When the patient arrives at the hospital on the day of surgery, there are several important steps that occur. If the anesthesia team is agreeable, clear liquids are allowed up until 2 hours before anesthesia induction unless a contraindication such as gastroparesis exists. In addition, all patients receive subcutaneous heparin and consideration is given to addition of a single dose of alvimopan (that can be postoperatively continued in the event of conversion to an open procedure). The evidence for routine use in laparoscopic procedures is controversial, so the authors do not routinely give it if the procedure is completed with the hand-assist technique. Chlorhexidine wipes are also used (as a third application in addition to what the patient has already done at home) to wipe patients down in the preoperative holding area to decrease skin bacteria. This step is also separate from the official prep that patients get in the operating room.

Before induction of general anesthesia, sequential compression boots are placed. Normothermia is maintained and a warming device is used at all times. Patients are positioned in the modified lithotomy position. Arms are tucked at the side; and in high-risk patients, a noninvasive monitor (esophageal Doppler) is used for goal-directed therapy or plethysmography variance impedance monitor. A beanbag is used to allow steep Trendelenburg positioning—ensuring to pad all pressure points. In nonobese patients, a gel pad can be used because it does not require any additional taping. With positioning, it is essential to check that both knees are in line with the opposite shoulder and that the stirrups are lowered as much as possible to avoid collision with instruments during the procedure. Access to the anal verge is also required in case a hand-sewn anal anastomosis is required as well as to facilitate intraoperative endoscopic assessment if needed (Fig. 31-1).

A bladder catheter is placed, although this step does not need to be done on the field after sterile preparation unless ureteral stents are needed. The authors have selectively used stents. Chlorhexidine solution is used to prep the abdomen from the nipples to the mid thigh. If a hand-sewn anastomosis is possible, the perineum is also fully prepped, although this prep is not routinely required.

Port placement is incredibly important for ergonomic flow of the procedure. A Pfannenstiel incision allows use of the surgeon’s hand to facilitate rapid total colectomy, and this port then can be used for proctectomy under direct visualization or with laparoscopic assistance. This incision has a low hernia formation rate and should be made large enough to comfortably admit the operating surgeon’s hand. A good rule is to make the incision the same length as the surgeon’s glove size (e.g., size 7 glove
requires a 7-cm incision). This incision should be made about two fingerbreadths above the pubic symphysis; and after raising subfascial flaps, the peritoneum and muscle should be divided in the midline all the way to the pubis and as far up as the umbilicus to ensure adequate exposure without compromising the comfort of the surgeon’s hand during a long procedure. The main disadvantage of this incision location is that if conversion to open is required, it results in an inverted T incision. If conversion is likely, an alternative is to place the hand-assist device through a lower midline or upper abdominal incision.

After placement of the hand port, the abdomen can then be insufflated and an additional camera port (10 mm) is placed near the umbilicus. With the abdomen insufflated, a four-quadrant inspection is then performed routinely to rule out any unexpected findings or metastatic disease. Additional 5-mm working ports are then placed laterally. To reach all quadrants of the abdomen, often a total of four working ports are required: lower ports about two fingerbreadths medial to the anterior superior iliac spines and upper ports about one palm breadth above these. Try to avoid placement of a port near the ileostomy or stoma site, because this can contribute to pouching difficulties. Although the port can be placed directly through the planned stoma site, this often creates a mechanical disadvantage because the placement is too medial for optimum use. The authors therefore do not routinely practice this method (Fig. 31-2).

Monitors need to be positioned on both sides of the patient, with the ability to move them more toward the head or the feet as the dissection proceeds throughout the case. Enough space should be created so that the surgeon can move freely along the arms as well, which means the operating table should be enough distance away from the anesthesia machine and any energy generator, insufflation, and camera equipment to allow this to happen.

Typically, the operating surgeon will begin by standing on the right side of the patient and use his or her right hand through the hand assist and an instrument through one of the ports in the left hand. A camera operator can then stand either beside the surgeon or between the legs. A teaching surgeon may instead stand between the legs and then can use the right hand in the abdomen to expose for a trainee or resident surgeon who can use two ports as does the operating surgeon while the teaching surgeon also operates the camera.

The hand can be a very useful tool, if appropriately used. Part of the learning curve for hand-assist surgery is learning how to keep it out of the field of view of the camera. Use of the C-shape configuration of the hand with maximal thumb keeps the hand up and away from the camera vision, which stays below this. The hand should hover from above for most of the dissection, with the exception of the lateral division of the colonic attachments, at which point the dissecting instruments may either need to be placed through the fingers or above the hand, as it pulls the colon away from these attachments.

The authors and the editors find it most time efficient to begin with takedown of the splenic flexure. After the abdomen is insufflated, the omentum and transverse colon are set up for this, and it eliminates the need for additional positioning. The reverse Trendelenburg position can be used. The gastrocolic omentum is divided to enter the lesser sac (or if preservation of the omentum is desired, the omentum can be placed over the liver and the avascular plane is divided to enter the lesser sac from below—Fig. 31-3). After entry into the lesser sac (as confirmed by visualization of the posterior aspect of the stomach), the distal transverse colon is progressively retracted caudally with the inserted hand. An energy device is used to take down any attachments heading toward the splenic flexure. This is continued all the way around until the white line of Toldt is visualized on the lateral aspect of the descending colon. In particularly challenging cases where the planes are not clear, an alternate approach is to identify the inferior border of the pancreas using a medial-to-lateral approach near the origin of the inferior mesenteric vein (IMV). This maneuver allows entry into the lesser sac from below, which can then facilitate taking down the lateral attachments later.