Laparoscopic Lateral-to-Medial

Morris E. Franklin Jr

Guillermo Portillo

Karla Russek

Introduction

A laparoscopic approach to colon resection has been quoted as showing numerous advantages when compared to similar open procedures including less postoperative pain, reduced ileus, reduced immunosuppression, decreased length of hospital stay, improved cosmesis, and earlier return to normal activities. Numerous reports have shown equal or better survival in cancer patients when a laparoscopic approach is utilized.

Several options of performing laparoscopic colon surgery have been developed, but according to the authors there are three currently accepted techniques. Laparoscopically assisted, in which the dissection is completed all through a laparoscopic approach, but the specimen is extracted by way of an incision, with an extracorporeal anastomosis subsequently performed.

Laparoscopically hand-assisted, where the dissection is hand aided and the specimen is extracted by the hand port or an incision.

Laparoscopic, where all of the dissection, vascular control, bowl resection, and anastomosis are laparoscopically performed, with the specimen being extracted through natural orifices such as the anus or vagina. According to the editors, the laparoscopic approach also includes specimen delivery through either the abdominal wall or a perineal incision.

The authors’ preferred method is the totally intracorporeal technique, suitable for left colon resections, including partial resections, sigmoid, and low anterior resections, which may be used in a large number of patients. In cases of right colon resection a totally intracorporeal anastomosis is preferable with a small muscle splitting incision or vaginal extraction.

These techniques allow a more anatomical and physiologic resection. It is well known that surgical trauma modifies and modulates the immunological response; therefore, minimizing trauma to the abdominal wall may enhance the recovery of the patient. We have seen a faster recovery and a diminished number of complications compared to published reports with laparoscopically assisted and hand-assisted laparoscopic surgery.

The purpose of this chapter is to demonstrate and discuss the technical tips that the authors have found to be beneficial in the performance of laparoscopic colorectal surgery.

Indications and Patient Selection

Results from randomized prospective trials have proven that the laparoscopic method, in experienced hands, yields results that are at least equivalent, from an oncologic perspective, to traditional open methods. A laparoscopic approach has become the preferred method for performing colectomy for all benign and malignant conditions.

Accurate preoperative tumor localization is an important consideration when planning a successful laparoscopic colectomy for malignancy. Patients can undergo colonoscopy, when possible, the day prior to surgery, obviating the need for two separate bowel preparations; the lesion can be marked with tattoo ink. At the time of surgery, the air that was insufflated during colonoscopy will have been evacuated, thus colonic distension should not pose a problem during the procedure. While endoscopic localization of right-sided tumors may be ascertained if the lesion is visualized within sight of the ileocecal valve, there is no comparable landmark when dealing with transverse colon or left-sided lesions.

India ink and other nonchemically carbon-based inks are the most common agents used. Intraoperative colonoscopy should be performed if the tattoo cannot be seen or if the surgeon is not confident with the localization as is described elsewhere in this chapter. Pre operative barium enema can also be extremely useful in localization of specific lesions and is used routinely in our practice.

Surgery

Port Placement

Pneumoperitoneum is achieved by a Veress needle placed in the right side, right upper quadrant, right mid flank outside of rectus sheath. There are many different port site arrangements utilized for laparoscopic left and sigmoid colectomy. The patient’s body mass index and abdominal breadth should be taken into consideration when choosing port locations; target quadrants should be identified and the ports placed to assure adequate access. When placing the right lower quadrant port to accommodate the endoscopic stapler, the surgeon must consider the angle that the stapler will achieve coming across the rectosigmoid. Similarly, instruments introduced through the left-sided port(s) should reach to the splenic flexure and also allow retraction of the sigmoid colon mesentery deep in the pelvis. As with other advanced laparoscopic procedures, working ports should be triangulated to the operative field to avoid sword fighting of the instruments and to accommodate two-handed dissection.

Depending on the availability of and the need for a second assistant to hold the laparoscope, a 4-port or a 5-port setup is utilized. Once port placement is completed, the operation commences.

Surgical Technique

The initial maneuver is mobilization of the sigmoid and visualization of the left ureter. In the lateral-to-medial approach, the peritoneum is first incised with a steady dissection of the sigmoid colon and the high portion of the rectum toward a medial direction, with care taken to avoid injury to the external iliac artery, vein, and nerves. Mobilization of the sigmoid should be performed until the ureter is identified and the peritoneum has been incised to the level of middle hemorrhoidal vessels. If the vessels can be readily identified on the left they can be ligated. It is important to remember that
the ureter can easily be confused with the superior rectal artery and we feel each should be identified before incision. With the sigmoid colon on anterior stretch, the peritoneum is incised on the right of the rectosigmoid mesentery. This maneuver establishes a window through which the left ureter is identified. Laparoscopically, this step is quite easy and frequently the CO₂ will help establish this dissection plane. Following this phase, the inferior mesenteric artery and vein are identified 3–5 cm above the iliac bifurcation and can be ligated at the highest level possible. We recommend separate division of the artery and vein with either a bipolar cutting device or ligation with 10 mm clips and then followed by division and application of polydoioxane pre-tied endoloop. The artery should never be incised in one cut; rather, the artery should be partially incised, checked for residual back flow, or additional bleeding. If such bleeding occurs, additional clips and/or ligation may be applied as needed. With intracorporeal knot tying skills, the vessels may also be quite economically ligated with sutures.

The inferior mesenteric vein is often adjacent to the artery and as such care should be taken to identify this structure. In case of colon cancer the inferior mesenteric vein may be traced to its origin at the splenic vein or at least to the ligament of Treitz, and ligation and division performed at this point. Care should be taken to avoid injury of the ureter in this ligation. We perform splenic flexure mobilization in almost every patient, to help prevent tension on the anastomosis. The patient should be placed in reverse Trendelenburg position with the left side rolled up. Mobilization of the splenic flexure is easier to perform laparoscopically than during open surgery because of the excellent visualization and identification of anatomical structures with the laparoscope. We use three approaches for splenic flexure mobilization, lateral-to-medial, medial to lateral, and retroperitoneal approach.

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