Program Colorectal Pathway: Laparoscopic Left and Sigmoid Colectomy for Benign Disease

Fig. 3.1

(a, b) Splaying of the taeniae

In addition to providing an adequate resection, a principle of left/sigmoid resection for benign disease is to avoid a high ligation of the sigmoid pedicle. The avoidance of a high ligation decreases the risk of ureteral injury and hypogastric nerve injury. Some studies have indicated that avoiding a high ligation of the pedicle decreases the chance of anastomotic leak [13]. Other studies have not confirmed this association [14]. However, in our practice for benign disease, we preserve the sigmoid pedicle given this concern.

Preoperative Planning, Patient Work-Up, and Optimization

In the planning of a minimally invasive approach to surgical resection for diverticulitis, a number of factors must be considered preoperatively. For those patients whom have not had a colonoscopy in the 2 years prior to resection, repeat endoscopic evaluation is warranted. Some of our surgeons will perform an on-table colonoscopy on the day of surgery in order to avoid repeating a bowel preparation. For patients with complicated diverticulitis, additional factors must be taken into account preoperatively. Patients with residual diverticular abscess and/or fistula will keep their percutaneous drain up until the time of surgery. The drain will be prepped into the field and then removed once the abdomen has been entered. For those patients with suspected colovesical fistula, cystoscopy and ureteral stent placement are usually performed just prior to surgery. If the fistula takedown results in a bladder defect, it should be repaired with sutures. In regard to ureteral stent usage in the absence of colovesical fistula, the decision to place stents prophylactically is up to the individual surgeon. In general, when significant inflammation and/or residual phlegmon, abscess, or fistula is anticipated, left-sided stents are usually placed prophylactically to minimize the risk of an unrecognized ureteral injury.

All prior abdominal scars should be evaluated as potential extraction sites. Patients are educated about enhanced recovery pathways including non-opioid pain relief alternatives, early ambulation, and early resumption of diet. All of our patients undergoing elective colon surgery undergo mechanical and antibiotic bowel preparation the day before surgery. Please refer to the chapters on enhanced recovery protocol in colorectal surgery for more details on this topic (Chaps. 7 and 8).

Operative Setup

Patients are placed on a bean bag in a modified lithotomy position on a split-leg table. The arms are tucked at the sides and surrounded by foam padding and an inflated bean bag. The chest is wrapped circumferentially three times with three-inch silk tape affixing them to the table. The legs are split with the buttock at the bottom of the table to allow for trans-anal access, and then the legs are secured in place with Velcro straps. Patients are given subcutaneous heparin, and sequential compression devices are applied for deep venous thrombosis prophylaxis. Antibiotics are administered less than 1 hour prior to surgical incision. We use both monopolar cautery and the bipolar vessel sealer as our energy sources. Both of these instruments are placed on the field at the initiation of the case. A CO₂ colonoscope is available as needed for the procedure. Most cases are initiated with a colonoscopic evaluation of the colon. The Foley catheter is placed after colonoscopy in women to avoid risk of urinary tract infection as our group found that there was contamination of the catheter from colonoscopy if it had been placed pre-procedure. The catheter is draped over the leg to reduce contamination from the passage of staplers and endoscopes trans-anally.

Operative Technique

Port Placement

For straight laparoscopic procedures, a 12 mm Hassan port is placed in the umbilicus. 5 mm ports are placed in the right upper quadrant, the right lower quadrant, and the left lower quadrant (Fig. 3.2). Extraction is most often performed through a small Pfannenstiel incision or via an extension of the Hassan port site.

../images/465809_1_En_3_Chapter/465809_1_En_3_Fig2_HTML.jpg — Fig. 3.2

Room setup for laparoscopic sigmoid colectomy . (Used with permission of Springer Nature from Leroy et al. [26])

For a hand-assisted approach, the operation begins with the creation of an incision for the hand-port. Early along the learning curve of hand-assisted, an 8 cm lower midline incision is recommended in the case that conversion is required. Once the surgeon is comfortable with a hand-assisted approach, a Pfannenstiel incision 2 cm above the pubis is the preferred approach. The incision is cosmetically pleasing, has an extremely low risk of incisional hernia, and is an excellent incision to work in the pelvis where further dissection or an anastomosis can be completed. The hand device is placed into the incision, and then three 5 mm trocars are placed in the left lateral, right lateral, and umbilical positions (Fig. 3.3). The trocars are placed with the hand inside the abdomen to protect the intestines from injury. Following access to the abdomen, the procedural steps of the operation are performed in the same sequence whether the procedure is performed by straight laparoscopic or a hand-assisted laparoscopic approach .

../images/465809_1_En_3_Chapter/465809_1_En_3_Fig3_HTML.jpg — Fig. 3.3

Room setup for HAL sigmoid colectomy . (Used with permission of Springer Nature from Sonoda [25])

Left/Sigmoid Colectomy

The surgeon and assistant stand on the patient’s right side. The patient is placed in a mild Trendelenburg and left-side up position. In our practice, we perform a medial to lateral mobilization of the left/sigmoid colon. To do this, the omentum is lifted over the transverse colon, and the small bowel is moved out of the pelvis to the right upper quadrant (Fig. 3.4). The “bare area” of the left colon (the mesentery just lateral to the IMV between the left colic and first sigmoidal branches) is grasped and lifted. This mesentery is incised just lateral to the IMV, and a dissection begins between the left colon mesentery and Gerota’s fascia. The gonadal vessels will be below with Gerota’s fascia, and the dissection continues out to the lateral side wall. The left ureter is typically under the IMA pedicle and will not be seen unless dissection is carried backwards toward the aorta. The first one or two sigmoid branches are then identified, isolated, and divided with the bipolar vessel sealer. The left colon is then mobilized from medial to lateral in a plane overlying Gerota’s fascia (Fig. 3.5). This dissection extends out to the left pelvic sidewall, inferiorly into the upper retrorectal space, and superiorly up towards the splenic flexure.

../images/465809_1_En_3_Chapter/465809_1_En_3_Fig4_HTML.jpg — Fig. 3.4

The omentum is lifted over the transverse colon and the small bowel is moved to the right side of the abdomen. (Used with permission of Springer Nature from Leroy et al. [26])

../images/465809_1_En_3_Chapter/465809_1_En_3_Fig5_HTML.jpg — Fig. 3.5

Medial to lateral mobilization . (Used with permission of Springer Nature from Leroy et al. [26])

After the medial to lateral mobilization has been performed, the lateral attachments starting with the white line of Toldt are divided (Fig. 3.6). This maneuver connects the medial dissection plane to the lateral dissection plane. Moving up towards the splenic flexure, the lateral aspects of the splenic flexure are divided. For this part of the procedure, the assistant moves to the area between the legs and holds the camera with his left hand and the hook cautery with his right hand through the left-sided trocar. In this same position, the omentum is taken off of the distal transverse colon allowing the splenic flexure to be approached from a medial direction. Then the distal transverse mesocolon is freed from the inferior boarder of the pancreas. At this point, the colon should be assessed for reach down to the proximal rectum. If the reach is adequate, the mesentery can be taken with a bipolar device up to but not crossing the marginal artery on the proximal transection margin (the rest of the mesentery will be ligated once the colon is exteriorized). For the distal transection margin, the mesentery can be taken up to the edge of colon laparoscopically. However, if the procedure is being performed with a hand-assisted, that portion of the case can be done via the hand-port in an open fashion. At that point, the bowel can be exteriorized (Fig. 3.7), and the specimen can be brought out through the hand-port (in the case of hand-assisted) or through an extraction site (straight laparoscopy). In the situation of straight laparoscopy, a small wound protector should be used to ease specimen extraction and to protect the wound from contamination.

../images/465809_1_En_3_Chapter/465809_1_En_3_Fig6_HTML.jpg — Fig. 3.6

Taking down the lateral attachments. (Used with permission of Springer Nature from Sonoda [25])

../images/465809_1_En_3_Chapter/465809_1_En_3_Fig7_HTML.jpg — Fig. 3.7

Exteriorizing the sigmoid colon. (Used with permission of Springer Nature from Leroy et al. [26])

The proximal transection and distal transection are completed via the extraction site. For straight laparoscopy, the anvil is placed in the proximal colon which is returned to the abdomen. The stapled colorectal anastomosis can be performed while under laparoscopic view (or in some cases through the wound directly if a Pfannenstiel or lower midline incision is used). It is critical to ensure that there are no twists in the proximal colon or the mesentery and that the small bowel is not trapped under the left colon mesentery before the stapler is fired. For hand-assisted cases the anastomosis can be performed through the hand-port site. The anvil is secured to the stapler and closed under direct visualization. However, prior to firing of the stapler, a pneumoperitoneum is reestablished to ensure that the proximal colon and its mesentery are not twisted, that the small bowel is not trapped under the left colon mesentery, and that there is no tension upon the anastomosis. In either approach, the omentum is brought down over the small bowel and colon to an anatomical position. Following the anastomosis, air leak testing is performed with CO₂ colonoscopy, and the mucosa is examined for perfusion. The anastomosis may be reinforced with a few additional sutures depending upon the surgeon’s preference. For cases without significant spillage or concern for colovesical fistula, no closed suction drain is left behind. For patients in whom a colovesical fistula repair was performed, a closed suction is placed in the pelvis.

Pitfalls and Troubleshooting

Some of the most common pitfalls in this operation are extensive scarring due to diverticular inflammation which distorts the anatomy, a lack of reach of the proximal colon into the pelvis, or a positive leak test. Extensive scarring from repeated episodes of uncomplicated diverticulitis or complicated diverticulitis with abscess/fistula can preclude a straight laparoscopic approach. This is where the hand-assisted approach can be the most helpful. The hand and fingers allow for safe blunt dissection. In addition, portions of the procedure can be performed via the hand-port in an open fashion, should the situation demand it. If the procedure cannot be performed in a straight laparoscopic fashion, or if failure to progress occurs, one should consider a hand-assisted approach prior to converting to a midline laparotomy. A meta-analysis of the three published RCTs comparing hand-assisted laparoscopic to conventional laparoscopic colorectal resection showed a significantly lower rate of conversion in the hand-assisted patients, while morbidity rates and outcomes were equivalent [15].

Another possible intraoperative difficulty in surgery for diverticulitis is extensive residual disease requiring more distal transection onto the patient’s rectum. Usually, the goal is to keep the distal transection margin at the colorectal junction. However, in some scenarios such as a residual phlegmon/abscess involving the top of the rectum or a colovaginal fistula, it is necessary to dissect further distally onto the rectum than initially planned. In these scenarios, it is important to consider and warn the patient of potential functional consequences. More than 50% of patients who undergo low anterior resection for benign or malignant disease will develop signs and symptoms of low anterior resection syndrome. This is a defecatory dysfunction defined by urgency, frequent stools, incontinence, and incomplete emptying. These patients may require fiber supplementation and antidiarrheals to assist in improving quality of life. In more severe cases, biofeedback, sacral nerve stimulation, and colostomy can be considered.

Another common intraoperative difficulty is a lack of reach of the proximal transection margin to the rectum. This is particularly common if the patient’s disease extends up into the descending colon. There is a stepwise approach to achieving more laxity to allow for a tension-free anastomosis. First, the bowel must be assessed for what is holding it from the pelvis. If the splenic flexure has not been fully released, then that should be performed. Second, the IMV and or left colic can be transected close to the inferior margin of the pancreas to allow further mobility. The transection margin must be assessed for viability after that maneuver. Here, every lateral 1 centimeter of division provides two additional centimeters of reach. Third, the rectum can be mobilized below Waldeyer’s fascia, thereby straightening the rectum, which typically provides several additional centimeters of length. A final option is the Turnbull maneuver, wherein the distal transverse colon is brought down to the right of midline, through an ileal mesenteric defect [16]. All of these maneuvers can be performed via hand-assisted or straight laparoscopic methods .

Lastly, one of the most concerning pitfalls is a positive intraoperative leak test. If leaking is demonstrated, our recommendation is to either redo the anastomosis or, if an attempt at repair of the anastomosis is performed, strong consideration should be made for a diverting loop ileostomy. Data from our own institution demonstrate that out of 2360 patients who underwent left-sided anastomosis, 119 had a positive intraoperative leak test. Sixty-eight underwent suture repair alone, of which 9% had a clinical leak postoperatively. Fifty-one patients underwent either proximal diversion or reconstruction, and none of these patients had evidence of clinical leak postoperatively. Given these data, our strong recommendation is to either redo or divert the anastomosis in this clinical scenario. For all other patients, the decision to proceed with a diverting loop ileostomy to protect the colorectal anastomosis is based on three factors: the integrity and perfusion of the bowel, the degree of intraabdominal contamination , and the status of the patient. If following resection of the specimen the bowel is intact and well-perfused, the abdomen is free of infection, and the patient has remained hemodynamically stable during the case, there is no strict indication for a prophylactic diverting loop ileostomy. However, if any of those three factors are concerning, a diverting loop ileostomy should be strongly considered.

Outcomes

When considering laparoscopic approaches for patients with benign disease, there are two questions that need to be answered. The first is whether the laparoscopic or hand-assisted techniques are equivalent to an open surgical approach. In some ways, this is a difficult question to answer as, unlike cancer, there are not specific criteria of the surgical specimen that need to be obtained for the operation to be considered a success. Instead we have to rely on outcome measures like operative time, conversion rate, length of stay, and complications to assess whether the procedures are equivalent (or superior). The second question is which laparoscopic approach is appropriate (straight laparoscopic versus hand-assisted laparoscopy).

When laparoscopic colectomy was first introduced in the 1990s, diverticular disease-related complications were the last indications to be evaluated scientifically given the concerns of extensive scarring and/or inflammation as potentially precluding a minimally invasive approach. Following this initial hesitation, studies were conducted to compare laparoscopic versus open sigmoid colectomy for diverticulitis in the late 1990s/early 2000s (Table 3.1). Most studies found that the laparoscopic approach had longer operative times with conversion rates ranging from 6% to 20%. Length of stay was significantly shorter in the laparoscopic groups. With regard to complications, some studies found no differences between the groups, while other studies found that there were fewer complications with a laparoscopic approach. Even patients with complicated disease such as abscess or fistula were completed by a laparoscopic approach. This was detailed by Bartus and colleagues in 36 patients who underwent laparoscopic colovesical fistula takedown [17]. The conversion rate was higher for procedures involving fistula (25% versus 5%, p <0.001), but demonstrated that for many, the procedure could be performed successfully. Overall, for elective benign indications like diverticulitis, these studies demonstrated that a laparoscopic approach was possible and that it had a positive effect on the length of stay and extent of complication profile.

Table 3.1

Laparoscopic approach versus open surgical approach for diverticulitis

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