“Pure” Laparoscopic Sigmoid Colectomy - JGA
last updated March 2008
Patient Preparation:
Bowel prep prior to case
H&P / consent available in preop chart
Key Equipment and Instruments:
5mm, 11mm x2, and 12mm STEP ports
small Alexis retractor
10mm 30 degree laparoscope
lap cautery with foot control
10mm Ligasure long, hand-activated
Dorseys and Waavys
2 Cigarrette packs
Raytecs
GIA 60mm blue in room
Rigid proctoscope, long suction, anal dilators
EEA 29mm stapler
Setup
Beanbag on bed with jelly on top, induce, ertapenem 1g IV, OG tube, Foley, Allen stirrups
(lithotomy) with thighs horizontal and legs vertical, Foley draped under right thigh, tuck both arms,
deflate beanbag with shoulder bumps so there is no slippage when in steep Trendelenberg.
Cloth tape over chest in cross. Test rotate. Towels around legs. Duraprep. Swipe to anus. Leg
drapes. Towels. Ioband strips to anchor edges, extending onto leg drapes. Lap sheet. Set up
Valleylab suction/cautery, Ligasure 10mm long hand activated, camera with cords looped
patient’s right side within velcro. Handheld cautery in pocket.
Port Placement:
11mm working
5mm working
11mm camera
12mm working
Procedure:
Hasson or Veress needle at umbo. Insufflate. Place working ports
SIGMOID MOBILIZATION
Steep reverse Trendelenberg right side down.
Sweep all small bowel medially, Identify LOT, IMV, sup rectal pedicle
Score peritoneum medial to IMV (between IMV and aorta) at level above IMA
Sweep descending colon mesentery from retroperitoneum below. Separate retroperitoneum
from descending mesocolon to level of spenic flexure
Identify superior rectal pedicle. Retract sigmoid laterally and tent up
Score with bovie mesorectum. Separate sigmoid mesocolon and mesorectum from
retroperitoneum bluntly with cigarette. Work superiorly to level of IMA.
Identify left ureter
Divide IMA itself, or altermatively, left colic origin and sup rectal origin (Ligasure or GIA 30mm
white load)
Divide descending mesocolon, including left colic vein and IMV, to level of LOT. Preserve
marginal artery.
Retract sigmoid medially and divide lateral attachments with bovie.
SPLENIC FLEXURE TAKEDOWN
Retract descending colon medially, and bovie lateral attachments.
Reposition. Patient head up. Flip omentum towards head and open lesser sac from right to left
with bovie / ligasure. Take down splenic flexure right to left.
Continue onto transverse colon and COMPLETELY separate gastrocolic with bovie to about the
falciform (i.e. midline). Lap portion of case complete.
DIVIDE SIGMOIDORECTAL JUNCTION
Clean fat off planned resection line with bovie / ligasure
Complete rectal dissection. Develop plane posteriorly and use it to guide you anteriorly.
Divide descending colon with endoGIA 60 blue, dividing mesentery with Ligasure
Grasp distal sigmoid via RLQ port, open port site 3cm, deliver colon into wound.
PREPARE DESCENDING COLON
Use soft bowel clamp to clamp distal colon
Cut colon
2-0 prolene double armed pursestring.
Place EEA 29 anvil (black stapler). Tie pursetring. Leave one needle on initially
Clean off fat. If diverticulum within staple line, use suture to tuck in.
Dunk colon into abdomen
Use Alexis and clamp off with a peon to maintain pneumoperitoneum
MAKE ANASTOMOSIS
Surgeon goes between legs. Dilate anus to 31mm
EEA 29mm. Trocar should pass just anterior to staple line. If low anastomosis, make sure
vagina/bladder out of stapler. (on black stapler, only ½ twist needed after firing to release. On
white stapler, 2 full rotations needed)
Submerge anastomosis in saline.
Insert rigid proctoscope. Insufflate and look for air leak. Inspect suture line
Inspect donuts
Leave #19 round Blake drain in pelvis if dissection was below peritoneal reflections. OTW none.
CLOSE
No peritoneal closure
#1 maxon running for fascia
No fascial closure for port sites
3-0 dexon scarpas
4-0 biosyn running skin
Indermil only
Postoperative Care:
Cefoxitin x1 dose
Heparin SQ in am after surgery
ADAT when passing flatus