Laparoscopic Medial-to-Lateral

Jonathan Efron

Michael J. Stamos

Indications

The indications for laparoscopic left colectomy performed either by a medial-to-lateral approach or a lateral-to-medial dissection are diverse, including both malignant and benign conditions. Early in the history of laparoscopic colectomy, controversy existed as to the safety and feasibility of laparoscopic colectomy for cancer. This was secondary to early recurrence rates, primarily port site recurrences, which surgeons feared may be secondary to the technical aspects of laparoscopic colectomy, such as the pneumoperitoneum. Several prospective, randomized trials, however, have demonstrated equivalent recurrence and long-term survival rates between laparoscopic and open colectomies performed for cancer (1,2,3). Currently, malignancy is considered an optimal indication for laparoscopic colectomies. Some relative contraindications for performing a laparoscopic colectomy for cancer include T4 cancers with extensive involvement of other abdominal organs, or tumors that are greater than 8 cm in diameter.

Most benign conditions also lend themselves to laparoscopic resection by a medial-to-lateral approach. These reasons include diverticulitis, inflammatory bowel disease, and polyps. In complicated diverticulitis or Crohn’s disease with an associated pericolonic abscess, the medial approach may allow early identification of the ureter and iliac vessels, allowing for a safer lateral dissection in the inflamed tissue. Conversely, if the intestinal mesentery is significantly thickened from Crohn’s disease, approaching the dissection laterally may avoid injuring the mesentery preventing excess bleeding or the formation of a mesenteric hematoma. Dividing thickened Crohn’s mesentery is difficult with either vessel sealing devices or intracorporeal staplers and this may limit the ability of the surgeon to perform a medial-to-lateral dissection as division of the inferior mesenteric vessels may not be possible. Similarly, conditions such as sigmoid volvulus and rectal prolapse generally require minimal sigmoid mobilization and therefore are not well served by a medial-to-lateral approach with high ligation of the inferior mesenteric vessels.

When approaching a laparoscopic colectomy, standardizing the surgical technique helps to facilitate the operation. Standardization facilitates the procedure, allowing it to
be performed in a quick and efficient manner, decreases surgeon frustration, and decreases operative time. Each step must have specific targets and those targets should be reached in a timely fashion. If the surgeon is not meeting those goals and the operation is failing to progress, early conversion is advocated and may reduce the risk of intraoperative complications. Just as standardization facilitates performing the procedure, instituting standardized preoperative and postoperative care pathways have shown to be safe and cost effective, reducing length of stay and decreasing hospital costs (3,4,5,6).

Preoperative Planning

Preoperative preparation prior to laparoscopic colectomy includes ensuring that the patient’s medical comorbidities are well controlled and that he or she is an acceptable candidate for surgery. Preoperative teaching of the patient and family should include instructions on the patient’s postoperative responsibilities. These include early eating and ambulation, use of incentive spirometers, and expectations for early discharge. Implementing a fast-track protocol reduces hospital length of stay with similar morbidity and low readmission rates to patients treated off protocol (7,8,9).

Bowel preparation is a controversial practice for left colectomy that may still be initiated. Multiple prospective randomized studies have been performed examining the outcome of elective colonic resections with and without bowel preparation. Most authors have shown no difference in complication rates between the two groups, including anastomotic leak rates, whereas some investigators have shown a higher rate of wound infections in the patients who have received a bowel preparation (10,11). Recent large studies have again failed to show the necessity of routine bowel preparation (12,13,14). Patients who may require intraoperative colonoscopy for localization of polyps or tumors during the surgery will require mechanical bowel preparation. It is also the practice of the authors to prepare the patients with a mechanical bowel preparation if proximal fecal diversion is planned after completing the colectomy and anastomosis. If no mechanical oral preparation is used for a laparoscopic left colectomy, the patient should perform two disposable phosphate enemas before entering the operating room to allow unimpeded transanal passage of a circular stapler.

Final preoperative preparation includes instillation of intravenous antibiotics and administration of subcutaneous heparin. Sequential compression stockings should also be used. Placement of an epidural catheter is advocated by some surgeons for postoperative pain management to limit postoperative narcotic intake and to enhance recovery. Epidural placement should be performed in the preoperative area in addition to ensuring that adequate intravenous access is obtained prior to positioning the patient in the operating room as both arms will be tucked at the patient’s side during the operation. Keeping the patient warm in the preoperative area will help maintain core body temperature during the procedure.

Procedure

Preparation for the operation continues upon entry to the operating room. After placement of intravenous lines and epidural catheter if utilized, the patient is then induced under general anesthesia. The patient is placed in the modified lithotomy position with carefully padded Allen stirrups and with thigh high sequential compression stockings utilized. Positioning of the patient in the operating room should include tucking of the right (or both) arm(s) by the patient’s side to allow full access to that side of the patient, since the conduct of the operation has the operating surgeon and assistant standing on the right side and also intermittently between the legs to facilitate splenic flexure mobilization.

The monitors should be positioned so that they are available near the left shoulder of the patient as well as the left hip area for maximal viewing capability of this multiquadrant operation. The patient needs to be not only carefully padded to avoid any pressure injuries, but also carefully secured to the bed to allow extreme positioning changes during the operation. In particular, steep Trendelenburg position is utilized and
therefore gel pads placed above the shoulder or some other method of securing the patient (beanbag) are essential. In addition, these pads or beanbags must be thoroughly secured to the table. It is the practice of the authors to test the secure positioning of the patient prior to prepping and draping by moving the bed into extreme left side up position, and extreme Trendelenburg position prior to draping so that any potential issues regarding patient movement can be corrected before beginning the operation. This time is well spent and should not be disregarded. Following this positioning, the patient’s abdomen is prepped and draped extending over to the anterior axillary lines laterally and up to the rib cage superiorly and inferiorly down to and including the pubic area.

After draping, primary abdominal insufflation is typically obtained using a Veress needle technique. The primary insufflation site is placed off of the midline, generally two finger breadths lateral to and above the umbilicus in the right upper quadrant. This position may vary based on any prior surgery or expected adhesions in the abdominal cavity. Once insufflation is obtained, a 5 mm trocar is placed at that site and then two additional trocars are placed, one 5 mm size in the epigastric area just slightly to the left of midline and a 12 mm trocar in the right lower quadrant just medial and slightly superior to the anterior superior iliac spine. If necessary, a fourth 5 mm trocar can be placed in the left lower quadrant lateral to the rectus muscle, and this fourth trocar site can then be utilized for a muscle splitting incision for extraction of the specimen and insertion of the circular stapling anvil if utilized.

In the case of a cancer diagnosis, the initial steps are to perform a staging laparoscopy by first placing the patient in reverse Trendelenburg position to evaluate the liver and peritoneal surface and then returning to a slight Trendelenburg to evaluate the rest of the abdominal peritoneal cavity and the pelvis.

To begin the left colon mobilization, the patient is placed in steep Trendelenburg with slight left side up tilt and the small intestine is mobilized out of the pelvis. Not infrequently there are adhesions of the terminal ileum or cecal region to the right pelvic region that restrict mobility of the small bowel. These adhesions should be divided to ensure that the small bowel is fully mobilized and out of the pelvis and therefore not obscuring the view.

At this time any attachments of the sigmoid colon to the left pelvis or lateral pelvic side wall are appreciated. The mesosigmoid is grasped near its mid to distal portion using an atraumatic grasper and the colon is allowed, if mobile, to flip behind the mesentery out of the view of the operating surgeon. A grasper, placed through the epigastric trocar elevates the mesosigmoid anteriorly towards the anterior abdominal wall. It can be moved slightly from right to left to identify the plane of dissection behind the mesocolon just at or above the sacral promontory. The iliac vessels are often visualized at this time through the retroperitoneal surface and in a thin patient the right ureter may also be obvious. Dissection is commenced in this plane behind the mesosigmoid and above the sacral promontory but caudal to the inferior mesenteric artery (IMA) origin. The IMA is usually obvious because when the mesosigmoid is grasped and elevated anteriorly, it typically tents up and is quite prominent as the dissection continues.

The peritoneum overlying the dissection plane is scored along the sacral promontory into the pelvis and also cephalad toward the IMA. Establishing this dissection plane is an essential first step.

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