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.

Beginning the mobilization of the left flexure from the medial side by retracting the inferior mesenteric vein and exposing the Gerota's fascia. A bipolar dissection instrument is used for preparation.

Note: The principle here is "Purple staff down" – meaning that the Gerota's fascia, shimmering red to purple, is pushed or prepared dorsally, and the lighter, more yellowish layer of the sigmoid and descending mesocolon is held ventrally. The preparation is repeatedly performed from medial to lateral.

The duodenojejunal flexure is exposed as well as the dorsal part of the inferior mesenteric vein. The mesentery is tented with an atraumatic grasping forceps. Furthermore, the ovarian vessels, covered by the Gerota's fascia, are exposed. The preparation is advanced until the lower border of the pancreas is exposed.

Note: It is important to avoid continuing the preparation below the pancreas. At the lower border of the pancreas, the anterior surface of the pancreas is exposed, thus opening the omental bursa from below.