After insertion of the camera, it is mandatory to survey the entire intraperitoneal cavity. This becomes particularly relevant when performing these procedures for inflammatory bowel disease as well as for cancer, assessing for carcinomatosis and liver metastasis.

The surgeon stands on the left side of the patient, using the two left-sided ports, and the operating table is placed in the Trendelenburg position. Using two atraumatic bowel graspers, the large omentum as well as the small bowel is carefully pushed to the upper abdomen. This will allow better exposure of the terminal ileum and the ileocolic pedicle. If the terminal ileum is still not visualized correctly, the patient can be tilted towards the surgeon allowing for the small bowel to fall away from the surgical field. At this time, the assistant standing opposite to the surgeon will grasp the ileocolic junction and elevate it laterally and towards the right hip. This will stretch the ileocolic vessel by lifting it up from the retroperitoneum, defining the pedicle and exposing them to the surgeon. A sulcus will be demonstrated between the medial side of the ileocolic pedicle and the retroperitoneum. The surgeon will have an atraumatic grasper in his or her left hand and an advanced cautery device in his or her right. Cautery is used to open the peritoneum along both aspects of the pedicle, and with some blunt dissection the vessel is lifted away from the retroperitoneum. This is an avascular plane, and there will be no more need for sharp dissection. Bluntly, dissection continues to open the underside of the ascending colonic mesentery with exposure of the second portion of the duodenum. This is done by lifting the colonic mesentery with the left-handed instrument and dissecting the tissues off this plane with the right-hand instrument. Care is taken to keep the plane of dissection anterior to the congenital layer of peritoneum lying over the retroperitoneum, duodenum, and ureter. Dissection of the mesentery is now carried to the opposite side of the pedicle in order to isolate the vessel completely. A cautery device is used to clean the vessel from the mesenteric fat. At this time a clip (two proximal and one distal), energy device, or stapler may be used to transect the pedicle.

The assistant will re-grasp the distal end of the transected pedicle and lift it up allowing for continued dissection of the medial aspect of the ascending colon mesentery. With countertraction on the proximal transverse colon by the surgeon, the hepatic flexure will become apparent and division of the hepatocolic ligament using cautery or sharp dissectors is accomplished. During dissection of the ligament, the direction will be shifting so appropriate repositioning of the tensile forces for better exposure is mandated. This includes elevating with medial traction by the assistant of the transverse colon and medial traction of the ascending colon by the surgeon. This allows the surgeon to dissect through the tented peritoneum into the previously opened virtual space underneath. Once it has been taken down, the only remaining attachment is the lateral peritoneal attachment (white line of Toldt) along the ascending colon. This is divided using electrocautery all the way down to the cecum, with mobilization of the appendix. This frees the colon from the underlying duodenum and retroperitoneum and allows for complete medial retraction of the right colon.

The mobilization of the ileocecal junction is accomplished by first placing the patient in the Trendelenburg position, with the small bowel reflected superiorly. The mesentery of the terminal ileum is elevated and the union between the visceral peritoneum and retroperitoneum are identified. There is a thin layer of peritoneum that will need division, which can be accomplished with sharp dissection or electrocautery (see Video 20.1). This dissection plane extends from the ileocecal junction towards the superior mesenteric vessels, thus connecting the inferior aspect of dissection and the previously performed superior colonic dissection. The inferior ileal dissection is continued medially to expose the third part of the duodenum, with care not to enter the retroperitoneal layer and avoiding unnecessary embarrassment with the ureter. Now the colon is medially rotated and any leftover attachments are easily divided completing the ascending colon mobilization.

This step can be done before or after mobilization of the left colon. It is usually considered the more difficult step in a total colectomy. The patient will need to be placed in the reverse Trendelenburg position with the surgeon standing between the patient’s legs. The surgeon will have an atraumatic grasper in the left hand and an advanced energy device in the right hand placed through the lower ports. The cameraman will stand on the patient’s right and use an atraumatic grasper through the RUQ to elevate the omentum of the mid-transverse colon. The second assistant will be standing on the patients left and use an atraumatic grasper through the LUQ port and grasp the gastrocolic omentum and retract it cephalad. This displays the omentum like a curtain and allows the surgeon to dissect the bowel from the omentum using an energy source of his preference. Using counter tension the transverse colon is drawn caudal, and the lesser sac entered at the middle of the transverse colon through the avascular plane (see Video 20.2). From right to left the omentum is dissected of the colon, towards the splenic flexure.

The surgeon switches instruments between his left and right hand, and the dissection continues from the middle transverse colon towards the mobilized hepatic flexure. Dissection may continue through the avascular plane or through progressive ligation of the omentum depending on the patient’s anatomy. All remaining attachments of the colon should be divided to allow for the middle colic vessel ligation as the next separate step. Having mobilized the entire transverse colon, the assistants grasp the proximal and distal transverse colon – through the upper quadrant ports, and retract it upwards. In a same fashion as to mobilize the omentum from the transverse colon, this creates a curtain-like display, which allows the surgeon to identify the middle colic pedicle in the mesocolon. An opening in the mesocolon is created with attention to respect the more posterior structures encountered at this level, including the pancreas and fourth part of the duodenum. The middle colic vessels are then ligated from the left to the right, treating each branch with care and allowing for proximal control of the vessel with the bowel grasper. It is mandatory to confirm that it is the middle colic pedicle prior to division, since the superior mesenteric artery and vein are situated just posterior to the dissection plane.

At this point it is advisable to rotate the patients towards the right side and allow gravity to help expose the lateral attachments of the splenic flexure. Dissection continues around the splenic flexure to the proximal aspect of the descending colon. Once the splenic flexure is freed, attention then turns to the proximal transverse colon. Alternatively, the splenic flexure is taken from the superior approach (see Video 20.3).