Laparoscopic Colorectal Surgery at WLH Hospital

Figs. 1A and B: Hand-assisted colorectal surgery.
A B
Laparoscopic Colorectal Surgery
INTRODUCTION
Laparoscopic colon resections are being performed with
increasing frequency all over the world. However, the
use of minimal access surgery in colorectal surgery has
lagged behind its application in other surgical fields.
Since the first laparoscopic colectomy was described in
1991, a great deal of controversy has surrounded its use,
particularly in the management of colorectal cancer. After
the successful introduction of laparoscopic colectomy by
Jacobs, laparoscopic surgery for the treatment of colorectal
cancer, especially laparoscopic rectal surgery, has been
developed considerably. Several new important studies
have demonstrated the benefits and safety of laparoscopic
colorectal surgery, making it now the preferred approach in
the surgical management of many colorectal diseases.
The technique of laparoscopic colectomy has a long
learning curve because of the advanced laparoscopic skills
it entails. Unlike other laparoscopic procedures, such as
the Nissen fundoplication or cholecystectomy, colorectal
procedures involve dissection and mobilization of intra-
abdominal organs in multiple quadrants. Tilting of the
operating-roomtableinvariouspositionsduringanoperation
uses gravity to allow intra-abdominal organs to fall away
from the area of dissection, providing necessary exposure that
would normally be achieved through the use of retractors.
Intestinal resection requires laparoscopic ligation of large
vessels, mobilization and removal of a long floppy segment of
the colon, and restoration of intestinal continuity. Once the
colon segment has been thoroughly mobilized and its blood
supply divided, a small skin incision is made to exteriorize
the colon, then resection and anastomosis are performed
extracorporeally, and the rejoined colon is placed back into
the abdomen.
The laparoscopic approach continues to gain popularity
and has evolved to include not just “pure” laparoscopic
techniques but also hand-assist devices. Hand-assisted
surgery can be used as a bridge for surgeons who are not
completely familiar or facile with laparoscopic techniques,
and even for the most experienced laparoscopic surgeons,
it is often the preferred technique for surgery involving
left-sided pathology (Figs. 1A and B). The use of a hand-
assist device provides tactile feedback for the surgeon and
shortens operating-room time while still preserving many
of the advantages of laparoscopic surgery. By combining
laparoscopic surgery with the tactile feedback of a hand-
assisted device, surgeons can reduce operating-room time
and have a lower procedure conversion rate. The technique
involves making an incision the width of a hand and placing
a hand-assist device to facilitate laparoscopic dissection.
New handport devices make this technique possible
without loss of pneumoperitoneum, which is essential for
performing laparoscopic procedures. Because an incision
Prof. Dr. R. K. Mishra

341
CHAPTER 26: Laparoscopic Colorectal Surgery
Figs. 2A and B: Port-site metastasis after laparoscopic surgery.
A B
(4–5 cm) is necessary to remove the colon specimen at the
end of a laparoscopic operation, the difference between a
pure laparoscopic procedure and a hand-assisted operation
is generally a few additional centimeters (3–4 cm) of incision
length. Several clinical trials have demonstrated that there is
nodifferenceinpatientrecoveryordischargeforlaparoscopic
versus hand-assisted techniques. Larger incisions are
often needed, and because of the increased risk of wound
infections and pulmonary complications, this technique has
particular advantages with overweight or obese patients.
Mostpatientsarecandidatesforalaparoscopicapproach.
Whenthesurgeonisexperienced,evenpatientswithahistory
of abdominal surgery can form possible candidates. Though
there are clear benefits, they have not been as compelling
when compared to the clear advantages associated with
other laparoscopic procedures. The main reason is that
a colectomy, whether open or laparoscopic, results in a
delayed return of bowel function. Though recovery of bowel
function is quicker after laparoscopic surgery, the difference
is on the order of 1 or 2 days, resulting in a similar reduction
in length of hospital stay. Also, the laparoscopic approach is
associated with longer operating-room times. Even if long-
term benefits are equivalent between open and laparoscopic
techniques, the short-term benefits are real advantages for
patients. In practical terms, the laparoscopic approach is
associated with less pain, a faster recovery, earlier return
of bowel function, a shorter hospital stay, possible immune
benefits, and smaller scars, making it the preferred method
for intestinal resection.
The lack of tactile feedback during laparoscopic surgery
can make tumor localization difficult, especially if the lesion
location has not been tattooed on the colon wall before
surgery. It is imperative that the exact location of the tumor
is known prior to proceed with colectomy. Even when the
lesion location has been tattooed onto the colon, often the
mark can be challenging to see, or there may be confusion
regarding the location of the tattoo in relation to the tumor
(proximal or distal), which can affect surgical margins.
Intraoperative colonoscopy is a way of definitively localizing
a lesion and should be available during all laparoscopic
colectomies. A traditional colonoscopy uses room air as the
insufflating gas, which leads to significant bowel distension
and requires clamping of the proximal colon to minimize
this effect. Clamping the bowel can lead to injury, and even
when it is successfully performed, the degree of distension
often makes simultaneous laparoscopic visualization
difficult. These problems can be circumvented with the use
of CO2, rather than room air, as the insufflating gas. Because
CO2 is absorbed much more rapidly than room air, bowel
distension is minimized and dissipates quickly, making
proximal clamping unnecessary. The use of CO2 allows for
laparoscopic and endoscopic procedures to be performed
simultaneously, and this technique has been shown to be
safe and clinically useful. Besides tumor localization, CO2
colonoscopy may have other potential applications.
PORT-SITE METASTASIS
In the early experience of laparoscopic colectomy for cancer,
a few reports described immediate tumor recurrence at
the laparoscopic incision sites, referred to as port site
recurrences (Figs. 2A and B). It was hypothesized that
such early cancer recurrence happened after laparoscopy
due to tumor shedding and/or accelerated tumor growth,
secondary to the presence of gas in the peritoneal cavity.
However, multiple reviews have indicated that this is not the
case. In one such study, which included over 2,600 cases, the
rate of port-site recurrence was approximately 1%, which
is similar to that noted in open colorectal surgery. It is not
currently believed that laparoscopic colectomy is associated
with early wound recurrences.
Port-site implantation was a concern in the early period,
but it has been shown now that it can be prevented by:
■ Proper protection of port site while delivering the
specimen. (Endobags®
and pouches).
■ Avoid squeezing of the specimen by taking a liberal
incision.

342 SECTION 2: Laparoscopic General Surgical Procedures
■ Thorough wash to the wound, 5FU solution irrigation of
all ports
■ Slow-release of pneumoperitoneum
■ Lap-lift technique
The cost can be brought down by either doing a hand-
sewnanastomosisthroughthespecimendeliverysiteoruseof
conventional stapler for extracorporeal stapled anastomosis.
Minimal use of disposable ports and instruments can further
cut down the cost. The use of ultrasonic energy sources in the
form of harmonic shears (Ethicon®
and USSC®
) has added to
some of the cost of lap surgery.
The two burning issues are port-site metastasis in
malignancies and cost factor due to the use of endo staplers.
As mentioned earlier, for a benign condition such as rectal
prolapse, adenomas, rectal polyposis, and inflammatory
condition such as tuberculosis, ulcerative colitis, and simple
diverticulitis, laparoscopic surgery offers a patient-friendly
technique. Crohn's disease, though not very common
in India, laparoscopy can be offered for the diagnosis,
lymph node sampling, and curative resection. Ileocecal
tuberculosis is commonly seen in our country, and it is an
excellent option to provide the benefits of laparoscopy to
these patients whenever surgery is indicated. Incidental
colonic resection is unlikely to help the laparoscopic surgeon
team in mastering the techniques. The reduction of OT time
due to better coordination and cost-benefit to patients can
only be offered by repetitive performances. A dedicated
team effort will surely bring this specialty under the umbrella
of minimal access surgery as has happened in the western
world.
BOWEL PREPARATION IN
COLORECTAL SURGERY
Though widely accepted as sensible and logical, it has never
been subjected to any stringent scrutiny. The ideal method
of mechanical preparation should be simple, inexpensive,
without distress, and side effects to the patient. However,
such an ideal method does not exist. It must be chosen with
respect to patient acceptability, efficiency and influence on
fluid and electrolyte imbalance and fecal microflora. The
conventional method involves a 3-day regimen consisting of
low residue and clear liquid diet combined with purgation
using laxatives and enemas. Although satisfactory in bowel
cleansing in about 70% of patients, it is rather exhausting due
toreducedcalorieintake.Itistime-consumingandmayresult
in dehydration if the patient drinks an inadequate amount
of fluids. These disadvantages stimulated the development
of more reliable, efficient, and quicker methods, which are
given in the following text.
Elemental Diets
Low residue liquid or elemental diets were used with
the intention that nutrients could be absorbed in the
small intestine. Although, these results in low fecal bulk,
satisfactory cleansing is obtained in only 17% of the patients.
Nausea and vomiting can occur, and the evidence does not
favor elemental diets as a sole means of bowel preparation.
Whole-gut Irrigation
Saline: Normal saline is instilled through a nasogastric tube
at a constant rate of 50–70 mL/min in 4 hours, requiring a
total of 10–14 L of fluid. Cleansing effect is achieved in 90% of
the patients; however, the concentration of colonic bacteria
is not reduced unless antibiotics are added. Many patients
complain of abdominal distension, nausea, and vomiting.
Other drawbacks of this method include the large volume
of irrigants, need of nasogastric tube, risk of electrolyte
disturbance and water retention, and nursing care required
to assist the patient. It is contradicted in patients with
gastrointestinal obstruction, perforation, and toxic colitis
and has to be used with caution in patients with cardiac
problems.
Castor oil: It (30–60 mL) orally achieves good cleansing but
requires a large volume of magnesium citrate purgative to
achieve the desired results and requires to be given 2 days
before surgery followed by anal washouts a day prior which
entails preoperative admissions for 3–4 days. Unpalatabilty
is another drawback.
Mannitol: Mannitol is a nonabsorbable oligosaccharide
which acts as an osmotic agent by pulling fluid into the
bowel and producing a purgative effect by irritating the
colon. Being a sugar, it is quite palatable and can be flavored
by mixing it with fruit juice. Usually, 4 L of 5% solution is
consumed over 4 hours, which can be difficult and can result
in abdominal discomfort and nausea. To avoid these side
effects, hypertonic solutions (10–20%) can be used but these
predispose to dehydration and electrolyte losses. Overall,
good cleansing is produced in about 80% of the patients,
but leads to a high wound infection rate probably by acting
as a bacterial nutrient and production of explosive gases
as a result of fermentation into methane and hydrogen by
anaerobic bacteria is seen. The same can be overcome by
using of an antibiotic.
Polyethylene glycol (PEG): To overcome the drawbacks of
mannitol, PEG (PEGLEC) in a balanced electrolyte solution
was introduced which also acts as an osmotic purgative
(Fig. 3).
To achieve satisfactory cleansing in >90% of the patients,
anaverageof2–4LofPEGLECsolutionmustbeingestedwith
tea and lemon. Studies using PEG have shown a significantly
lower incidence of fluid retention and lesser aerobic and
anaerobic fecal bacterial counts compared to other agents.
It is nowadays used as an agent of choice for preparations
of the bowel before endoscopy and colonic surgery in a
nonobstructed patient.

343
Fig. 3: Bowel preparation in colorectal surgery.
Picolax: It (sodium picosulfate and magnesium citrate) is a
stimulant purgative that acts mainly on the left colon after
activation by colonic bacteria and on osmotic laxative that
cleanses the proximal colon. Two sachets in 2 L of water
are administered with dietary restrictions to improve
effectiveness. Although acceptable cleansing is achieved in
85% of patients undergoing barium enema and colonoscopy,
its efficacy for elective colorectal operations is poorly
documented. Picolax is well tolerated but does produces
fluid and electrolyte losses.
ANTIBIOTIC BOWEL PREPARATIONS
Mechanicalcleansingalonehasfailedtoachieveasignificant
reduction in the total bacterial load of the colon and,
therefore, the associated septic complications. Addition of
antibiotics, oral as well as parenteral, to mechanical cleaning
has resulted in a significant reduction of the infection rate
from 30 to 60% in an uncovered patient to as low as 2–10% in
otherwise patients covered with broad-spectrum antibiotics.
Oral Antibiotics
Because the aerobic Escherichia coli and the anaerobic
Bacteroides fragilis are frequently involved organisms in
septic complications following colorectal operations; oral
antibiotics active against both types of bacteria must be
given. Oral administration of erythromycin, neomycin, and
metronidazolearepopular.Severalstudieshavedocumented
the efficacy of oral antibiotics; however, an antimicrobial
used alone without mechanical cleansing has little impact
on the postoperative infection rate.
Parenteral Antibiotics
Since parenteral antibiotics are valid only when adequate
tissue levels are present at the time of contamination,
systemic administration should start immediately before
the surgery. A second- or third-generation cephalosporin
with metronidazole is the most commonly preferred agent.
Studies had shown conflicting results when parenteral
antibiotics were compared with oral or both. Whether
antibiotics bowel preparation should be oral, systemic,
or both are still a controversial issue. The majority of
the surgeons would prefer parenteral antibiotics or with
concomitant administration of oral antimicrobials together
with oral PEGLEC electrolyte solution as the method of
choice of preoperative bowel preparation.
Thoughobservationaldatasuggestthatmechanicalbowel
preparation before colorectal surgery reduces fecal mass
and bacterial count in the lumen, but the practice has been
questioned because the bowel preparation liquefies feces,
which could increase the risk for intraoperative spillage, and
maybeassociatedwithbacterialtranslocationandelectrolyte
disturbance. Though commonly practiced without the
benefit of evidence from randomized trials, and two of three
meta-analyses suggest a higher rate of anastomotic leakage
with mechanical bowel preparation thus calling for an end to
the practice of mechanical bowel preparation in view of the
possible disadvantages of this practice, patient discomfort,
and the absence of clinical value. There are others who
accept that though routine preoperative bowel cleansing is
no longer justified prior to colorectal surgery in general, they
call for further evaluation in cases such as total mesorectal
resection with low anastomosis where it may still have a
role and therefore to consider each case carefully, otherwise
the chance of making an inappropriate decision exists with
significant consequences for patients.
The majority of surgeons believe that patients should
have a standard bowel preparation 48 hours before the
operation and should receive a single-dose antibiotic dose
immediately preoperatively. For the bowel preparation,
patients follow a strictly fiber-free diet eight days before
surgery and take a sodium phosphate oral solution the day
before surgery. This method is very useful because it ensures
an empty digestive tract and a flat small bowel, which
facilitates the layering of intestinal loops, a crucial point for
achieving adequate exposure. Alternatively, the PEG can be
used. In this case, administration 2 days before surgery is
preferable to avoid distension of small bowel loops that may
be difficult to handle during the surgery.
RIGHT COLECTOMY
A right colectomy or ileocolic resection is the removal of
all or part of the right colon and part of the ileum (Fig. 4).

Fig. 4: Section to be removed in right colectomy.
These operations are performed for the removal of cancers,
certain non-cancerous growths as well as severe Crohn's
disease. If performed by an expert laparoscopic surgeon,
laparoscopic right colectomy and ileocolic resection are as
safe as “open” surgery in carefully selected cases.
Indications
The advanced laparoscopic skills required for laparoscopic
resection of the colon and rectum have precluded wide
dissemination of this procedure. By applying certain key
principles, laparoscopic right hemicolectomy can be made
simple, reproducible, easy to teach, easy to learn, and
cost-effective. Although benign tumors not resectable by
a colonoscopic procedure and structuring inflammatory
bowel disease may be good indications for laparoscopy, they
are not so common. The most common disease for right
colectomy is right-sided colon cancer. Colon cancer seems
to be a good indication for laparoscopic surgery if performed
using proper oncologic methods, i.e., early proximal ligation
of the major mesenteric vessels and wide mesenteric and
intestinal resection with complete lymphadenectomy. For
right colectomy, either laparoscopic mobilization of the
bowel and/or mesenteric resection, both are performed as
for open colectomy, and bowel division and creation of the
anastomosis can be performed extracorporeally.
Contraindications
■ Patients with complete obstruction caused by the cancer
■ Cancer extensively invading adjacent organs
■ Bulky cancer >10 cm in size should be excluded.
Accordingtotheseconcepts,aproperoncologicapproach
using laparoscopy for right colon cancer is described in this
chapter.
Equipment and Instruments
One can use the same basic equipment, such as light source,
insufflator, 30° angled laparoscope, and 5-mm graspers. To
this basic equipment, can be added reusable instruments
such as Babcock and alligator clamps, which should be at
least 38–40 cm in length to reach from the depths of the pelvis
to the upper abdomen using limited port sites. In developing
countries, these reusables can be used if necessary but
trying to keep disposable equipment to a minimum. Three
10 or 12 mm trocars with stability threads, plus reducers for
5-mm instruments should be used. Cannulas should allow
instruments to move through smoothly while maintaining
a good seal after multiple instrument passages. An energy
source device of one's choice can also be added, such
as bipolar, LigaSuretm
, or harmonic scalpel. Additional
disposable equipment is kept readily available in the
operating room and used only as needed. These include a
clip applier, linear vascular stapler, suction irrigator, and fan
retractor.
Patient Positioning and
Operating Room Setup
The patient is placed supine, and straps are used to secure
the patient during steep table position changes. The patient
is fixed in a moldable “bean bag” form with both arms
tucked in, and placed in a modified lithotomy position using
levitator stirrups (Figs. 5 and 6). A urinary catheter is placed
in the bladder, and the stomach is decompressed with a
nasogastric tube. Identical operating room personnel is used
forthelaparoscopiccaseasforanopenrighthemicolectomy.
The nurse is on the patient’s right. This is also where
the assistant stands, with the surgeon on the patient’s left
side facing the right colon. Hasson (open) technique is
preferred to safely insert the first port through the umbilicus.
After establishing pneumoperitoneum, the surgeon tries to
expose the right mesocolon and to mark the lower border of
the ileocolic vessels.
Afterinitialexplorationensuresnoprohibitiveadhesions,
two additional 10–12 mm ports are placed under direct
visualization, one in the left upper quadrant (in or lateral to
the rectus, avoiding the epigastric vessels, approximately a
handbreadth from the supraumbilical port) and one in the
suprapubic midline. Once all the trocars are in place, the
assistant moves to the patient's left side to direct the camera.
To start the initial dissection, the surgeon moves between
the patient’s legs, the assistants position themselves on the
patient’s left side, and the nurse stands near the patient’s
right knee. The primary monitor is placed near the patient’s
right shoulder to give the surgeon and the assistant’s optimal
viewing (Fig. 7).
The second monitor is placed on the left side close to the
head, a location that gives the best view for the nurse.

345
Fig. 5: Position of patient for colorectal surgery.
Fig. 6: Shoulder support to prevent sliding during colorectal surgery.
After completing the proximal vessel ligation with
lymphadenectomy and mobilization of the terminal ileum
and the cecum, the surgeon moves back to the patient’s left
side, and the first assistant stands between the patient’s legs
for take-down of right flexure and whole mobilization of the
right colon (Fig. 8).
Operative Technique
Right colectomy can be broadly divided in the following
steps:
■ Ligation of ileocolic vessels
■ Identification of right ureter
■ Dissection along the superior mesenteric vein
■ Division of omentum
■ Division of right branch of middle colic vessels
■ Transection of the transverse colon
■ Mobilization of the right colon
■ Transection of the terminal ileum
■ Ileocolic anastomosis
■ Delivery of specimen
The patient is positioned in Trendelenburg with the
right side inclined upward. This allows the small bowel and
omentum to fall toward the left upper quadrant, exposing
the cecum and assisting in retraction. The omentum and
transverse colon are moved toward the upper abdomen, the
ventral side of the right mesocolon is well visualized, and the
optimal operative field can be achieved. The small bowel is
mobilized out of the pelvis by grasping the peritoneum, not
bowel wall, near the base of the cecum and pulling cephalad
and to the left. The appropriate plane along the base of the
small bowel mesentery and around the cecum can be seen
and the peritoneum overlying it carefully opened, exposing
the correct retroperitoneal plane.
The ureter is identified either before opening the
peritoneum in a thin patient or after, being visualized as
it courses over the right iliac vessels. Dissection is then
continued around the base of the cecum. Moving cephalad
and laterally, the white line of Toldt is incised as the right
colon is retracted medially and cephalad by grasping the cut
edge of the peritoneum, not the bowel.

Fig. 7: Position of surgical team during colorectal surgery.
Fig. 8: Mobilization of cecum and right colon.
Before starting the dissection, the ileocolic pedicle
must be definitively identified by retracting the right
mesocolon. Various approaches, such as lateral-to-medial
(lateral approach), medial-to-lateral (medial approach),
and retroperitoneal approach, have been documented.
The medial approach is quite effective for complete
lymphadenectomy with early proximal ligation, minimal
manipulation of the tumor-bearing segment, and ideal entry
to proper retroperitoneal plane.
Various approaches to the right colon mobilization have
been described.
■ Lateral to medial (“classic” open approach)
■ Medial to lateral approach
■ Retroperitoneal approach
It is believed that the medial approach is optimal in order
to maintain conventional oncologic principles. First, the
mesocolon near the ileocecal junction is lifted to confirm
the ileocolic pedicle. The root of the ileocolic pedicle is
usually located at the lower border of the duodenum. The
independent right colic vessels, if present, are located at
the upper border at the duodenum. However, the majority
of patients do not have the independent right colic vessels
(vessels originating directly from the superior mesenteric
artery and vein (Figs. 9A and B). The surgeon should
initially stand on the patient’s left side to confidently know
the ileocolic pedicle from the superior mesenteric vessels,
and to mark the lower border of the ileocolic pedicle.
Once the ileocolic pedicle is identified, the surgeon
moves between the patient’s legs and the scope is inserted
through the suprapubic port. The medial side of the right
mesocolon is first incised, starting from the previously
marked region below the ileocolic pedicle, followed by the
incision of the peritoneum over to the superior mesenteric
vessels. This is done before mobilization of the right colon.
With adequate traction of mesocolon toward the right upper
quadrant, the ileocolic vessels are easily mobilized from
the subperitoneal fascia leading onto the duodenum. Their
origins are identified from the superior mesenteric vessels at
the lower border of the duodenum and divided.
The surgeon’s first step in the dissection is to mark the
inferior border of the ileocolic pedicle. From between the
legs, the surgeon dissects the peritoneum overlying the
ileocolic vascular pedicle over to the superior mesenteric
vessels.
After mobilization of the ileocolic pedicle from the
duodenum, the dissection of the ventral side of the superior
mesenteric vein (SMV) leads to the dissection of the origin of
the ileocolic artery. In type B, the ileocolic artery is running
behind the superior mesenteric vein. After mobilization and
division of the ileocolic pedicle from the duodenum, the
dissection of the ventral side of the SMV leads to a complete
dissection of the root of the middle colic artery and vein.
Careful dissection onto the duodenum and the caudad
portion of the pancreas must be exercised in the exposure
of the middle colic vessels. Dissection around Henle’s trunk
(thetruckofmesentericveinsconsistingofthegastroepiploic
vein fusing with the right branch of the middle colic vein
or the main middle colic vein) may lead to the exposure
of an accessory right colic vein. Accessory right colic vein
and right branches of middle colic vessels are clipped and
divided. However, if an accessory right colic vein is difficult
to confirm in this situation, this vein may be easily detected
later at the take-down of the right flexure.
After securing the vessels, the operating table is tilted into
the steep Trendelenburg position with the right side down to
move the small intestine toward the right upper quadrant.
After confirming the right ureter and gonadal vessels

347
Figs. 9A and B: (A) Position of major blood vessels at the time of surgery; (B) Important vessels supplying right side of colon.
A B
Figs. 10A and B: Specimen of right side of colon after right colectomy.
A B
through the subperitoneal fascia at the right pelvic brim, the
peritoneum is incised along the base of the ileal mesentery
upward to the duodenum, and the ileocecal region is
mobilized medially to lateral. After this mobilization, the
surgeon moves back to the patient’s left side, and the scope
is inserted through the umbilical port. The right mesocolon
is mobilized from medial to lateral. Again, this approach
allows dissection into the proper retroperitoneal plane. The
right gonadal vessels and ureter are safe from injury in this
plane, so exposing them is not necessary. This approach also
allows the surgeon to work in a straight path from medial to
lateral, without tissue to obstruct the vision that can occur
while working from lateral to medial. This plane connects
the previous dissection plane from the caudad side.
The anatomy around the right flexure is essential to
avoid inadvertent bleeding, especially from around Henle's
(gastrocolic) trunk. However, if the previous mesenteric
dissection is fully performed from the caudad side and the
accessory right colic vein is divided, the right flexure is easily
taken down only by dividing the hepatotoxic ligament. If the
accessory right colic vein is difficult to detect at the previous
dissection, it can be easily confirmed from Henle’s trunk at
this situation and should be divided before extracting the
right colon to avoid its injury. Up to this point, the primary
tumor has been minimally manipulated using medial to
lateral approach. Finally, the right flexure and right colon,
including the tumor-bearing segment, are detached laterally,
which completes the mobilization of the entire right colon
(Figs. 10A and B).
Once the entire right colon is freed, it is withdrawn
through an enlargement of the port site at the umbilicus. The
wound must be covered with a wound protector to prevent
contamination or metastasis. The resection of ileum and
transverse colon, and the anastomosis are accomplished
extracorporeally by the functional end-to-end anastomotic
method using conventional staplers or by a hand-sewn
method (Figs. 11A and B). The anastomotic site is returned
to the peritoneal cavity. Wounds and peritoneal cavity are
copiously irrigated. All wounds are closed, and operation is
completed.
The identification of a small tumor in the colon may be
difficult even in conventional open surgery. In laparoscopic
surgery, where there is no tactile sensation, pre- or
intraoperative marking of the tumor is frequently needed.

Figs. 11A and B: Transaction of ileum by the stapler.
A B
Various kinds of marking methods are available, e.g., dye
injection and mucosal clip placement by preoperative
colonoscopy, which has been reported for the tumor
localization. Several reports demonstrated the usefulness of
tattooing the colonic wall adjacent to the tumor with India
ink in four quadrants using preoperative colonoscopy.
However, effective injection in all four points of the bowel
is sometimes challenging to achieve. In some cases, surgeons
failed to achieve serosal staining visible at laparoscopy,
which forced them to use intraoperative colonoscopy. This
complicatedthelaparoscopiccolonicresectionbecauseofthe
distendedbowelrelatedtoairinsufflationduringcolonoscopy.
Conclusion
Right-sided colon cancer can be adequately treated by
proper laparoscopic procedures adherent to the oncologic
principles. Port-site metastasis after laparoscopic colon
cancer surgery is unlikely to be a major risk factor when the
procedure is performed according to oncologic principles.
It is believed that laparoscopic right colectomy for cancer
performed by expert surgeons is accepted as less invasive
surgery without sacrificing the survival benefit compared
with conventional open right colectomy.
SIGMOIDECTOMY
Laparoscopic sigmoid colon resection is indicated for both
benign (diverticulitis, segmental Crohn's disease, polyp
unresectable by colonoscopy) and malignant (primary colon
cancer)etiologies,andisoneofthemostcommonoperations
done by laparoscopic methods. In chronic diverticular
disease, the indications for laparoscopic sigmoid resection
are the same as for open surgery. Sigmoid colectomy for
diverticulitis can be technically challenging because of
severe inflammation in the left lower quadrant and pelvis.
Patient Positioning and Operating Room Setup
A proper patient position is key to both facilitating operative
maneuvers and preventing complications such as nerve and
vein compression and traction injuries to the brachial plexus.
The patient is placed supine, in the modified lithotomy
position, with legs abducted and slightly flexed at the knees.
The patient’s right arm is alongside the body, whereas the
left arm is usually placed at a 90° angle. Adequate padding is
used to avoid compression on bone prominences.
A nasogastric or orogastric tube and a urinary catheter
are placed. Adequate thromboembolism prophylaxis should
be used, as preferred by the surgeon, and intermittent leg
compression stockings can be used as well. The procedure
is usually performed with two assistants and a scrub nurse
(Fig. 12). The surgeon is on the right side of the patient,
and the second assistant is also on the right side. The first
assistant stands between the patient's legs and the scrub
nurse at the lower right side of the table. The team remains
in the same position throughout the entire procedure. It is
advisable to use a table that can be easily tilted laterally and
placed into steep Trendelenburg and reverse Trendelenburg
position in order to facilitate exposure of the pelvic space and
of the splenic flexure. The laparoscopic unit with the main
monitor is located on the left side of the table. It is useful to
use a second monitor placed above the patient’s head.
Cannula Positioning
Standardize cannula placements are five or six cannulae for
left-sided colectomies. This allows us to achieve excellent
exposure, which may be particularly valuable at the
beginning of a surgeon’s learning curve. Using six cannulae
allows the use of more instruments in the abdominal cavity
for retraction of bowel and structures, especially in the
presence of abundant intra-abdominal fat or the dilated
small bowel, as well as during mobilization of the splenic
flexure.
Cannula fixation to the abdominal wall is essential, to
avoid CO2 leakage, and in cases of malignancy, to minimize
the passage of tumor cells and help reduce the incidence
of port-site metastases. This is mainly achieved by fitting
the size of the incision to the cannula size or by fixing the

349
Fig. 12: Position of surgical team in colorectal surgery.
Fig. 13: Port position for sigmoidectomy for benign disease. Fig. 14: Alternating port position for sigmoidectomy
for malignant disease.
cannula to the abdomen with a suture placed around the
stopcock of the cannula. Use of screw-like cannulae has
drawbacks that it increases the parietal trauma. Generally,
it is better to perform an “open” technique for the insertion
of the first cannula, which is placed at the midline, above the
umbilicus, to reduce the risk of injury of abdominal organs.
With some experience, the task becomes easy and very rapid.
However, in the case of previous abdominal surgery, we
usually inflate the abdominal cavity using the Veress needle
in the left subcostal area, in order to insert the first cannula
as far lateral as possible, in the right hypochondrium, to
avoid potential areas of adhesions.
The first cannula (12 mm), which is used for the optical
device, is positioned on the midline 3–4 cm above the
umbilicus. The two operating cannulae are introduced,
one at the junction between the umbilical line and the
right midclavicular line, and the other 8–10 cm inferiorly,
on the same line. The latter is a 12 mm operating cannula
to allow the introduction of a linear stapler at the time of
bowel resection. This cannula accommodates the following:
scissors (monopolar, high-frequency hemostasis device,
clip, staplers), a monopolar hook, surgical loops, a suction-
irrigationdevice,andanatraumaticgrasper.Afourthcannula
is placed on the left midclavicular line at the level of the
umbilicus. This is a 5-mm cannula, which accommodates
an atraumatic grasper used for retraction and exposure
during the medial approach for the dissection of the left
mesocolon. When performing mobilization of the splenic
flexure, this cannula becomes an operating cannula. A fifth
5-mm cannula is placed 8–10 cm above the pubic bone, on
the midline, and is used for retraction (Figs. 13 and 14).
For most of the procedure, it accommodates a grasper
used to expose the sigmoid and descending mesocolon. At
the end of the procedure, the incision at this cannula's site
is lengthened to allow extraction of the specimen. Some
surgeons sometimes use an additional cannula, which is a

5 mm cannula situated on the right midclavicular line in the
subcostalareaandaccommodatesanatraumaticgrasperused
to retract the terminal portion of the small intestine laterally
at the beginning of the dissection and to retract the transverse
colon during the mobilization of the splenic flexure.
Operative Technique
Exposure
To complete exposure of the operative field, active
positioning of the bowel is usually necessary in addition to
the passive action of gravity, especially in the presence of
obesity or bowel dilatation. The greater omentum and the
transverse colon are placed in the left subphrenic region and
maintained in this position by the Trendelenburg tilt. An
atraumatic retractor, introduced through the cannula on the
left side, may also be used. Subsequently, the proximal small
bowel loops are placed in the right upper quadrant using
gentle grasping (Figs. 15A and B).
The distal small bowel loops are placed in the right lower
quadrant with the cecum and maintained there with gravity.
If gravity is not sufficient, as occurs mainly in the presence of
abundantintra-abdominalfatordilatedbowel,anadditional
maneuver is used. An instrument passed through the right
subcostal cannula is passed at the root of the mesentery and
grasps the parietal peritoneum of the right iliac fossa; the
shaft of the grasper thus provides an autostatic retraction
of the bowel loops, keeping them away from the midline
and the pelvic space. This technique of exposure offers an
excellent view of the sacral promontory and the aortoiliac
axis. This particular view on the operative field is essential
for the medial-to-lateral vascular approach.
The uterus may be an obstacle to adequate exposure in
the pelvis. In postmenopausal women, the uterus can be
suspended to the abdominal wall by a suture (Fig. 16). This
suture is introduced halfway between the umbilicus and the
pubis and opens the rectovaginal space. In younger women,
the uterus can be retracted using a similar suspension
by a suture around the round ligaments or using a 5-mm
retractor passed through the suprapubic cannula. Very often,
conversiontoopensurgeryiscausedbydifficultyinexposure,
not only at the beginning but also throughout the procedure.
To perform a medial approach, time is dedicated to the
perfect achievement of this exposure, which will serve not
only for the initial vascular approach, but also for about half
of the remaining operative time. After adequate exposure has
been achieved, the following steps of the technique include
the vascular approach, the medial posterior mobilization
of the sigmoid, the extraction of the specimen, and the
anastomosis. Additional steps include the mobilization of
the splenic flexure, performed when further lengthening of
the bowel is needed to perform a tension-free anastomosis.
This step of the exposure is preliminary, and it is done
in a similar manner, regardless of the type of disease. The
remainder of the procedure is different if the indication for
surgery is cancer or benign disease.
Sigmoid Colon Resection for Cancer
In laparoscopic colorectal sigmoidectomy for cancer
or for benign disease, the vascular approach is the first
step of the dissection. It is believed that it allows us
Figs. 15A and B: Exposure of sigmoid colon after shifting the omentum upward.
A B
Fig. 16: Securing the uterus by suture for proper exposure of rectum.

351
Figs. 17A and B: Vascular supply of left side of colon.
(SRA: superior rectal artery; LCA: left colic artery; IMA: inferior mesenteric artery)
A B
Figs. 18A to D: Incision of peritoneum over sacral promontory.
A B
C D
to avoid unnecessary manipulation of the colon and
tumor, which may cause tumor cell exfoliation, and to
perform a good lymphadenectomy following the vascular
anatomy. The vessels are gradually exposed once the
peritoneum at the base of the sigmoid mesocolon is incised
(Figs. 17A and B). The medial-to-lateral view allows us
to see the sympathetic nerve plexus trunks, the left ureter,
and gonadal vessels, avoiding ureteral injuries and possibly
preserving genital function.
Primary Vascular Approach (Medial Approach)
Peritoneal Incision
The sigmoid mesocolon is retracted anteriorly, using a
grasper introduced through the suprapubic cannula:
This exposes the base of the sigmoid mesocolon. The visceral
peritoneum is incised at the level of the sacral promontory
(Figs. 18A to D). The incision is continued upward along
the right anterior border of the aorta up to the ligament of

Treitz. The pressure of the pneumoperitoneum facilitates the
dissection, as the diffusion of CO2 opens the avascular planes.
Identification of the Inferior
Mesenteric Artery
The dissection of the cellular adipose tissue is continued
upward by gradually dividing the sigmoid branches of
the right sympathetic trunk. The dissection behind the
inferior mesenteric artery (IMA) involves preservation of
the main hypogastric nerve trunks but also division of the
small branches traveling to the colon to expose the origin
of the IMA (Figs. 19A and B). To ensure an adequate
lymphadenectomy, the first 2 cm of the IMA are dissected
free, and the artery is skeletonized before it is divided.
This dissection at the origin of the IMA involves a risk of
injury to the left sympathetic trunk situated on the left border
of the inferior mesenteric artery. A meticulous dissection of
the artery (skeletonization) helps to avoid this risk, because
only the vessel will be divided, and not the surrounding
tissues. Dissection performed close to the artery also
minimizes the risk of ureteral injury during the ligation of
the inferior mesenteric artery. The IMA can then be divided
between clips, or by using a linear stapler (vascular 2.5 or
2.0-mm cartridges. The artery is divided at 1–2 cm distal to
its origin from the aorta ideally after the take-off of the left
colic artery (Figs. 20A to H).
Identification of the Inferior Mesenteric Vein
The inferior mesenteric vein (IMV) terminates when
reaching the splenic vein, which goes on to form the portal
vein with the SMV. Anatomical variations include the IMV
draining into the confluence of the SMV and splenic vein
and the IMV draining in the SMV.
The IMV is identified to the left of the IMA or in case
of difficulty, higher, just to the left of the ligament of Treitz
junction (Fig. 21). The vein is divided below the inferior
border of the pancreas or above the left colic vein. Once
again, clips are sure options to ligate and divide this vessel
(Figs. 22A to D).
Mobilization of the Sigmoid and
Descending Colon
The mobilization of the sigmoid colon follows the division
of the vessels. This step includes the freeing of posterior and
lateral attachments of the sigmoid colon and mesocolon
and the division of the rectal and sigmoid mesenteries. The
approach is either medial or lateral. It is wise to routinely
perform this medial-to-lateral laparoscopic dissection
for all indications. The medial approach is well adapted
for laparoscopy because it preserves the working space
and demands the least handling of the sigmoid colon.
In a randomized trial comparing the medial-to-lateral
laparoscopic dissection with the classical lateral-to-medial
approach for resection of rectosigmoid cancer, Liang et al.
showedthatthemedialapproachreducesoperativetimeand
the postoperative proinflammatory response. Besides the
potential oncologic advantages of early vessel division and
“no-touch” dissection, it is believed that he longer the lateral
abdominal wall attachments of the colon are preserved, the
easier are the exposure and dissection.
Posterior Detachment
The sigmoid mesocolon is retracted anteriorly using the
suprapubic cannula to expose the posterior space. The plane
between Toldt's fascia and the sigmoid mesocolon can then
be identified. This plane is avascular and easily divided.
The dissection continues posteriorly to the sigmoid
mesocolon going laterally toward Toldt's line. The sigmoid
colon is then completely free, and the lateral attachments
can then be divided using a lateral approach.
Figs. 19A and B: Arterial supply of sigmoid colon.
A B

353
Figs. 20A to H: Dissection of inferior mesenteric artery
A
C
E
G
B
D
F
H
Lateral Mobilization
The extent of the dissection is superiorly formed by the
inferior border of the pancreas, laterally following Gerota's
fascia and inferiorly the psoas muscle where the ureter
crosses the iliac vessels. The sigmoid loop is pulled toward
the right upper quadrant (grasper in right subcostal cannula)
to exert traction on the line of Toldt (Fig. 23). The peritoneal
fold is opened cephalad and caudad, and the dissection joins
theonepreviouslyperformedmedially.Duringthisstep,care
must be taken to avoid the gonadal vessels and the left ureter
because they can be attracted by the traction exerted on the Fig. 21: Venous supply of sigmoid colon.

mesentery. Ureteral stenting (infrared stents) can be useful
in cases in which inflammation, tumoral tissue, or adhesions
and endometriosis make planes difficult to recognize.
Dissection of the Upper Mesorectum
This area of dissection should be approached with
caution, especially on the left side: The mesorectum
there is closely attached to the parietal fascia where
the superior hypogastric nerve and the left ureter are
situated. The upper portion of the rectum is mobilized
posteriorly following the avascular plane described before,
then laterally, until a sufficient distal margin is achieved
(Figs. 24A to D).
Resection of the Specimen
Division of the Rectum
Once the upper rectum is freed, the area of distal resection
is chosen, allowing a distal margin of at least 5 cm. The fat
surrounding this area is cleared, using monopolar cautery,
ultrasonic dissection, or the LigaSuretm
device. Doing so, the
superior hemorrhoidal arteries are divided in the posterior
upper mesorectum. The distal division is performed using a
linear stapler.
The stapler is introduced through the right lower
quadrant cannula. It is wise to use stapler loads 3.5 mm,
45 mm blue cartridges, which are applied perpendicular to
the bowel (Figs. 25A to F). Articulated staplers can also be
useful, although they are usually unnecessary at the level of
the upper rectum (Figs. 26A and B).
Proximal Division
The proximal division site should be located at least 10 cm
proximal to the tumor. It is performed by first dividing the
mesocolon and, subsequently, the bowel (Fig. 27).
The division of the mesocolon is more easily performed
with the harmonic scalpel, or the LigaSuretm
, although linear
staplers can also be used. The distal portion of the divided
Figs. 22A to D: Dissection of inferior mesenteric vein.
A
C
B
D
Fig. 23: Lateral approach.

355
Figs. 24A to D: Dissection of upper mesorectum.
A
C
B
D
Figs. 25A to F: Division of rectum using stapler.
A
C
E
B
D
F

IMA is identified, and the division of the mesocolon starts
right at this level and continues toward the chosen proximal
section site at a 90° angle. A linear stapler is then fired across
the bowel. The stapler (blue load) is introduced through the
right lower quadrant cannula. The specimen is placed in a
plastic retrieval sac introduced through the same cannula.
This permits the continuation of the procedure without
manipulation of the bowel and tumor. If the resected
specimen is large and obscures the operative fields, the
extraction can be done before completing the mobilization
of the left colon.
Mobilization of the Splenic Flexure
In the frequent event that a long segment of the sigmoid
colon has been resected, mobilization of the splenic flexure
is required. This can be achieved in different ways. It is
important for the surgeon to be familiar with all approaches
in order to select the most suitable approach. Sufficient
mobilization of the splenic flexure may be achieved by
simply freeing the posterior and lateral attachments of the
descending colon. This is begun by a medial approach to
free the posterior attachments of the descending and distal
transverse colon, followed by the dissection of the lateral
attachments, or by doing the same task in the reverse order.
Lateral mobilization is sometimes sufficient in cases of
sigmoid cancer, where the posterior mobilization can be
omitted.
Lateral Mobilization of the Splenic Flexure
This approach is often used in open surgery and can also
be used in simple laparoscopic colectomies. The first step
is the section of the lateral attachments of the descending
colon. An ascending incision is made along the line of
Toldt using scissors introduced via the left-sided cannula.
The phrenicocolic ligament is then divided using scissors
introduced through this cannula. Retraction of the
descending colon and the splenic flexure toward the right
lower quadrant using graspers introduced through the
right lower and suprapubic cannulae helps to expose the
correct plane (Figs. 28A and B). The attachments between
the transverse colon and the omentum are divided close
to the colon until the lesser sac is opened. The division of
these attachments is continued as needed to facilitate the
mobilization of the colon into the pelvis.
Medial Mobilization
This approach dissects the posterior attachments of the
transverse and descending colon first. The dissection plane
naturally follows the plane of the previous sigmoid colon
mobilization, cephalad, and anterior to Toldt’s fascia. The
transverse colon is retracted anteriorly to expose the inferior
border of the pancreas, and the root of the transverse
mesocolon is divided anterior to the pancreas and at a
distance from it, to enter the lesser sac. The dissection
then follows toward the base of the descending colon and
distal transverse colon, dividing the posterior attachments
of these structures. The division of the lateral attachments,
as described above, then follows the full mobilization of the
splenic flexure. If the mobilized colon reaches the pelvis
easily, it may be safely assumed the anastomosis will be
tension free as well.
Extraction of Colon
The extraction of the specimen is performed using
double protection: A wound protector as well as a retrieval
sac (Figs. 29 and 30). The wound protector is also helpful
to ensure that there is no CO2 leak during the intracorporeal
colorectal anastomosis, which follows the extraction. This
allows a reduction of the size of the incision and potentially
minimizes the risk of tumor cell seeding.
Fig. 27: Division 10 cm proximal and 5 cm distal to tumor.
Figs. 26A and B: Disposable circular staplers used
in colorectal surgery.
A
B

357
Fig. 29: Extraction of colon.
Figs. 28A and B: Mobilization of the splenic flexure of the colon.
(IMV: inferior mesenteric vein)
A B
The Incision to Extract the Specimen
The size of the incision, its location, and the extraction
technique take into account the volume of the specimen,
the patient's body habitus, cosmetic concerns, and the
type of disease. The incision is generally performed in the
suprapubic region. The proximal division is performed
intracorporeally, as described above, and the specimen
placed into a thick plastic bag before being extracted through
the incision at the suprapubic area.
Anastomosis
For anastomosis, a mechanical circular stapling device
passed transanally to perform the anastomosis is used.
Performing the anastomosis includes an extra-abdominal
preparatory step, and an intra-abdominal step performed
laparoscopically.
The extra-abdominal step takes place after the extraction
of the specimen. The instrument holding the proximal bowel
presents it at the incision where it can easily be grasped with
a Babcock clamp and pulled out. If necessary, the colon
is divided again in a healthy and well-vascularized zone
(Figs. 31A and B).
The anvil (at least 28 mm in diameter) is then introduced
into the bowel lumen and closed with a purse-string;
then, the colon is reintroduced into the abdominal cavity
(Fig.32).Theabdominalincisionisclosedtore-establishthe
pneumoperitoneum. For an air-tight closure, it is sufficient
to twist the wound protector at the level of the incision
using a large clamp (Figs. 33A and B). The circular stapler is
introduced into the rectum through the gently dilated anus.
The rectal stump is then transfixed with the tip of the head
of the circular stapler. In women, the posterior vaginal wall
should be retracted anteriorly by the assistant passing the
stapler (Fig. 34). Once the center rod and anvil are clicked
into the distal part of the circular stapler, twisting of the
colon and the mesentery should be checked. The stapler
is then fired after ensuring that the neighboring organs are
away from the stapling line. The stapler is then twisted open
and withdrawn. The anastomosis is checked for leaks by
verifying the integrity of the proximal and distal rings, as well
as performing an air test (Figs. 35 and 36).
Wound Closure
The cannula sites are checked internally for possible
hemorrhage. To do so, a grasper is passed through the
cannula, and the cannula is removed, leaving the grasper in
the abdomen. Because of the smaller diameter of the grasper
compared with the cannula, if the bleeding was so far
concealed by the tamponade effect of the cannula, it would
be revealed promptly. The cannula is then reintroduced
to allow maintenance of the pneumoperitoneum while
performing the same check at all cannula sites.
When the check is completed, the CO2 is desufflated
through the cannulae, and cannulae are removed. No routine

Figs. 30A and B: Extraction of specimen through wound protector.
A B
Figs. 31A and B: Preparation of the proximal loop of the colon for anastomosis.
A B
drainageoftheanastomoticareaisperformed.Thesuprapubic
incision is closed in layers using running absorbable sutures,
and all fascial defects of 10 mm and more are closed. The skin
is closed with a subcuticular absorbable suture.
Sigmoidectomy for Diverticular Disease
The outcomes after laparoscopic sigmoidectomy for
diverticulitis are similar or even better to those seen in
the open method, with faster recovery and decreased
postoperative pain. Hand-assisted laparoscopic sigmoid
resection for diverticulitis is also an attractive alternative to a
“pure” laparoscopic method in complicated cases.
The vascular approach for patients with benign diseases
of the sigmoid colon is performed with the following steps.
Peritoneal Incision
The peritoneal incision can be similar to the cancer
technique, particularly in difficult cases (obesity,
inflammatory mesocolon). In most cases, the surgeon
should try to preserve the vascularization of the rectum and
the left colic vessels. The opening of the peritoneum can
be limited to the mesosigmoid parallel to the colon at mid-
distance between the colon and the root of the mesosigmoid.
An initial lateral mobilization of the sigmoid can be useful
in this approach. The branches of the sigmoid arterial trunk
can be divided separately anteriorly to inferior mesenteric
vessels or together after creating windows in the mesentery
to divide the various branches. A linear stapler or, better, the
LigaSuretm
Atlas 10-mm device can be used for this task.
Resection of the Specimen
In diverticular disease, one should perform the distal
resection of the bowel below the rectosigmoid junction.
Fig. 32: Fixing the anvil on the proximal loop of colon.

359
Fig. 34: Anvil and stapler ready for anastomosis. Fig. 35: End-to-end anastomosis done with the help of circular stapler.
The rectosigmoid junction is located just above the
peritoneal reflection at the pouch of Douglas (Fig. 37). It is
preferred to perform the mobilization of the splenic flexure
at this moment, before resection at the proximal limit, using
the same principles as described above.
Extraction of the Specimen
Before extracting the colon, it is important to divide the
mesocolon at the level of the proximal side of the division.
After adequate mobilization is achieved, the colon is
extracted through a suprapubic incision, protected by
the plastic drape described above, and proximal division
performed externally on a compliant and well-vascularized
part of the colon. The anastomosis is performed as described
above for cancer.
Special Considerations
Ureteral injuries are one of the most important
complications, which can be avoided by a perfect exposure
and the respect of the correct plane of dissection. Indeed, a
dissection properly performed above the Toldt's fascia does
not expose the ureter to accidental injury. Difficult cases,
such as important inflammatory reaction, cancer invasion
or adhesions, and, sometimes, endometriosis, may alter the
anatomy of the region and render the identification of the
ureter troublesome. In these special cases, prevention of
ureteral injury may be facilitated by the use of infrared wires
inserted in ureteral stents. The infrared light is cold and safe
for use in close contact with the ureteral tissue, and, on the
other side, makes it easy to recognize the structure under the
light of an adequate laparoscope.
LOW ANTERIOR RESECTION
Two surgical procedures with curative intent are available to
patients with rectal cancer:
1. Lower anterior resection
2. Abdominoperineal resection
Lower anterior resection may improve quality of life and
functional status. Lower anterior resection, formally known
as anterior resection of the rectum and anterior excision of
the rectum or simply anterior resection, is a common surgery
for rectal cancer. It is commonly abbreviated as LAR. LAR is
generally the preferred treatment for rectal cancer insofar as
thisissurgicallyfeasible.Laparoscopiclowanteriorresection
for rectal cancer has gained full acceptance among general
surgeons. Hand-assisted laparoscopic surgery (HALS) LAR
also has equal recognition, mainly due to the technical
difficulties encountered during pelvic dissection.
Figs. 33A and B: Clamping and twisting of wound protector to prevent gas leak.
A B

Figs. 36A to L: Anastomosis by the help of a circular stapler.
A
C
E
G
I
K
B
D
F
H
J
L

361
Patient Positioning
The patient is placed supine on the operating table
(Fig. 38). After induction of general anesthesia and insertion
of an orogastric tube and Foley catheter, the legs are placed
in stirrups. The arms are tucked at the patient's side, and
the beanbag is aspirated. The abdomen is prepared with an
antiseptic solution and draped routinely.
Position of Surgical Team
The primary monitor is placed on the left side of the
patient at approximately the level of the hip. The operating
nurse is placed between the patient’s legs. There should
be sufficient space to allow the surgeon to move from
either side of the patient to between the patient’s legs,
if necessary. The primary operating surgeon stands on
the right side of the patient with the assistant standing
on the patient’s left and moving to the right side, caudad
to the surgeon, once ports have been inserted (Fig. 39).
A 30-degree telescope is used.
Port Position
The primary optical port is introduced subumbilical using a
modified Hasson approach. Having confirmed entry into the
peritoneal cavity, a purse-string suture is placed around the
subumbilical fascial defect, the abdomen to be insufflated
with CO2 to a pressure of 12 mm Hg.
The telescope is inserted into the abdomen and an initial
diagnostic laparoscopy is performed, carefully evaluating
the liver, small bowel, and peritoneal surfaces. A 12-mm
port is inserted in the right lower quadrant approximately
2–3 cm medial and superior to the anterior superior iliac
spine. It is carefully inserted lateral to the inferior epigastric
vessels, paying attention to keep track of the port going as
perpendicular as possible through the abdominal wall. A
5-mm port is then inserted in the right upper quadrant at
least a hand’s breadth superior to the lower quadrant port.
A left lower quadrant 5-mm port is inserted. A 5-mm left
upper quadrant port is also inserted to aid splenic flexure
mobilization. Again, all of these remaining ports are kept
lateral to the epigastric vessels. This may be ensured by
diligence to anatomic port site selection and using the
laparoscope to transilluminate the abdominal wall before
making the port-site incision to identify any obvious
superficial vessels.
Theassistantnowmovestothepatient’sleftside,standing
caudad to the surgeon. The patient is rotated with the left
side up and right side down, to approximately 15–20° tilt, and
often as far as the table can go. This helps to move the small
bowel over to the right side of the abdomen. The patient is
then placed in the Trendelenburg position. This again helps
gravitational migration of the small bowel away from the
operative field. The surgeon then inserts two atraumatic
bowel clamps through the two right-sided abdominal ports.
The greater omentum is reflected over the transverse colon
Fig. 37: Before and after sigmoidectomy. Fig. 38: Patient position for low anterior resection.
Fig. 39: Position of the surgical team for LAR.
(LAR: low anterior resection)

so that it comes to lie on the stomach. If there is no space in
the upper part of the abdomen, one must confirm that the
orogastric tube is adequately decompressing the stomach.
The small bowel is moved to the patient’s right side, allowing
visualization of the medial aspect of the rectosigmoid
mesentery. This may necessitate the use of the assistant’s
5-mm atraumatic bowel clamp through the left lower
quadrant to tent the sigmoid mesentery cephalad.
Defining and Dividing the
Inferior Mesenteric Pedicle
An atraumatic bowel clamp is placed on the rectosigmoid
mesentery at the level of the sacral promontory,
approximately halfway between the bowel wall and the
promontory itself. This area is then stretched up toward the
left lower quadrant port, stretching the inferior mesenteric
vessels away from the retroperitoneum. In most cases, this
demonstrates a groove between the right or medial side of
the inferior mesenteric pedicle and the retroperitoneum.
Electrosurgery or harmonic is used to open the peritoneum
along this line, opening the plane cranially up to the origin
of the inferior mesenteric artery, and caudally up to the
sacral promontory. Blunt dissection is then used to lift
the vessels away from the retroperitoneum and presacral
autonomic nerves. The ureter is then looked for under the
inferior mesenteric artery. If the ureter cannot be seen, and
the dissection is in the correct plane, the ureter should be
just deep to the parietal peritoneum, and just medial to the
gonadal vessels. Care must be taken not to dissect too deep
and injure the iliac vessels.
If the ureter cannot be found, it has usually been elevated
on the back of the inferior mesenteric pedicle, and one needs
to stay very close to the vessel not only to find the ureter but
also to protect the autonomic nerves. If the ureter still cannot
be found, the dissection needs to come in a cranial direction,
which is usually into clean tissue allowing it to be found. If
this fails, a lateral approach can be performed. This usually
gives a fresh perspective to the tissues, and the ureter can
often be found quite easily. In very rare cases, the ureter still
may not be found. The ureteric stent should be used, and
it helps in easy identification of ureter and prevents it from
getting injured. It is good not to proceed if the ureter cannot
be defined. The dissection is continued up to the origin of
the inferior mesenteric artery, which is carefully defined
and divided using a high ligation, above the left colic artery.
A clamp is placed on the origin of the vessel to control it if
clips or other energy sources do not adequately control the
vessel. Endo Gia stapler can also be used for easy division of
the vessel.
Having divided the vessels at the origin of the artery,
the plane between the descending colon mesentery and
the retroperitoneum is developed laterally, out toward the
lateral attachment of the colon, and superiorly, dissecting
the bowel off the anterior surface of the Gerota's fascia up
toward the splenic flexure. This makes the inferior vein quite
obvious, and this vessel can also be divided just inferior to
the pancreas. This allows increased reach for a coloanal
anastomosis with or without neorectal reservoir.
Mobilization of the Lateral Attachments
of the Rectosigmoid and Descending Colon
The surgeon now grasps the rectosigmoid junction with his
left-hand instrument and draws it to the patient's right side.
This allows the lateral attachments of the sigmoid colon to
be seen and divided using electrosurgery or harmonic.
Bruising from the prior retroperitoneal mobilization of
the colon can usually be seen in this area. Once this layer
of peritoneum has been opened, one immediately enters
into the space opened by the retroperitoneal dissection.
Dissection now continues up along the white line of Toldt,
toward the splenic flexure. As the dissection continues, the
surgeon’s left-hand instrument needs to be gradually moved
upalongthedescendingcolontokeepthelateralattachments
under tension. In this way, the lateral and any remaining
posterior attachments are freed, making the left colon and
sigmoid a midline structure. Elevating the descending
colon and drawing it medially is useful, as this keeps small
bowel loops out of the way of the dissecting instrument
and facilitates the dissection. In some patients, particularly
very obese or otherwise large patients, it is difficult to reach
high enough through the right lower quadrant port. For this
reason, the surgeon’s right-hand instrument is moved to
the left lower quadrant port site. This permits greater reach
along the descending colon.
Mobilization of the Splenic Flexure
Complete lateral mobilization of the left colon up to the
splenicflexureisperformedasaninitialstep.Thedescending
colon is pulled medially using an atraumatic bowel clamp in
the right lower quadrant port, and the scissors are placed in
the left iliac fossa port. A 5-mm left upper quadrant port may
be necessary, particularly in those with a very high splenic
flexure, or in very tall or obese individuals. The lateral
attachments of the left colon are divided, and the colon is
dissected off the Gerota's fascia over the left kidney.
Once the lateral attachments of the colon have been
freed, it is necessary to move medially and enter the lesser
sac. Some surgeons prefer to perform this as an initial step
before lateral mobilization. To enter the lesser sac, the
patient is tilted to a slight reverse Trendelenburg position. An
atraumatic bowel clamp is inserted through the right upper
quadrant port. If the left upper quadrant port is available,
this can also be used. The assistant holds up the greater
omentum, toward its left side, like a cape. The surgeon grasps
the transverse colon toward the left side using a grasper in
the right lower quadrant port to aid the identification of

363
the avascular plane between the greater omentum and the
transverse mesocolon. Harmonic scalpel or monopolar
scissors can be used through the left lower quadrant port
to dissect this plane and enter the lesser sac. The surgeon
usually moves to stand between the patient’s legs for this
part of the procedure. This dissection is continued toward
the splenic flexure.
Following separation of the omentum off the left side of
the transverse colon, connection to the lateral dissection
allows the splenic flexure to be fully mobilized. The colon
at the flexure is retracted caudally and medially, and any
remaining restraining attachments are divided.
Rectal Mobilization
The patient is returned to the Trendelenburg position, and
the small bowel is reflected cranially. Atraumatic bowel
clamps inserted through the left-sided ports are used to
elevate the rectosigmoid colon out of the pelvis and away
from the retroperitoneum and sacral promontory, to enable
entry into the presacral space. The posterior aspect of the
mesorectum can be identified and the mesorectal plane
dissected with diathermy, preserving the hypogastric nerves
as they pass down into the pelvis, anterior to the sacrum.
Dissection continues down the presacral space in this
avascular plane toward the pelvic floor.
Attention is now switched to the peritoneum on the
right side of the rectum. This is divided into the level of the
seminal vesicles or rectovaginal septum. This is repeated on
the peritoneum on the left side of the rectum. This facilitates
further posterior dissection along the back of the mesorectum
to the pelvic floor, to a level inferior to the lower edge of the
mesorectum, just posterior to the anal canal. For an LAR, it is
necessary to perform a total mesorectal excision and hence
the rectum must be dissected down to the muscle tube of
the rectum below the inferior extent of the mesorectum.
In many cases, particularly in those who are obese or men
with a narrow pelvis, some or all of the anterior and lateral
dissection must be completed to get adequate visualization,
to complete the posterior dissection.
An atraumatic bowel clamp through the left iliac fossa
port is used to retract the peritoneum anterior to the rectum
forward. The peritoneal dissection is continued from the free
edge of the lateral peritoneal dissection, anteriorly. Lateral
dissection is continued on both sides of the rectum and is
extended anterior to the rectum, posterior to Denonvilliers’
fascia, separating the posterior vaginal wall from the anterior
wall of the rectum or down to the level of the prostate in men.
The difficulty of dissection will vary depending on the body
habitus of the patient, the diameter of the pelvis, and the size
of the tumor. Occasionally, rectal mobilization can be very
difficult to perform laparoscopically. In some cases, it may
need to be completed in an open manner through a small
Pfannenstiel incision.
Division of Rectum
The lower rectum may be divided with a stapler either
laparoscopicallyorbyopensurgery,dependingontheeaseof
access related to the size of the pelvis (Fig. 40). A rotaculator
laparoscopic stapler may be used to divide the muscle tube
of the rectum below the level of the mesorectum. The stapler
is inserted through the right lower quadrant incision, and
two firings of the stapler are usually required to divide the
rectum. There is no residual mesorectum to divide at this
level. A digital examination is performed to confirm the
location of the distal staple line. If there is any doubt about
the adequacy of the distal margin, a rigid proctoscopy is
performed.
It is sometimes impossible to divide the rectum
laparoscopically as the angulation of the endovascular
stapler is limited to 45°, necessitating the open division of
the rectum. In some patients, getting an assistant to push
up on the perineum with their hand may lift the pelvic floor
enough to get the first cartridge of the stapler low enough. In
some cases, placing a suprapubic port allows easier access
with the stapler to allow the division of the rectum.
Some patients are either too obese or have a very narrow
pelvis or a long anal canal, and the stapler cannot be passed
low enough. Two options exist. One is to perform a transanal
intersphincteric dissection, remove the specimen, and then
perform a handsewn coloanal anastomosis. The second is to
perform a short Pfannenstiel incision, which allows a linear
30-mm stapler to be positioned and the rectum divided.
Extraction and Anastomosis
The specimen can be extracted either through a Pfannenstiel
incision or a left iliac fossa incision; in both incisions, a
wound protector is used in cases with a polyp or cancer to
reduce the risk of tumor implantation in the wound. The left
colon mesentery is divided with cautery. The left colon is
divided, and the specimen is removed. Pulsatile mesenteric
bleeding is confirmed and the vessels ligated with 0
polyglycolate suture ties. Depending on the preference of
the operating surgeon, a colonic pouch or coloplasty may
Fig. 40: Low anterior resection.

be performed. A 2/0 Prolene purse-string suture is inserted
into the distal end of the left colon or pouch, the anvil of a
circular stapling gun inserted, and the purse-string suture
is tied tightly. If a Pfannenstiel incision has been made, the
coloanal anastomosis can be performed under direct vision
and open manipulation following the insertion of a circular
stapling gun into the rectal stump. If a left iliac fossa incision
has been used, the colon is returned to the abdomen, and the
incision closed, the pneumoperitoneum recreated, and the
anastomosis is formed laparoscopically. The anastomosis
can be leak-tested by filling the pelvis with saline and
inflating the neorectum using a proctoscope or bulb syringe.
ABDOMINOPERINEAL RESECTION
Laparoscopic abdominoperineal resection is an operation
in which the anus, rectum, and sigmoid colon are removed
(Fig. 41). It is used to treat cancer located very low in the
rectum or in the anus, close to the sphincter muscles.
Laparoscopic surgery for anorectal carcinoma is steadily
gaining acceptance. The advantage offered by laparoscopy
has always centered on improved vision. This advantage
seems to be put to best use in the case of rectal cancer
surgery, where logistic impediments, viz., narrow pelvis and
impaired visibility as the dissection proceeds caudad, have
proved to be obstacles to colorectal surgeons during open
surgery. Recent studies have shown that the size of the tumor
does not hamper the feasibility of performing laparoscopic
abdominoperineal resection. We need to consider the
possibility of an increased circumferential margin rate for
large-size tumors. This may be addressed by preoperative
radiotherapy and chemotherapy before undertaking surgery
on these large tumors. It is important to note, though, that the
oncological safety is not only dependant on the abdominal
procedure but also the adequacy of the perineal part of
the operation. Besides, should tumor injury be detected
intraoperatively, it is advisable to convert to open surgery to
control the amount of contamination and complete the rest
of the procedure.
Patient Position
The patient is placed supine on the operating table on a
beanbag. After induction of general anesthesia and insertion
stirrups.Thearmsaretuckedatthepatient’sside.Theabdomen
is prepared with an antiseptic solution and draped routinely.
The primary monitor is placed on the left side of the patient
up toward the patient’s feet. The secondary monitor is
placed on the right side of the patient at the same level and
is primarily for the assistant during the early phase of the
surgery and port insertion. The operating nurse’s instrument
table is placed between the patient’s legs. There should be
sufficient space to allow the surgeon to move from either
side of the patient to between the patient’s legs, if necessary.
The primary operating surgeon stands on the right side of
the patient with the assistant standing on the patient’s left
and moving to the right side, caudad to the surgeon, once
ports have been inserted.
Port Position
ThisisperformedusingaHassonapproach.A10-mmsmiling
subumbilical incision is made. This is deepened down to the
Fig. 41: Anus, rectum, and sigmoid colon removed in APR.
(APR: abdominoperineal resection)

365
linea alba, which is then grasped on each side of the midline
usingKocherclamps.Ascalpel(No.15blades)isusedtoopen
the fascia between the Kocher clamps, and a Kelly forceps
is used to open the peritoneum bluntly. Having confirmed
entry into the peritoneal cavity, a purse-string suture of 0
polyglycolic acids is placed around the subumbilical fascial
defect. A 10-mm reusable port is inserted through this port
wound, allowing the abdomen to be insufflated with CO2 to
a pressure of 12 mm Hg. The laparoscope is inserted into the
abdomen and an initial laparoscopy is performed, carefully
evaluating the liver, small bowel, and peritoneal surfaces.
A 12-mm port is inserted in the right lower quadrant
approximately 2–3 cm medial and superior to the anterior
superior iliac spine. This is carefully inserted lateral to the
inferior epigastric vessels, paying attention to keep track
of the port going as perpendicular as possible through the
abdominal wall. A 5-mm port is then inserted in the right
upper quadrant at least a hand’s breadth superior to the
lower quadrant port. A left lower quadrant 5-mm port is also
inserted.
Exposure and Dissection of Retroperitoneum
The assistant now moves to the patient’s left side, standing
caudad to the surgeon. The patient is rotated with the left
side up and right side down, to approximately 15–20° tilt, and
often as far as the table can go. This helps to move the small
bowel over to the right side of the abdomen. The patient is
then placed in the Trendelenburg position. This again helps
gravitational migration of the small bowel away from the
operative field. The surgeon then inserts two atraumatic
bowel clamps through the two right-sided abdominal ports.
The greater omentum is reflected over the transverse colon
so that it comes to lie on the stomach. If there is no space in
the upper part of the abdomen, one must confirm that the
orogastric tube is adequately decompressing the stomach.
The small bowel is moved to the patient’s right side, allowing
visualization of the medial aspect of the rectosigmoid
mesentery pedicle. This may necessitate the use of the
assistant’s 5-mm atraumatic bowel clamp through the left
lower quadrant to tent the sigmoid mesentery cephalad.
Complete mobilization of the left colon is not required.
Adequate mobilization must allow the formation of a left
iliac fossa colostomy without tension. Following the division
of the inferior mesenteric artery, the left mesocolon is
separated from the retroperitoneum in a medial-to-lateral
direction using a spreading movement. An atraumatic
bowel clamp inserted through a right-sided port is placed
under the left colonic mesentery, which is elevated away
from the retroperitoneum, and using a scissors inserted
through the other right-sided port, the attachments to the
retroperitoneum are swept down, until the lateral abdominal
wall is reached.
Division of the Left Colon
The mesentery of the left colon is divided from the free
edge, cranial to the previously divided inferior mesenteric
artery, toward the left sigmoid colon. The mesentery can
be divided with diathermy, and the marginal artery can be
clipped and then divided. Alternatively, an energy source
such as a LigaSuretm
may be used to divide the mesentery up
to the edge of the bowel. This may be done before freeing the
lateral attachments of the sigmoid and left colon as it aids in
retraction.
After the division of the mesentery, the lateral
attachments of the sigmoid to the abdominal wall are divided
along the white line. Care is taken to avoid damage to the
retroperitoneal structures. The colon is then divided using
a linear endoscopic stapler at the site where the colonic
mesentery has been divided.
Rectal Mobilization
In women, the uterus may be hitched out of the area of
dissection with a suture. Atraumatic bowel clamps that are
inserted through the left-sided ports are used to elevate
the rectosigmoid colon out of the pelvis and away from the
retroperitoneum and sacral promontory, to enable entry into
the presacral space. The posterior aspect of the mesorectum
can be identified and the mesorectal plane dissected with
diathermy, preserving the hypogastric nerves passing down
into the pelvis anterior to the sacrum. Dissection continues
down the presacral space in this avascular plane toward the
pelvic floor. Attention is now switched to the peritoneum on
the right side of the rectum. This is divided to the level of the
seminal vesicles or rectovaginal septum. This is repeated
on the peritoneum on the left side of the rectum. This
facilitates further posterior dissection along the back of the
mesorectum to the pelvic floor, to a level inferior to the lower
edge of the mesorectum. Usually, when the approach is
low on the posterior surface of the mesorectum, it becomes
necessary to perform a lateral and anterior dissection.
A bowel grasper inserted through the left iliac fossa port
is used to retract the peritoneum anterior to the rectum
forward. The peritoneal dissection is continued from the free
edge of the lateral peritoneal dissection, anteriorly. Lateral
dissection is continued on both sides of the rectum. It is
extended anteriorly to the rectum in front of Denonvilliers’
fascia, separating the posterior vaginal wall from the anterior
wall of the rectum or down past the level of the prostate in
men. The most inferior rectal dissection can be completed
from the perineal approach. For anterior tumors, the
dissection may be performed anterior to Denonvilliers’
fascia, or by taking one side of the fascia to protect the
anterolateral nerve bundle.
It is necessary to perform a total mesorectal excision
and hence the rectum must be dissected down close to the
muscletubeoftherectumbelowthelevelofthemesorectum.

The levators may then be divided from above, staying
well wide of any potential tumor, or the division may be
performed from below after making the perineal incision.
Formation of Trephine Left Iliac
Fossa Colostomy
The divided distal end of the left sigmoid colon is grasped
with atraumatic bowel clamps, which are locked. A trephine
colostomy is made in the left iliac fossa at a site that has
been marked by an enterostomal therapist before surgery.
A skin disk is excised, and a longitudinal incision is made in
the anterior rectus sheath, and the left rectus muscle is split.
The peritoneum is held with two hemostats and incised. The
stapled colon is delivered to the trephine and grasped with
Babcock forceps and delivered through the trephine.
The staple line is excised, and the end colostomy is
matured using 3/0 chromic catgut sutures.
Perineal Dissection
The perineal dissection is performed with a conventional
open approach (Figs. 42A and B). The anus is sutured closed
with 0 nylon, and an elliptical skin incision is made. The
incision is deepened using diathermy, and the ischiorectal
fossae are entered on either side, well lateral to the external
sphincter muscle. The dissection continues laterally and
posteriorly to expose the levator ani muscles (Fig. 43). The
tip of the coccyx is used as the posterior landmark, and the
pelvic cavity is entered by dividing the levator ani muscle just
anterior to the tip of the coccyx. A finger can be placed into
the pelvis onto the upper border of the levator ani, which is
divided with diathermy onto the underlying finger. Care is
taken anteriorly to divide the remaining levator ani while
protecting the posterior surface of the vagina or prostate/
urethra. The specimen may then be delivered out of the
pelvis, which facilitates the division of the remaining anterior
attachments of the rectum, reducing the risk of damage to
the prostate or posterior wall of the vagina. The specimen is
removed,thepelviccavityirrigatedofbloodordebris,andthe
perineal tissue closed in layers using polydioxanone sutures.
HARTMANN REVERSAL
The Hartmann procedure is a standard life-saving operation
for acute left colonic complications. It is usually performed
Figs. 42A and B: Perineal dissection.
A B
Fig. 43: Perineal anatomy.

367
as a temporary procedure with the intent to reverse it later
on. This reversal is associated with considerable morbidity
and mortality by the open method. The laparoscopic
reestablishment of intestinal continuity after Hartmann
procedure has shown better results in terms of a decrease in
morbidity and mortality.
There are several laparoscopic techniques of the reversal
of the Hartmann procedure. The principle common to
all techniques is a tension-free intracorporeal stapler
anastomosis. The introduction of a circular stapler in the
rectal stump helps in the identification and mobilization of
the rectal stump. Others have mobilized the colostomy first
and have used the colostomy site as a first port or used a
standard umbilical port.
It is technically challenging and requires an experienced
laparoscopic surgeon but offers clear advantages to patients.
Main reasons reported for conversion to open were dense
abdominal–pelvic adhesions secondary to diffuse peritonitis
at the primary operation, the short delay before the
reconstruction, difficulty in finding the rectal stump, and
rectal scarring. Leaving long, nonabsorbable suture ends
at the rectal stump or suturing it to the anterior abdominal
wall helps in its localization. Other relative limitation
factors could be a large incisional hernia from the previous
laparotomy and contraindications to general anesthesia and
laparoscopy.
Patient Position
The patient is placed supine on the operating table, on a
in a lithotomy stirrup position. The arms are tucked at the
patient’s side, and the beanbag is aspirated.
The abdomen is prepared with an antiseptic solution and
draped routinely.
at approximately the level of the hip. The secondary monitor
is placed on the right side of the patient at the same level and
and moving to the right side, caudad to the surgeon once
ports have been inserted. A 30-degree camera lens is better
to be used.
The colostomy is mobilized and all adhesions dissected
through the fascial opening until an adequate segment
of bowel has been freed from the surrounding tissues.
The bowel is trimmed as necessary, and a purse-string
suture is positioned before insertion of the anvil of a curved
EEA stapling device. The bowel is returned to the abdomen,
the fascia is closed with a monofilament suture, but before
tying the suture a 12-mm port is inserted at this site, and the
abdomen is insufflated.
Thelaparoscopeisinsertedintotheabdomenthroughthe
stoma port to assess adhesions and allow direct visualization
for subsequent port insertion, and an initial laparoscopy
is performed, carefully evaluating the liver, small bowel,
and peritoneal surfaces. A 10-mm port is inserted in the
umbilicus for camera location. A 5-mm right lower quadrant
trocar is placed approximately 2–3 cm medial to the anterior
superior iliac spine. This is carefully inserted lateral to the
inferior epigastric vessels, paying attention to keep track
of the port going as perpendicular as possible through the
abdominal wall. A 5-mm port is then inserted in the right
upper quadrant at least a hand’s breadth superior to the
lower quadrant port. A left upper quadrant 5-mm port is
inserted. Again all of these remaining ports are kept lateral
to the epigastric vessels. This may be ensured by diligence
to anatomic port site selection and using the laparoscope to
transilluminate the abdominal wall before making the port-
site incision to identify any obvious superficial vessels.
The assistant now moves to the patient’s right side,
standing caudad to the surgeon. The patient is rotated with
the left side up and right side down, to approximately 15–20°
degrees tilt, and often as far as the table can go. This helps to
move the small bowel over to the right side of the abdomen.
The patient is then placed in the Trendelenburg position.
This again helps gravitational migration of the small bowel
away from the operative field. The surgeon then inserts
two atraumatic bowel clamps through the two right-sided
abdominal ports. The greater omentum is reflected over the
transverse colon so that it comes to lie on the stomach. If
there is no space in the upper part of the abdomen, one must
confirmthattheorogastrictubeisadequatelydecompressing
the stomach. The small bowel is moved to the patient’s
right side, allowing visualization of the proximal rectum.
Variable degrees of adhesiolysis may be required. This may
necessitate the use of the assistant’s 5-mm atraumatic bowel
clamp through the stoma trocar or left upper quadrant.
Left Colon Mobilization
Anatraumaticbowelclampisplacedonthedescendingcolon
to take down the inflammatory and native attachments to
free it laterally. The omentum is dissected off the transverse
colon, and the lesser sac is entered. The splenic flexure
is released to allow a tension-free reach to the proximal
rectum. The colonic mesentery should be mobilized off the
Gerota's fascia. The left ureter is identified at the pelvic brim
and freed from the proximal rectum to avoid injury. The
ureter should be just deep to the parietal peritoneum, and

just medial and posterior to the gonadal vessels. Care must
be taken not to dissect too deep or caudad, leading to injury
of the iliac vessels.
Mobilization of Rectum
An atraumatic bowel clamp inserted through the left lower
quadrant port is used to elevate the proximal rectum out of
the pelvis and away from the retroperitoneum and sacral
promontory, to enable entry into the presacral space. The
posterior aspect of the mesorectum can be identified and the
mesorectal plane dissected with diathermy, preserving the
hypogastric nerves as they pass down into the pelvis anterior
to the sacrum. Dissection needs to progress only to allow the
advancement of the circular stapler to the end of the rectum
and assure that all the sigmoid has been resected. If residual
sigmoid is present, the linear endoscopic stapler should be
used to divide the bowel at the level of the proximal rectum.
A site for rectal division should be chosen in proximal,
peritonealized rectum, which assures that the anastomosis
will be distal to the sacral promontory. The rectum is divided
laparoscopicallywithalinearendoscopicstaplerthroughthe
right lower quadrant trocar. One or two firings of the stapler
may be required to divide the rectum. The mesorectum is
divided using monopolar and bipolar cautery at this level.
Specimen Extraction and Anastomosis
If residual sigmoid is required, the specimen is extracted
throughthestomasiteport.Pneumoperitoneumisrecreated,
and the circular stapled anastomosis is formed under
laparoscopic guidance. The anastomosis can be leak-tested
by filling the pelvis with saline and inflating the neorectum
using a proctoscope or bulb syringe, and the orientation
and lack of tension confirmed. The fascia of all the 10 mm
or above port is closed, and the usual manner is followed for
skin dressing.
Conclusion
The reversal of the Hartmann procedure can be difficult
due tendency of the Hartmann segment to become densely
adherent deep in the pelvis. The laparoscopic reversal has
made this major operation easier, safe, and practical. As a
majority of these patients is in the elderly age group, it has
the advantage of early mobilization, less pain, short hospital
stay, and returns to normal life.
RESECTION RECTOPEXY
Total rectal prolapse with chronic constipation and anal
incontinence is a devastating disorder. It is more common
in the elderly, especially women, although why it happens
is unclear. Rectal prolapse can cause complications (such
as pain, ulcers, and bleeding), and cause fecal incontinence
(Figs. 44A to C). Surgery is commonly used to repair the
prolapse. Rectopexy with or without bowel resection is the
most frequent surgical procedure, with 0–9% recurrence
rates in many years. Laparoscopic resection rectopexy is
safely feasible as a minimally invasive treatment option for
rectal prolapse.
Patient Position
The patient is placed supine on the operating table, on a
in Dan Allen stirrups. The arms are tucked at the patient’s
side. The abdomen is prepared with an antiseptic solution
and draped routinely.
at approximately the level of the hip. The secondary monitor
is placed on the right side of the patient at the same level and
and moving to the right side, caudad to the surgeon once
ports have been inserted. A 0-degree camera lens is used.
Port Position
This is performed using a Hasson approach. A smiling
10-mm subumbilical incision is made. This is deepened
down to the linea alba, which is then grasped on each side of
the midline using Kocher clamps. A scalpel (No. 15 blades)
is used to open the fascia between the Kocher clamps, and
a Kelly forceps is used to open the peritoneum bluntly.
The telescope is inserted into the abdomen, and an initial
laparoscopyisperformed,carefullyevaluatingtheliver,small
bowel, and peritoneal surfaces. A 12-mm port is inserted in
the right lower quadrant approximately 2–3 cm medial and
superior to the anterior superior iliac spine. This is carefully
inserted lateral to the inferior epigastric vessels, paying
attention to keep track of the port going as perpendicular as
possible through the abdominal wall. A 5-mm port is then
inserted in the right upper quadrant at least a hand’s breadth
superior to the lower quadrant port. A left lower quadrant
5-mm port is inserted. All the ports are more or less obeying
the baseball diamond concept.
Dissection
The patient is rotated with the left side up and right side
down, to approximately 15–20° tilt, and often as far as the
table can go. This helps to move the small bowel over to

369
the right side of the abdomen. The patient is then placed in
the Trendelenburg position. This again helps gravitational
migrationofthesmallbowelawayfromtheoperativefield.The
surgeon then inserts two atraumatic bowel clamps through
the two right-sided abdominal ports. The greater omentum
is reflected over the transverse colon so that it comes to lie
on the stomach. If there is no space in the upper part of
the abdomen, one must confirm that the orogastric tube is
adequately decompressing the stomach. The small bowel is
moved to the patient’s right side, allowing visualization of
the medial aspect of the rectosigmoid mesentery. This may
necessitate the use of the assistant’s 5-mm atraumatic bowel
clamp through the left lower quadrant to tent the sigmoid
mesentery cephalad.
Division of Inferior Mesenteric Vessel
An atraumatic bowel clamp is placed on the rectosigmoid
mesenteryatthelevelofthesacralpromontory,approximately
halfway between the bowel wall and the promontory itself.
This area is then stretched up toward the left lower quadrant
port, stretching the inferior mesenteric vessels away from the
retroperitoneum. In most cases, this demonstrates a groove
between the right or medial side of the inferior mesenteric
pedicle and the retroperitoneum. Cautery is used to open the
peritoneum along this line, opening the plane cranially up
to the origin of the inferior mesenteric artery, and caudally
past the sacral promontory. Blunt dissection is then used to
lift the vessels away from the retroperitoneum and presacral
autonomic nerves. The ureter is then looked for under the
inferior mesenteric artery. If the ureter cannot be seen, and
the dissection is in the correct plane, the ureter should be
just deep to the parietal peritoneum, and just medial to the
gonadal vessels. Care must be taken not to dissect too deep
or caudad, leading to injury of the iliac vessels.
If the ureter cannot be found, it has usually been elevated
on the back of the inferior mesenteric pedicle, and one needs
to stay very close to the vessel not only to find the ureter
but also to protect the autonomic nerves. If the ureter still
cannot be found, the dissection needs to come in as a cranial
dissection, which is usually into clean tissue allowing it to be
found. If this fails, a lateral approach can be performed. This
usually gives a fresh perspective to the tissues, and the ureter
can often be found quite easily. In very rare cases, the ureter
still may not be found.
The dissection should allow sufficient mobilization of
the IMA so that the origin of the left colic artery is seen. The
vessel is carefully defined and divided just distal to the left
colic artery. A clamp is placed on the origin of the vessel to
Figs. 44A to C: Rectal prolapse
A
B C

control it if clips or other energy sources do not adequately
control the vessel. In general, a cartridge of the endoscopic
linear stapler is used to divide the vessel. Having divided the
pedicle, the plane between the sigmoid colon mesentery and
lateral attachment of the colon. Limited mobilization of the
mesentery of the anterior surface of Gerota’s fascia and of
the left colon should be performed to enhance the fixation
of the rectum.
of the Rectosigmoid
The surgeon now grasps the rectosigmoid junction with his
left-hand instrument and draws it to the patient’s right side.
be seen and divided using cautery. Bruising from the prior
retroperitoneal mobilization of the colon can usually be
seen in this area. Once this layer of peritoneum has been
opened, one immediately enters into the space opened
by the retroperitoneal dissection. No dissection should be
performed more proximally along the white line of Toldt,
toward the splenic flexure.
Mobilization of Rectum
quadrant port is used to elevate the rectosigmoid colon out
of the pelvis and away from the retroperitoneum and sacral
posterioraspectofthemesorectumcanbeidentified,andthe
to the sacrum. Dissection continues down the presacral
space in this avascular plane toward the pelvic floor. Only the
posterior 60% of the rectum needs to be mobilized; however,
dissection should be continued all the way to the levator ani
muscles. A transanal examining finger should be used to
confirm the distal extent of the dissection. The lateral stalks
should be preserved. The peritoneum on either side of the
rectum should be incised to the level of the lateral stalks. The
lateral stalks should generally be preserved, the exception
being when further dissection must completely reduce a
very distal prolapsing segment.
Rectal Division
Thefullymobilizedrectumshouldbeelevatedoutofthepelvis
and a site selected for optimal rectal tension to maintain a
full reduction of the prolapse. A site for rectal division should
be chosen in proximal, peritonealized rectum, which assures
that the anastomosis will be rostral to the sacral promontory.
The rectum is divided laparoscopically with a linear
endoscopic stapler through the right lower quadrant trocar.
One or two firings of the stapler may be required to divide
the rectum. The mesorectum is divided using monopolar
and bipolar cautery at this level.
Specimen Extraction and Anastomosis
The specimen is extracted through a left iliac fossa incision.
Before making the incision, the proximal colonic transaction
point should be grasped with a locking atraumatic bowel
grasper. This site should allow a colorectal anastomosis
that will provide a safe amount of tension on the rectum to
maintain prolapse reduction. After extracorporeal bowel
transaction, adequate vascularity of the colon should be
assured. A 2/0 Prolene purse-string suture is inserted into
the distal end of the left colon; the anvil of a circular stapling
gun is inserted, and the purse-string suture is tied tightly.
The colon is returned to the abdomen, and the left iliac fossa
incision is closed in layers with 0 polyglycolic acid suture.
Pneumoperitoneum is recreated, and the circular stapled
anastomosis is formed under laparoscopic guidance. The
anastomosis can be leak-tested by filling the pelvis with
saline and inflating the neorectum using a proctoscope or
bulb syringe.
Rectopexy (Figs. 45A and B)
The rectum is retracted rostrally to the desired tension to
allow complete reduction of the prolapse. The rectopexy is
then performed from the right side using the two remaining
ports. Two or three nonabsorbable sutures are used to attach
the mesorectum distal to the anastomosis to the sacral
promontory. Alternatively, nitinol or titanium tackers may
be employed using one of the mechanical fixation devices
used for mesh hernia repairs.
WELLS OR MARLEX RECTOPEXY
Rectal prolapse is a distressing condition, especially when
associatedwithfecalincontinenceandconstipation.Itusually
occurs in children or the elderly. Presently laparoscopic
approach is favored as it has better results, especially in
terms of less postoperative pain, shorter hospital stay, and
Figs. 45A and B: Resection rectopexy.
A B

371
lower cost. The pelvic sympathetic and parasympathetic
nerves run along with the rectum; if dissection is not carried
out in the proper plane, injury can occur, leading to bladder
dysfunction, impotence, and retrograde ejaculation. This
is an important consideration when trying to decide which
procedure to perform, especially in men, although the risk
of injury should be <1–2%. Perineal procedures and anterior
resection have a low risk of outlet obstruction. Abdominal
procedures of rectopexy that tack the rectum to the sacrum
can cause outlet obstruction if the rectum is wrapped
circumferentially, often requiring the release of the fixation
to treat the problem.
In a Marlex rectopexy (Ripstein procedure), the entire
rectum is mobilized down to the coccyx posteriorly, the
lateral ligaments laterally, and the anterior cul-de-sac
anteriorly. A nonabsorbable material, such as Marlex mesh
or an Ivalon sponge, is then fixed to the presacral fascia. The
rectum is then placed on tension, and the material is partially
wrapped around the rectum to keep it in position. The
anterior wall of the rectum is not covered with the sponge or
mesh in order to prevent a circumferential obstruction. The
peritoneal reflections are then closed to cover the foreign
body. The Marlex mesh or sponge causes an inflammatory
reaction that scars and fixes the rectum into place.
The Wells procedure was followed by rectal dysfunction
accompanied by increased constipation and evacuation
problems. The Ripstein procedure, preserving the lateral
ligaments, appears not to affect such symptoms adversely.
Modified mesh rectopexy aligns the rectum, avoids
excessive mobilization and division of lateral ligaments,
thus preventing constipation and preserving potency. We
recommend this technique for patients with complete rectal
prolapse with up to grades 1, 2, and 3 incontinence based on
Browning and Parks classification.
During wells rectopexy, the dissection should allow
sufficient mobilization of the IMA so that the origin of the
left colic artery is seen. The pedicle is not divided.
The plane between the sigmoid colon mesentery and
lateral attachment of the colon. Limited mobilization of the
mesentery of the anterior surface of Gerota's fascia and of
the left colon should be performed to enhance the fixation
of the rectum.
Ripstein operation often improved anal continence in
patients with rectal prolapse and rectal intussusception. This
improvement was accompanied by increased maximum
resting pressure (MRP) in patients with rectal prolapse,
indicating recovery of internal anal sphincter function. In
one of the studies at the Department of Surgery, Karolinska
Institute at Danderyd Hospital, Stockholm, Sweden,
MRP (52+/– 23 mm Hg) was found in patients with rectal
prolapse who underwent Ripstein operation than in patients
with rectal intussusception. No postoperative increase
in MRP was found in patients with rectal intussusception.
This suggests an alternate mechanism of improvement in
patients with rectal intussusception.
of the Rectosigmoid
For rectal prolapse surgery lateral mobilization, the
surgeon grasps the rectosigmoid junction with his left-
hand instrument and draws it to the patient's right side.
be seen and divided using cautery. Bruising from the prior
retroperitoneal mobilization of the colon can usually be
seen in this area. Once this layer of peritoneum has been
opened, one immediately enters into the space opened
by the retroperitoneal dissection. No dissection should be
performed more proximally along the white line of Toldt,
toward the splenic flexure.
Rectal Mobilization
quadrant port is used to elevate the rectosigmoid colon out
of the pelvis and away from the retroperitoneum and sacral
posterioraspectofthemesorectumcanbeidentified,andthe
to the sacrum. Dissection continues down the presacral
space in this avascular plane toward the pelvic floor. Only the
posterior 60% of the rectum needs to be mobilized; however,
dissection should be continued all the way to the levator ani
muscles. A transanal examining finger should be used to
confirm the distal extent of the dissection. The peritoneum
on either side of the rectum should be incised to the level
of the lateral stalks. The lateral stalks should generally be
preserved, the exception being when further dissection must
completely reduce a very distal prolapsing segment. The
rectum is not divided in the case of Wells rectopexy.
Rectopexy
A2–4cmportionofpolypropylenemeshisrolledandinserted
through the umbilical trocar. The camera is reinserted,
and the mesh is positioned at the sacral promontory. A
mechanical device used for hernia mesh fixation is used to fix
the mesh to the promontory. This may be inserted through
the right lower quadrant port, but if adequate access cannot
be obtained, a 5-mm suprapubic port may be inserted. Great
care must be taken not to tear or strip off the presacral fascia
when stapling the mesh in place.
The rectum is retracted rostrally to the desired tension
to allow complete reduction of the prolapse, which is
confirmed by digital rectal examination. The rectopexy is
then performed from the right side using the two right-sided
trocars. Two or three nonabsorbable sutures are used to
attach the distal mesorectum to the mesh at the promontory,

sufficient to maintain adequate tension. Alternatively, the
mechanical fixation device used for mesh fixation may be
employed.
The Complications of Colorectal Surgery
The exact frequency and severity of complications are
difficult to determine due to heterogeneous definitions,
patient populations, procedures, comorbidities, and
intensity of follow-up. One perspective of the incidence of
complications can be gleaned from four recent randomized
controlled trials comparing laparoscopic to open colon
resections for cancer (Table 1).
The risk factors related to colorectal surgery include:
■ Perioperative blood transfusion
■ American Society of Anesthesiology (ASA) score grade
2 or 3
■ Male gender
■ Surgeons
■ Types of operation
■ Creation of an ostomy
■ Contaminated wound
■ Use of a drain
■ Obesity
■ Long duration of operation
Wound Infection
Superficial wound infections are the most common
complication of colorectal surgery. The previously held
belief that preoperative cathartic and oral antibiotic bowel
preparation was mandatory to prevent postoperative
infections has recently been debunked by multiple
randomized controlled trials. Superficial wound infections
are recognized by any combination of erythema, induration,
tenderness, or drainage at the wound site. Systemic signs of
fever and tachycardia may also be present. The infection may
manifest as an abscess, cellulitis, or a combination of the two.
When suspected, the wound should be carefully inspected,
and when a collection is detected, it is drained by reopening
the wound. Gram stain can assist in the management and
antibiotic selection.
Anastomotic Leak
During laparoscopic colorectal surgery, the anastomotic
leak is a common, potentially life-threatening complication
associated with significant morbidity, increased risk of
local recurrence of cancer, decreased functional outcomes,
increased length of stay, high risk of (permanent) ostomy,
and death. Leaks are variably defined in the literature, but in
general, regarded as perianastomotic stool, gas, or abscess,
peritonitis, or a fecal fistula. The incidence of an anastomotic
leak following colectomy is generally reported between 2
and 6%. Anastomotic leaks present in one of three ways:
1. Asymptomatic leak
2. Subtle, insidious leak
3. Dramatic early leak
Aftersurgery,theasymptomaticleakisincidentallyfound
during endoscopic or radiographic studies. The incidence
of radiographically detected leaks is 4–6 times higher than
clinically detected leaks. These leaks, which often present
weeks or months later, are typically walled off sinuses, and
are,asageneralrule,harmless.Treatmentisrarelynecessary.
The subtle, insidious leak can present perioperatively
with nonspecific signs and symptoms common in the
postoperative period. Such signs include low-grade fevers,
mild leukocytosis, protracted ileus, and failure to thrive
and occur 5–14 days following surgery. Management of the
stable patient without signs of peritonitis usually begins with
imaging to identify and localize the process. Traditionally,
water-soluble contrast enema has been the primary study to
identify leaks. Drawbacks include lower sensitivity for right-
sided anastomosis as the contrast dilutes out before reaching
the proximal bowel. It also provides little information
on extracolonic conditions such as ileus and collections.
TABLE 1: Complication rates following laparoscopic and open colon resections.
Barcelona trial Cost trial Classic trial Color trial
Wound infection 11.9% 2.5 8.7 3.3%
Persistent ileus 5.5% 2.8
Evisceration 0.9% 0.8%
Bleeding 0.5% 1.2% 4.8% 1.9%
Anastomotic leak 0.9% 6.0% 2.3%
Pneumonia 0% 6.5% 1.9%
UTI 0.5% 1.2% 2.3%
ARF 1.4%
DVT 1%
Cardiac 2.6% 1.2%
(ARF: acute renal failure; DVT: deep venous thrombosis; URI: urinary tract infection)

373
Abdominopelvic CT scan with triple contrast (oral,
intravenous, and rectal) has become the imaging modality of
choice to evaluate suspected postoperative intra-abdominal
infection. Specificity during the first 5 days postoperative,
however, is reduced. During this period, infectious processes
may be challenging to differentiate from acute postoperative
inflammation and fluid collections. Sensitivity is much
improved beyond 5–7 days. CT scan and contrast enema can
also be used as complementary studies.
If there are large collections, it can often be amenable
to percutaneous, transgluteal, or transanal image-guided
catheter drainage. The images should be reviewed with an
interventional radiologist to identify a safe window of access
that avoids vascular structures and other organs. Abscesses
<3–4 cm are too small for most pigtail catheters and will often
resolve with a course of antibiotics. In the era of modern
CT scanning and interventional radiology, the routine
practice of repeat laparotomy, abdominal washouts, large
sump drains, and open abdominal wound management is
rarely necessary and can be reserved for patients who fail to
respond to, deteriorate following, or are not candidates for
percutaneous drainage.
Sometimes the management of the patient with
progressive generalized peritonitis with or without
septic shock requires resuscitation in ICU with broad
spectrum antibiotics and urgent laparotomy. Laparoscopic
management may be considered if the surgeon has sufficient
laparoscopic skills and operative experience. At the time of
surgery, the anastomosis should be scrutinized for signs,
which led to its failure. This can guide the appropriate
method of repair.
After laparoscopic colorectal surgery, if the findings at
operation show ischemia and necrosis of greater than one
third of the anastomosis, the anastomosis should be resected
with the creation of a stoma. If the mucous fistula can be
brought up to the skin, it should ideally be fashioned through
the same site as the proximal ostomy. When performed in
this fashion, subsequent ostomy reversal can be done via
a circumstomal incision, obviating the need for formal
laparotomy and its associated morbidity. If the findings at
operation identify a smaller leak with healthy bowel, the
anastomosis can usually be salvaged with suture repair,
proximal diversion, and washout of the distal segment. Our
preferred diversion is a loop ileostomy.
Early Postoperative Small Bowel Obstruction
After colorectal laparoscopic surgery, early postoperative
bowel obstruction is rare, occurring in 1% of patients.
This time period accounts for 5–29% of all small bowel
obstructions. Most obstructions are caused by adhesions
which form within 72 hours of surgery and then become
very dense and vascular after 2–3 weeks. Obstructions are
more common following colorectal and gynecological
procedures than following appendectomy or procedures
located above the transverse colon. Signs and symptoms of
early postoperative small bowel obstruction are similar to
and hard to differentiate from the more common paralytic
ileus. Patients typically develop abdominal distention,
nausea, and vomiting, but cannot tolerate nasogastric tube
clamping or removal. Most patients have a slow, smoldering
course, with emergencies being the exception.
The surgeon should try to manage obstruction
conservatively initially. There is a fine balance between
waiting for the obstruction to resolve and rushing a patient
to the operating room. In the first week following surgery,
obstruction is hard to differentiate from ileus. Between
2 weeks and 2 months, postoperative adhesions become
thick, vascular, and obliterate natural planes, making surgery
muchmoredifficultandpronetocomplications.Thedecision
to operate should, therefore, occur between 7 and 14 days.
If the patient has symptoms of obstruction, plain films
readily diagnose most small bowel obstructions. Oral
administration of water-soluble contrast followed by a plain
abdominal film or CT scan 4 hours later is a good predictor
of the resolution of a small bowel obstruction. The contrast
in the colon indicates the obstruction is likely to resolve with
nonoperative means. CT scan may be useful in identifying
signs of ischemia, other intra-abdominal processes and in
localizing the site of obstruction for operative planning.
Initial management of the stable patient involves fluid
and electrolyte replacement, bowel rest, nasogastric tube
drainage, and nutritional evaluation. Total parenteral
nutrition should be started as soon as the detected
leak. Operation is advised for high-grade or complete
bowel obstruction, concern for strangulated bowel, or
unresolved small bowel obstruction despite prolonged NGT
decompression.
If proper care is ensured, most patients resolve with
nonoperative management. If surgery becomes necessary,
it should occur prior to the 2 weeks mark, after which the
acute adhesions become dense, vascular, and problematic.
Surgery involves careful re-exploration and lysis of
adhesions. Operative findings usually reveal either a single
adhesive band or multiple matted adhesions, each occurring
with similar frequency.
After colorectal surgery, if obstruction develops,
laparoscopic exploration and adhesiolysis is being
increasingly utilized for small bowel obstructions. Advanced
laparoscopic skills and experience are a prerequisite
because access is difficult in these patients. Poor candidates
for laparoscopic management include patients with signs
of peritonitis, multiple previous operations for small bowel
obstruction, small bowel diameter >4 cm, or other medical
contraindication to laparoscopy. Pneumoperitoneum
should be established with an open technique at a site
remote from the previous incision. Atraumatic graspers are
used to explore the bowel in a retrograde fashion beginning
with decompressed bowel at the ileocecal valve. Distended

bowel is fragile and should not be grasped: grasping the
adjacent mesentery reduces the risk of inadvertent bowel
perforation. Adhesiolysis is best performed with scissors or
bipolar cautery devices to reduce the risk of adjacent bowel
injury. Conversion rates range from 7 to 43%. Proactive
reasons to convert include poor visualization, nonviable
intestine, multiple dense adhesions, deep pelvic adhesions,
and failure to progress in a reasonable time.
Sexual Dysfunction
Sexual dysfunction following rectal surgery is related to the
extent of pelvic nerve dissection and occurs in both men and
women. In men, damage to the sympathetic nerves during
high ligation of the IMA or posterior dissection at the sacral
promontory can lead to retrograde ejaculation. In addition,
damage to the parasympathetic plexus (nerve erigentes)
during lateral and anterior dissection can lead to erectile
dysfunction. The pathophysiology of sexual dysfunction
in women is likely multifactorial and includes damage to
the parasympathetic nerves during deep pelvic dissection
as well as postoperative mechanical changes in the pelvis,
which contribute to loss of sexual desire, vaginal dryness,
altered orgasm, and dyspareunia. Sexual dysfunction is more
difficult to diagnose in women, in part because the presence
of incontinence often discourages women from engaging in
sexual activity.
TIPS AND TRICKS
To avoid intraoperative complications:
■ Create adequate exposure.
■ Use proper traction and counter traction.
■ Develop the right planes.
■ Standardize the assistant’s role.
■ Beware of the variations of vasculature and anatomy.
■ Should visualization be compromised during the
procedure?, it is easy to switch to a 30° laparoscope for
a more topographical view. Applying the angled 30°
laparoscope can also be helpful to manage external arm
collisions during tight set-up situations, as the camera
arm angle changes depending on the endoscopy used.
Additionally, with an angled 30° laparoscope, the
surgeon has the ability to rotate the viewing angle of the
scope (out of the horizontal image plane) and minimize
collisions as well.
■ Leave 1–1.5 cm on either side of the transacted IMA and
IMV so that if any bleeding occurs, grasping of the vessel
is still possible to allow the application of the hemostatic
technique (clips, LigaSuretm
or suture).
■ Distance the ports as much as possible from each other
during initial port placement (minimum of 7.5 cm).
Placing the patient in a steeper Trendelenburg position
can increase the vertical spacing between the arms and
potentially eliminate or minimize arising collisions.
■ Before dividing any tissues, identify the ureter and
gonadal vessels one more time.
■ During all procedure steps, clear communication with
the patient-side assistant is essential.
CONCLUSION
The laparoscopic technique reduces parietal aggression and
achieves the same results as traditional surgery. Patients
recover faster and experience less pain, with fewer wound
infections, postoperative hernias, less time in the hospital,
and reduced costs. But laparoscopic colonic surgery requires
extensive and highly specialized training, with few surgeons
qualified to perform these procedures. The recent conclusion
of the oncologic debate, together with the rapid development
of technological means and the increase in public awareness,
will probably result in a substantial increase in the number
of surgeons performing laparoscopic colorectal surgery. The
laparoscopic technique is an excellent approach, though not
yet the gold standard. Smooth performance of this technique
depends on the quality of the equipment, perfect knowledge
of the operative steps, exposure of operative field, and the
experienceofthesurgicalteam.Operativetimesaresomewhat
longer than open procedures but become shorter along the
learning curve. Right colectomies are shorter and easier to
perform than left-sided and rectal resections and should be
employed for teaching residents. The conversion rate would
not necessarily drop after the first 50 cases and should reflect
good surgical judgment rather than a surgical failure.
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