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Sigmoidectomy, laparoscopic - general and visceral surgery
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Creating the pneumoperitoneum and placing the trocars
Make a medial skin incision about 3cm superior to the umbilicus. Introduce the trocar for the laparoscope (T1) into the abdominal cavity through a minilaparotomy and create the pneumoperitoneum. After gross inspection of the abdominal cavity, introduce the working trocars (T3, T3, T2) under direct view.
Be aware that creating the pneumoperitoneum with a Veress needle may risk injury to large intraabdominal blood vessels.
Mobilizing the sigmoid
Mobilizing the splenic flexure
Reposition the patient to reverse Trendelenburg while still in right lateral recumbent. Start freeing the descending colon and splenic flexure laterally from the left. In doing so, pull the descending colon mediad and successively divide the colonic adhesion with the Gerota fascia.
Starting in the middle of the transverse colon dissect the greater omentum off it, which will free the splenic flexure and open up the lesser sac. During this dissection the splenocolic ligament and attachments between the pancreas and colon will also be divided. Finally, the left colon including its splenic flexure has been freed from all posterior structures, allowing a tension-free anastomosis.
- Abrupt traction on the colon may result in injury to the spleen.
- Dissection is facilitated by bringing the OR table from Trendelenburg (head low) back to level while still keeping the patient in right lateral recumbent.
Tubular Dissection of the mesosigmoid
Undo the reverse Trendelenburg and the right lateral recumbent. Incise the mesosigmoid medially, introduce the retractor and divide the mesosigmoid close to the sigmoid colon while maintaining traction antiroad and keeping the mesentery under constant exposure. Carry the dissection upstream of the rectosigmoid transition (identifiable by the disappearance of the omental appendices and taeniae of colon). Dissection along the colon will ensure that the inferior mesenteric artery and its main branches are spared.
- Identification of left ureter and ovarian/testicular vessels
Dividing the upper rectum
Determine the levels of division. The proximal level should be upstream of the inflamed or diverticular bowel segment. Position an intestinal clamp at the level of the planned distal level of division. After transanal irrigation (wash-out), insert the stapler preferably at right angles to the course of the rectum.
In some cases a second stapler may be required to completely transect the tissue. Grasp the margin of the proximal division with atraumatic forceps and remove the intestinal clamp.
- Avoid accidental trapping of tissue in the stapler when transecting the rectum.
Extracorporeal sigmoid transection
Return the patient back from Trendelenburg. Enlarge the trocar incision (T2) in the left lower quadrant by about 4cm. Exteriorize the specimen, together with the trocar, onto the abdominal wall. This is facilitated by distending the incision Roux retractors. Dissect the mesocolon down to the intestinal wall and check for adequate perfusion of the marginal artery of Drummond. The following video clip demonstrates application of the crushing purse-string clamp and the subsequent purse-string suture. This is followed by transection of the sigmoid with straight scissors and handing off the specimen to histopathology.
Inserting the anvil and interiorizing the bowel
After atraumatic dilation of the anus carefully introduce the circular stapler transanally into the rectum. Extend the stapler shaft only after exact position in the rectum. Perforation of the rectal stump should be in its center and immediately adjacent to the staple line. Push the anvil shaft onto the stapler shaft until it clicks. Avoid a colonic rotation to the left by checking the taenia libera along the whole length of the mobilized colon. Only then close the stapler and fire it, thereby completing the anastomosis. Gently pull back the stapler and check for the presence of two complete “doughnuts”.
- Avoid accidental trapping of tissue or organs of the lesser pelvis in the stapler when transecting the rectum.
Return the patient back to light Trendelenburg position, fill up the lesser pelvis with irrigation fluid and transanally insufflate the rectum with 100ml of air.
- Any rising bubbles would indicate primary anastomotic failure.
- Suction the irrigation fluid and drain the lesser pelvis with an Easy-Flow drain.