Sigmoidectomy, laparoscopic

Make a medial skin incision about 3cm superior to the umbilicus. Introduce the trocar for the laparoscope (T1) into the abdominal cavity through a minilaparotomy and create the pneumoperitoneum. After gross inspection of the abdominal cavity, introduce the working trocars (T3, T3, T2) under direct view.

Note:

Be aware that creating the pneumoperitoneum with a Veress needle may risk injury to large intraabdominal blood vessels.

Position the patient right lateral recumbent.

Dissecting on the Gerota facia divide the embryonic adhesions between peritoneum and sigmoid toward the splenic fissure. Left ureter and left- iliac vessels must be positively identified.

Reposition the patient to reverse Trendelenburg while still in right lateral recumbent. Start freeing the descending colon and splenic flexure laterally from the left. In doing so, pull the descending colon mediad and successively divide the colonic adhesion with the Gerota fascia. 

Starting in the middle of the transverse colon dissect the greater omentum off it, which will free the splenic flexure and open up the lesser sac. During this dissection the splenocolic ligament and attachments between the pancreas and colon will also be divided. Finally, the left colon including its splenic flexure has been freed from all posterior structures, allowing a tension-free anastomosis.

Tips:

• Abrupt traction on the colon may result in injury to the spleen.
• Dissection is facilitated by bringing the OR table from Trendelenburg (head low) back to level while still keeping the patient in right lateral recumbent.

Undo the reverse Trendelenburg and the right lateral recumbent. Incise the mesosigmoid medially, introduce the retractor and divide the mesosigmoid close to the sigmoid colon while maintaining traction antiroad and keeping the mesentery under constant exposure. Carry the dissection upstream of the rectosigmoid transition (identifiable by the disappearance of the omental appendices and taeniae of colon). Dissection along the colon will ensure that the inferior mesenteric artery and its main branches are spared.

Caution:

• Identification of left ureter and ovarian/testicular vessels