Laparoscopic oncological sigmoid resection

Periumbilical incision. Open entry with the Hasson trocar after placement of two fascial stay sutures. Under laparoscopic vision, the working trocars are placed pararectally:

5 mm left lower abdomen, 5 mm right mid-abdomen, 12 mm right lower abdomen after prior instillation of local anesthetic.

Position the patient head down and on the right side, then exploration and confirmation that the sigmoid tumor is not visible. Next, display the vascular axis of the inferior mesenteric artery and vein and inspect the pelvis. A dilative angiopathy with significant kinking of the pelvic vessels is observed.

In the right hemiabdomen, multiple adhesions to the anterior abdominal wall are evident. Initially, a careful adhesiolysis is performed following appendectomy and transverse upper abdominal laparotomy for cholecystectomy (not shown).

Now, an intraoperative colonoscopy is performed to locate the tumor. For this, the sigmoid-descending junction is clamped with a soft grasping forceps. The endoscopy shows the finding in the middle of the sigmoid. The tumor area is marked endoluminally with a clip.
 
Note: In cases where tumors are not macroscopically visible, intraoperative endoscopic marking is a sensible measure.

Tensioning of the sigmoid colon to the left lateral and incision of the peritoneum on the right. Initially, preparation with the monopolar scissors to create a gas depot between the separation layers of Gerota's and Waldeyer's fascia and the mesocolon/mesorectum. By dissecting the kinked pelvic vessels, the trunk of the inferior mesenteric artery is exposed via a medial para-aortic approach while preserving the pre-aortic nerve plexus.

Preparation of Gerota's fascia dorsally with clear identification of the left ureter. Then display of the trunk of the inferior mesenteric artery, which is clipped 2 cm behind its origin from the aorta using absorbable clips (Lapro-Clips).

Note: In oncological sigmoid procedures, identification of the left ureter is mandatory. The ureter and ovarian vessels remain covered by the parietal fascial layer covering the retroperitoneum.