Single Incision Laparoscopic Right Colectomy

Indication

Polyps and polyp syndromes

Malignancy

Inflammatory bowel disease

Diverticulitis

Ischemic colitis

Rectal prolapse

Volvulus

Constipation

Colostomy and reversals

Contraindications

Unstable patients or those with a life-threatening pathology (such as perforation and peritonitis) are not suitable candidates for laparoscopic colectomy.

Several relative contraindications exist for SILC, similar to MPLC. Patient who have had peritonitis or multiple previous surgeries are less likely to be successfully operated by a laparoscopic approach. Patients with complex anatomy due to their disease process, for example Crohn’s disease with fistulae and obstruction, may not be amenable to laparoscopic identification of anatomic landmarks. Patients who have bowel obstruction and significant bowel distension are often best served by an open approach because adequate pneumoperitoneum, and therefore visualization, cannot be secured around the distended bowel. There may be literally no space within which to work. Finally, patients with a large palpable mass or phlegm on after induction of general anesthesia will require a commensurate incision for specimen extraction and may be best served by open laparotomy. Unstable patients or those with a life-threatening pathology (such as perforation and peritonitis) are not suitable candidates for laparoscopic colectomy.

Transitioning from MPLC to SILC

Although SILC is closely related to MPLC, some differences are present between the two techniques and thoughtful planning of training and practice is important. First, because the instruments are placed in parallel through one incision, the instruments must be managed in the same, or collinear, planes. This can lead to “boxing,” or instrument clashing, externally instead of “sword-fighting” internally. The level of the ports and the instruments must be staggered to help minimize this problem.

Tissue management can be more challenging in SILC. Triangulation of instruments internally is lost with SILC and the motion of the instruments must often be back and forth, rather than side to side. Therefore, suspension of the tissue, rather than traction, may be most useful. Management of the tissues requires precise visualization and exposure. More specifically in laparoscopic colon and rectal surgery than other laparoscopic surgeries, the tissues that are manipulated are not all resected. It is important to avoid mechanical or thermal injury to surrounding and adjacent structures. Tissue management includes using a traumatic graspers on bowel to help avoid any injury to bowel that will not be resected.

Aside from choosing an alternative access device to MPLC, there is no special equipment needed. Access devices are available from several major device manufacturers. The same surgical instrumentation used for MPLC can be utilized for SILC.

Skills courses, video observation training and proctoring can all be important components of safe skill acquisition prior to, and in addition to, clinical practice.

Techniques

Operating Room

As with any laparoscopic colectomy, a moveable operating table is essential for positioning the patient for optimal exposure of the target organ. Because Trendelenberg and other steep positions are employed during the case, some surgeons place the patient on a conforming beanbag or use tape across the chest to secure the patient. The patient’s arms are tucked bilaterally to allow for ease of surgeon movement around the table. If the patient is too large to safely tuck both arms the left arm should be tucked to facilitate surgeon movement around the table while the right arm remains extended.

Even for right-sided operations, low lithotomy position is ideal for minimally invasive laparoscopic colorectal surgery because it affords free access to all aspects of the abdominal wall. The surgeon or assistant can stand between the patient’s legs for upper or lateral abdominal work. For MPLC in lithotomy position, it is most important that the patient’s thighs be at or below the plane of the anterior-superior iliac spine to allow for free movement of the laparoscopic instruments in the field. This is less important in SILC since all instruments are placed through the umbilical incision.

Prior to induction of anesthesia, subcutaneous heparin is given and compression boots are placed and activated. An indwelling urinary catheter may be placed at the surgeon’s discretion. An orogastric tube is placed for decompression of the stomach, which is particularly helpful for visualization during mobilization of the hepatic flexure. Appropriate perioperative antibiotics are given within 30 min of incision.

The patient is prepped and draped with the entire abdominal wall exposed in order to always be prepared for the possibility of conversion to a multiport or an open procedure.

The video monitor should be positioned ipsilateral to the target organ, that is, in the right lower quadrant, at a height that allows for neutral positioning of the surgeon’s neck. The surgeon stands opposite the target organ, on the left side of the patient. The assistant may stand next to the surgeon in the cephalad position. The operating table height should be lowered so that when the abdomen is insufflated the surgeon can operate with his or her shoulders level. Sometimes standing on a platform will add ergonomic advantage when the patient’s abdomen is large or protuberant. A consistent operating room team of nurses and technicians familiar with laparoscopic colectomy will facilitate flow and ease of the operation.

Access Devices, Optics and Instrumentation

Access Devices

There is an array of principles for port placement for MPLC, but there is standardized umbilical access device placement for SILC. Most surgeons use a vendor designed platform with openings for trocars. An insufflation port is part of the device. Three, sometimes four, trocars are placed through the device. The level or height of both the ports and the instruments must be staggered at the level of the device to help minimize instrument clashing externally, or boxing.

Most instruments and devices can be used through 5 mm ports. The sole limitation on port size selection currently is that endoscopic staplers must be placed through a 10/12 port. A 5 mm trocar can always be up-sized later in the case if needed. Trocars should be oriented toward the operative target for the surgeon’s ergonomic benefit.

Optics

Optimal visualization is key to a safe and expeditious surgery. Special considerations for SILC optics include the need to stagger the position of the instruments externally at the access port site. A 30° down scope will facilitate visualization. When using a straight scope, a bariatric length is recommended in order to keep the camera apparatus away from the instruments at the umbilicus, again to reduce clashing. Alternatively, flexible tip scopes that can deflect within the field to change the angle of view can be used. Video monitors should be placed at a height to facilitate neutral positioning of the neck and shoulders as the surgeon operates. The monitors must be mobile so that they can be moved to accommodate changing operative fields.

Energy Devices

In order to perform intra-corporeal soft tissue mobilization and vascular division we utilize instruments such as thermal sealing devices that seal tissue by melting it. All thermal sealing devices have some lateral spread of heat for a few mm that occurs with activation of the instrument. It is important to have the device applied only to the tissue that is to be sealed or divided. It is also important to be able to visually verify a clear zone around the device. The advantage to use of the thermal sealing device in SILC is that it can also be used as a grasper and a retractor.

There is some evidence that thermal sealing of vessels is associated with fewer mishaps than stapling vascular structures [1]. However, all devices can fail and it is important to have a backup plan for management of bleeding vessels. An endoscopic looped suture can be very useful to stop bleeding from a pedicle that has failed another technique.

Monopolar cautery can be used in association with scissors or other instrumentation. It is crucial to avoid any electrical injury to surrounding tissues from arcing along instrumentation. Any unsheathed portion of an instrument is live with electrical current and can cause injury to surrounding structures. Intuitively, it seems more likely to occur in the setting of collinear instrument management. Because of this particular risk of arcing of current and remote thermal injury to tissues, many surgeons simply do not use monopolar energy in single incision laparoscopic surgeries.

Staplers and Wound Protection

Division of the colon requires endoscopic staplers, which come in different lengths and may have the ability to articulate. For right colectomy, many surgeons will simply divide the bowel extra-corporeally. A wound protection device for the abdominal wall site of extraction is used to minimize bacterial contamination and tumor implantation. If the platform for single incision laparoscopic surgery does not include a sleeve for the abdominal, a separate sleeve can be placed.

Only gold members can continue reading. Log In or Register to continue