery (IMA).