Proctectomy from Above

James P. Tiernan

Conor P. Delaney

LAPAROSCOPIC LOW ANTERIOR RESECTION

Perioperative Considerations

An oral polyethylene-based bowel preparation is given the day prior to surgery along with received three doses of 1-g neomycin and 500-mg metronidazole orally the day before surgery.
Tumors are generally visualized endoscopically by the operating surgeon and tattooed.
Magnetic resonance imaging should be reviewed prior to the operation to have a road map regarding tumor, threatened margins, and pelvic anatomy.
Preoperative subcutaneous heparin is administered within 2 hours of surgery, and sequential compression devices are used to help prevent deep venous thrombosis prophylaxis.
Pelvic ureteral stents are selectively used (eg, perforation, reoperative, radiation, tumor involvement).

Sterile Instruments and Equipment

10-mm balloon port
2 mm × 5 mm port, 1 mm × 12 mm port
Red rubber catheter cut into 5 cm pieces
10-mm 0-degree camera
5-mm laparoscopic blunt-tip bipolar energy device
3 mm × 5 mm laparoscopic atraumatic bowel graspers with locking ratchets
5-mm laparoscopic scissors with bipolar cautery attachment
Extra-long (bariatric) laparoscopic atraumatic bowel graspers and scissors available for morbidly obese cases
5-mm laparoscopic Maryland grasper or laparoscopic Allis clamp
End-to-end circular stapler 28-31 mm
Bean bag

Patient Positioning

Begin supine with the patient positioned on the bean bag (Fig. 31-1).
After induction of anesthesia, adopt the Lloyd-Davies position: ensure perineum just overhangs operating table edge, with legs in Yellowfins stirrups (Fig. 31-2).
Arms should be tucked next to torso, with foam padding used to prevent any pressure injuries at the hands and pressure points. In obese patients, the left arm may be left on an arm board (Figs. 31-1 and 31-2).
Knees should be flexed to ˜30-40 degrees.
Lower the Yellowfins so that the thighs are almost neutral to the torso to ensure adequate space for laparoscopic instruments to reach the splenic flexure.

FIGURE 31-1 ▪ The patient is positioned with their buttocks at the lower edge of the operating table.

FIGURE 31-2 ▪ Padded stirrups are used to position the legs to enable access to the perineum without compromising laparoscopic ergonomics, and the left arm can be left out for larger patients.

Instrument and Personnel Positioning

Primary monitor on patient’s left, secondary monitor on patient’s right.
Scrub technician stands between the legs with instrument table.

Primary surgeon begins on patient’s right; assistant begins on patient’s left and then repositions to patient’s right, standing cephalad to surgeon.

Port Insertion

Subumbilical 10-mm vertical incision (see Fig. 31-3)

FIGURE 31-3 ▪ Port positioning. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
Deepen incision to the linea alba, and grasp linea alba on each side with Kocher clamps, elevate and incise vertically with cautery. Bluntly insert a Kelly forceps through the peritoneum to enter the abdominal cavity.
Insert a purse-string suture into the fascial defect using 2-0 Vicryl and apply a Rommel tourniquet, fashioned from a 5-cm piece of rubber catheter and a hemostat (see Fig. 31-4).

FIGURE 31-4 ▪ Ports inserted with Rommel tourniquet applied.
Insert the Hassan balloon port, inflate the balloon, tighten the Rommel tourniquet, and attach the gas and establish peritoneum to a pressure of 12-14 mm Hg.
Perform a full laparoscopic evaluation of the abdomen.
Insert a 12-mm port at the ileostomy site. It is important that this site is medial enough to allow access of the right lower quadrant (RLQ) instrument to the right pelvic sidewall. In obese patients who have been marked for a right upper quadrant (RUQ) ileostomy, a RLQ site is chosen in line with this, and low enough to reach the anorectal junction with a stapler. Take care not to injure the inferior epigastric vessels at insertion.
Insert an RUQ and left lower quadrant (LLQ) abdominal 5-mm ports. An additional 5-mm port can be inserted later in the procedure if required—most commonly in the left upper quadrant (LUQ) for a high splenic flexure in the obese.

Technique

Left Colon Mobilization

Position the patient in steep Trendelenburg and right side down.
Assistant moves to patient’s right, caudad to the operating surgeon and holds the camera, and holds the camera in their right hand, and will later hold the LLQ instrument in their right hand.
Using two atraumatic bowel graspers inserted through the right-sided ports, reflect the greater omentum over the transverse colon. A nasogastric tube may be inserted to deflate the stomach to aid this maneuver.
To expose the inferior mesenteric vessels and sacral promontory, gently sweep the small bowel and its mesentery to the patient’s right, exposing the right colonic mesentery, ligament of Treitz, and sacral promontory.

TIPS

Using a closed bowel grasper, sweep the small bowel close to the base of its mesentery so that the loops of bowel “flop” over to the patient’s right side. Think as if one is trying to put one-third of the small bowel in the LUQ, one-third in the RUQ, and one-third in the RLQ. Sometimes, it is helpful to free congenital adhesions around the cecum and small bowel mesentery. If loops of bowel still obstruct the desired view despite operating table positioning, a 5-mm liver retractor can be placed through and LUQ port; however, this is rarely necessary.

The surgeon chooses the optimal part of the distal sigmoid to place the mesentery under traction to view the groove between the mesentery and the sacral promontory, and hands this to the assistant who is using the LLQ port and tents the sigmoid mesentery anteriorly and cephalad (Fig. 31-5A). The sigmoid is grasped at the right mesenteric margin, or lower on the mesentery, even halfway between the bowel and the sacral promontory to gently stretch it upward toward the LLQ port.

FIGURE 31-5 ▪ Incision of the medial sigmoid mesentery peritoneum and medial-to-lateral dissection. A. The mesentery is on tension to identify the groove for incision. B. Following the peritoneal opening the carbon dioxide from the pneumoperitoneum aids in the separation of tissue planes. C. Continued medial-to-lateral dissection between the retroperitoneum and the mesentery of the colon.

Make an incision in the peritoneum using cautery, beginning just above the sacral promontory in the sulcus between the mesentery and the retroperitoneum (see Figs. 31-5B and 31-5C). This point can be difficult to define, especially in obese males, and so immediately assess where the CO₂ is going, and if this helps define a better plane. If unsure, reassess and start distal to the sacral promontory to get into the presacral space, and work back proximally.

FIGURE 31-6 ▪ Mesocolon dissected away from retroperitoneum (Toldt fascia) using a medial-tolateral approach.

Open the peritoneum cephalad toward the origin of the tented inferior mesenteric artery (IMA) and extend it caudally past the sacral promontory.
Using a combination of sharp and blunt dissection, lift the sigmoid mesentery and vessels away from the retroperitoneum, ensuring the dissection is superficial to the ureter, gonadal vessels, and autonomic nerves, usually seeing a smooth “capsule” over the IMA, the congenital visceral fascia of the mesentery, working laterally in a medial-to-lateral fashion (Fig. 31-6).