You need to log in to watch this media!

Click here to log in.

Laparoscopic sigmoidectomy for cancer

Authors

Abstract

The description of the laparoscopic sigmoidectomy for cancer covers all aspects of the surgical procedure used for the management of sigmoid colon cancer.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, vascular approach, mobilization of sigmoid colon, division of sigmoid colon, mobilization principles, lateral mobilization, medial mobilization, extraction of sigmoid colon, preparation of anastomosis, anastomosis.
Consequently, this operating technique is well standardized for the management of this condition.

Media type

Publication

2001-06

Popular

Favorites

Audio

E-publication

WeBSurg.com, Jun 2001;1(06).
URL: http://www.websurg.com/doi-ot02en164.htm

Laparoscopic sigmoidectomy for cancer

1. Introduction

The sigmoid colon is the most frequent location for colon cancer. Sigmoid colon resection is the first line treatment in most cases of sigmoid colon cancer. A laparoscopic approach may be used to perform sigmoid resection in a manner equivalent to the open technique. Indeed, most laparoscopic surgeons consider laparoscopic sigmoidectomy relatively straightforward.
Laparoscopic sigmoid colon resection for cancer was described in a standardized manner as early as 1994 (Geis et al., 1994). Nevertheless, it should be reserved for highly skilled surgical teams participating in controlled multicenter studies.

2. Anatomy

• Colon

The sigmoid colon is the mobile terminal portion of the left colon. Except in advanced stages of cancer, the mobility of the sigmoid colon depends on the length of the sigmoid loop and on cancer-associated pathologies such as diverticulosis.
The vascular supply of the sigmoid colon is based entirely on the inferior mesenteric artery and its branches. Thorough knowledge of the vascular anatomy and its variations is essential for a safe resection.
The close proximity of the vessels to the left sympathetic trunk and the left ureter represents potential risks in sigmoid colon resection.

• Arteries

• Overview

The arteries are all branches of the inferior mesenteric artery (IMA).
1. Inferior mesenteric artery (IMA)
2. Left colic artery (LCA)
3. Trunk of sigmoid arteries
4. Superior rectal artery (SRA)
5. Marginal arteries

• Inferior mesenteric artery

The inferior mesenteric artery (IMA) originates from the anterior surface of the abdominal aorta, 1 to 3 cm below the third portion of the duodenum, to form the main blood supply of the left colon. It gives off branches for the left colon, the sigmoid colon, and the rectum.

• Left colic artery

The left colic artery (LCA) is the first branch of the IMA and supplies the vasculature of the left colon. After crossing over the inferior mesenteric vein (IMV), the LCA courses along the IMV’s left border for a variable distance. It then approaches the marginal arteries, which it generally joins somewhere between the splenic flexure and the transverse colon. Its preservation is possible during mobilization of the left colon.

• Sigmoid arteries

There are at least 3 sigmoid arteries (SA), often originating from a common trunk distal to the LCA. Variations are common. These sigmoid branches can originate separately from the IMA up to the promontory or from the LCA. They are always situated medial to the sigmoid veins and posterior to the superior rectal vein.

• Superior rectal artery

The superior rectal artery (SRA) is the terminal branch of the IMA. It is located just anterior to the fascia propria of the rectum at the rectosigmoid junction. It gets progressively closer to the rectal wall as it divides into a right and a left branch, or into even more branches in 17% of cases (Ayoub, 1978). These branches supply the upper two thirds of the rectum. The larger right branch often extends from the IMA (Ayoub, 1978). These 2 branches divide 2 or 3 more times without anastomosing and end on the pelvic floor. All these arterial branches remain in the mesorectum along with the rectal veins, which drain into the superior rectal vein (SRV) and then into the IMV.

• Veins

• Overview

Rectal, sigmoid, and left colic veins join to form the inferior mesenteric vein (IMV).
1. Inferior mesenteric vein (IMV)
2. Left colic vein (LCV)
3. Trunk of sigmoid veins
4. Superior rectal vein (SRV)
5. Marginal veins

• Inferior mesenteric vein

The sigmoid and left colic veins join to form the inferior mesenteric vein (IMV).
1. Portal vein
2. Splenomesenteric trunk
3. Splenic vein
4. Inferior mesenteric vein (IMV)
5. Superior mesenteric vein (SMV)

• Sigmoid veins

There are several sigmoid veins (SV). They run separately or as a common trunk into the SRV to form the IMV.

• Left colic veins

The left colic veins (LCV) often join into a main trunk. There are often 2 LCVs for 1 LCA. Accessory venous branches, originating from the descending colon, run directly into the IMV. They must be divided to allow mobilization of the left colon.

3. Operating room set-up

• Patient

It is essential that the patient be appropriately positioned to avoid complications (nerve and vein compression, injuries to the brachial plexus) and to facilitate the procedure and anesthetic monitoring.
- Trendelenburg position with a 15° to 25° tilt and a 5° to 10° right tilt;
- lithotomy position;
- buttocks placed at the distal edge of the table;
- thighs and legs stretched apart with a slight flexure;
- right arm alongside the body;
- left arm at a right angle or alongside the body (surgeon’s preference);
- gastric tube and urinary catheter;
- heating device.

• Team

1. Surgeon
2. First assistant
3. Second assistant
4. Scrub nurse
5. Anesthesiologist
Although the procedure can be performed with a single assistant, it is preferable to have 2 assistants and a scrub nurse, especially when experience in performing the procedure is limited.
The team can remain in the same position throughout the entire procedure.

• Equipment

- The table must allow for both abdominal and perineal access. It is advisable to use a table that can be easily tilted laterally and placed into steep Trendelenburg and reverse Trendelenburg position, facilitating perineal exposure.
- The laparoscopic unit is located to the left of the patient along with the main monitor. It may be useful to use a second monitor placed above the patient's head.
- To perform the procedure in excellent conditions, a 3CCD camera is mandatory.
- A high output (>= 9L/min) insufflator should be used to electronically monitor pressures. Its inertia should be low to make up for losses in carbon dioxide (induced or not).
- Voice-controlled robotic arm
1. Laparoscopic unit
2. Electrocautery
3. Operating table
4. Monitor
5. 3CCD camera
6. Instrument table

4. Trocar placement

• Number of trocars

Although a sigmoidectomy can be performed using only 3 trocars, for complicated presentations and especially when the surgeon’s experience in performing the technique is limited, the use of more trocars is preferable. This helps to ensure the safety of the procedure by allowing improved exposure of the operative field and the mesentery, and by facilitating mobilization of the splenic flexure.
We readily use 6 trocars, with a trend toward reducing trocar size. The patient’s body habitus, previous surgical history and the initial laparoscopic exploration via the supraumbilical trocar should be used as guides for introducing the various operating trocars.

• Principles

Firm trocar fixation in the wall is important. This is achieved by adapting the size of the incision to the trocar and, if needed, fixing the trocar to the abdomen with a suture. We no longer use screw-like devices, as they increase parietal trauma.

• Optical

Trocar A: 10/12 mm, 0° optical
The trocar is positioned on the median line 3 to 4 cm above the umbilicus or 20 cm above the pubis in patients with a small stature.
This trocar accommodates a 0° optical.

• Operating

• Trocar B

This is a 5 mm operating trocar, used for retraction during mobilization of the splenic flexure (caudal retraction of the left colon), during which time trocar D is used for operating instruments. At the end of the procedure, Trocar B may be replaced by a 12 or 15 mm trocar for introduction of a linear stapler.
It is situated on the right midclavicular line, at the level of the umbilicus.
This trocar accommodates an atraumatic grasper.

• Trocar C

This is a 5 mm operating trocar, used for retraction during mobilization of the splenic flexure (caudal retraction of the left colon). At the end of the procedure, it may be replaced by a 12 or 15 mm trocar for introduction of a linear stapler.
It is situated on the right midclavicular line, 8 to 10 cm below trocar B.
This trocar accommodates:
- scissors (monopolar, high-frequency hemostasis device, clip, staplers), bipolar hook, surgical loop, suction-irrigation device;
- an atraumatic grasper.

• Retractors

• Trocar D

This is a 5 mm retractor, except during mobilization of the splenic flexure, when it is used as an operating trocar.
It is situated on the left midclavicular line, at the level of the umbilicus.
This trocar accommodates:
- an atraumatic grasper;
- scissors (monopolar, high-frequency hemostasis device, clip, staplers), bipolar hook, surgical loop, suction-irrigation device.

• Trocar E

This is a 5 mm retractor, except during mobilization of the splenic flexure when it is used as an operating trocar. It accommodates a grasper used to expose the sigmoid mesocolon and left mesocolon.
It is situated 8 to 10 cm above the pubis on the median line.
This trocar accommodates a grasper and a suction-irrigation device.

• Trocar F

This is a 5 mm retractor that accommodates an atraumatic grasper used to laterally retract the terminal portion of the small intestine and to better expose the attachments of the omentum to the transverse colon during mobilization of the splenic flexure.
It is situated on the right midclavicular line in the subcostal position.
This trocar accommodates an atraumatic grasper.

5. Instruments

• Optical devices

Most authors use laparoscopes with 0° and 30° visual axes and with a 70° visual field.
Some authors use a laparoscope with a 45° visual axis.

• Operating devices

1. Grasper
2. Bipolar
3. Ultrasonic dissectors
4. Linear stapler
5. Scissors
6. Clip applier
7. Circular stapler
8. Plastic-coated drape to protect the incision after freeing the colostomy

• Retracting devices

1. Flexible retractor
2. Peanut swab

• Others

Efficient suction-irrigation device for lavage and dissection (lysis of adhesions)

6. Exploration

• Exploration

As with open surgery, all laparoscopic procedures begin with an exploration of the abdominal cavity. The exploration is panoramic. Visceral organs may be manipulated with blunt instruments to complete the exploration. This can be combined with an ultrasound examination of the liver to search for associated pathologies that may contraindicate the laparoscopic procedure.

• Ultrasonography

Exploration of the liver is associated with an ultrasound examination. Considered mandatory in oncology for some authors (Milsom), it is performed with a flexible 10 mm catheter. It can supplement preoperative imaging studies, especially if a surgical liver procedure is performed during the same operation.

7. Exposure

• Exposure

Improved exposure greatly facilitates the surgical procedure.
Proper exposure is a function of a host of factors. These include the working space in the abdominal cavity, the quality of the preoperative gastrointestinal (GI) preparation, the positioning of the patient as well as a perfect understanding of the organization of the operating field.

• Working space

• Principles

The working space depends on the quality of the preoperative GI preparation, the positioning of the patient and complete relaxation allowing the abdominal wall to distend correctly under the pressure of the pneumoperitoneum.

• Intestinal preparation

An empty digestive tract facilitates the layering of intestinal loops. It is achieved by a strict, fiber-free diet 3 to 8 days prior to surgery.
As most experts do, polyethylene glycol is no longer used before surgery to complete the intestinal preparation.
The day before, or even on the day of the operation, the patient is placed on a fibre-free diet and undergoes enemas.

• Patient positioning

To prevent the patient from sliding, shoulder supports or straps around the thorax may be used.
In our current practice, we rarely use such measures, despite a 20° to 30° Trendelenburg position and a right tilt.

• Muscle relaxation

In addition to the pressure of the pneumoperitoneum (12 mm Hg), complete relaxation of the muscular wall is essential to create the working space.

• Layering intestinal loops

• Gravity

Layering the intestinal loops requires gravity and retraction of organs.

• Transverse colon

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 trocar D, may also be used.

• Proximal portion/jejunum

The jejunum is retracted toward the right hypochondrium, below the right transverse colon. The right tilt and Trendelenburg position, along with an atraumatic retractor if needed, maintain the small intestine in this position.

• Distal portion/small intestine

The distal portion of the small intestine is placed in the right iliac fossa along with the cecum. If the small intestine is too bulky, this operative maneuver can be difficult, notably in obese patients.

• Specific cases

• Obese patient

Obesity characterized by a flaccid muscular wall (female patients) is not a major handicap as ample working space remains. In the setting of a tonic muscular wall (male patients) and short, fatty mesenteries, the surgeon must progressively layer the intestinal loops to expose the dissection areas.

• Adhesions

By freeing the digestive tract, layering can be performed for better exposure of the operating field. It is sometimes useful to preserve adhesions, especially at the level of the cecum or the splenic flexure.

• Uterus

The uterus may be an obstacle to adequate exposure in the pelvis. In postmenopausal female patients, the uterus can be suspended to the abdominal wall by a suture. This suture is introduced halfway between the umbilicus and the pubis to suspend the vagina and make it horizontal, thereby opening the rectovaginal space.

8. Vascular approach

• Vascular approach

The initial vascular approach makes it possible to dissect the sigmoid mesocolon posteriorly and medially without manipulating the colon and the tumor. It must be associated with a lymphadenectomy, removing the lymph nodes of the inferior mesenteric chain.
Except in simple cases where vessels are visible due to transparency, the vessels are gradually exposed once the peritoneum of the sigmoid mesocolon has been widely opened.
Before dividing the vessels, it is important to identify the sympathetic nerve plexus trunks and the left ureter in order to preserve them.

• Peritoneal incision

The peritoneum is opened upward along the right anterior border of the aorta, starting the incision from the promontory and extending it to just below the third portion of the duodenum.
Anterior traction of the sigmoid mesocolon, using a grasper introduced through trocar E, exposes the base of the sigmoid mesocolon. The pneumodissection (entry of CO2 into the retroperitoneal space), which results from the pneumoperitoneum, facilitates the dissection.

• Identification of IMA

Dissection of the fatty cellular tissue is pursued upward and from right to left by gradually dividing the sigmoid branches of the right sympathetic trunk to expose the origin of the IMA.
This operative step is essential as it allows a safe dissection of the IMA at its origin.

• Division of IMA/branches

• Overview

To remove the lymph node tissue, the IMA is dissected 1 to 2 cm in a circular fashion before clipping.
A more extensive dissection can also be performed. The IMA is skeletonized and the left colic artery is identified and isolated in order to be preserved.

• Division 1 cm from aorta

A gold standard in cancer, it involves a risk of injury to the left sympathetic trunk situated on the left border of the IMA. A meticulous dissection of the artery to apply clips before division is the only way to avoid this risk.
Dissection performed close to the artery has a low risk for damaging the left ureter if clips are used to ligate the IMA.

• Division distal to LCA

This allows preservation of the vascular supply of the left colon, but it can limit the mobility of the left colon. The sympathetic nerve trunks situated to the left of the IMA must be preserved.
If clips are used, the ureter must not be visible before ligature and division of the artery.

• Identifying and dividing IMV

The IMV is identified to the left of the IMA or in case of difficulty, higher, to the left of the ligament of Treitz (duodenojejunal flexure). It is then crossed anteriorly by the LCA, which then runs along its left border. The IMV is divided below the inferior border of the pancreas or above the left colic vein.

9. Mobilization/sigmoid

• Overview

Mobilization of the sigmoid colon follows the division of the vessels.
This step includes the freeing of posterior and lateral attachments and the division of rectal and sigmoid mesenteries.
The approach is either medial or lateral. We prefer using the medial approach, except in thin patients whose sigmoid colon is very mobile. The medial approach is well adapted for laparoscopy as it preserves the working space and demands the least handling of the sigmoid colon.

• Posterior freeing

A medial approach is used.
After division of the vessels, the sigmoid mesocolon is retracted anteriorly (trocar E) in order to open the posterior space. The plane between Toldt’s fascia and the sigmoid mesocolon can then be identified. This plane is avascular and easily detached. It is exposed when the dissection is pursued posterior to the sigmoid mesocolon (not laterally nor to the left of the aorta).
The dissection is pursued laterally to Toldt’s line, posteriorly and external to the colon.
The left sympathetic nerve trunk, the ureter and genital vessels, covered by Toldt’s fascia, are viewed internally to externally during dissection.
The lateral attachments can then be divided using a lateral approach.

• Resection of mesorectum

Cylindrical, retrovascular division is used to resect the freed upper portion of the mesorectum.
The use of ultrasonic dissectors or a high frequency hemostasis device can facilitate this act. Nevertheless, the surgeon must be careful in the left region: the mesorectum there is closely attached to the left lateral fascia where the superior hypogastric nerve and the left ureter are situated.
The superior rectal vessels are again divided in the mesorectum.

• Lateral freeing

The sigmoid loop is pulled toward the right hypochondrium (grasper in trocar F) to exert traction on the left layer of the sigmoid mesocolon.
The base of this layer is opened toward the paracolic gutter and the pelvis. In case of adhesions of the sigmoid colon to the abdominal wall, this operative step can be difficult.
After incision of the left layer of the sigmoid mesocolon, the medially performed posterior detachment is joined. During this step, care must be taken to avoid genital vessels and the left ureter as they can be tethered by the medial pressure exerted on the mesentery. In case of difficulty, it is useful to combine with a medial posterior approach. Identification of the ureter with a ureteral catheter (luminous bougie or not) does not seem necessary to us.

10. Division/sigmoid

• Principles/Division

Once it is freed, the sigmoid colon is divided, at least 5 cm below the tumor and 10 cm above the tumor. This rule is applicable for long, supple sigmoid colons. Otherwise, complete sigmoidectomy must be performed down to the colorectal junction, or even down to the upper portion of the rectum for lesions of the distal portion of the sigmoid colon.

• Distal division

• Overview

Division of the rectum or the colorectal junction is performed at least 5 cm below the tumor, removing all of the surrounding fat. Exclusion of the colon below the tumor, just above the staple line, is advised. Lavage of the rectal stump can then be performed before dividing it with the stapler.

• Exclusion of rectum

The freed distal portion of the sigmoid colon is excluded with either ligature, a clamp or a row of staples. The rectum is then washed with a saline solution or a solution with polyvinylpyrolidone iodine by introducing a cannula via the anal canal.

• Division of rectum

Division is performed using a sharp suturing device to divide and staple without opening the digestive tract. The stapler is introduced through trocar C into the right iliac fossa. We prefer using staplers for thick tissues (green cartridges), which are applied perpendicular to the digestive tract. Staplers with adjustable angles can be useful.

• Proximal division

• Overview

Proximal division should be performed at least 10 cm above the tumor. It includes division of the mesocolon, followed by division of the colon. It is not necessary to exclude the colon, which will be subsequently divided.

• Division of mesocolon

Division is performed with a high frequency hemostasis device, ultrasonic dissectors or linear staplers, removing the totality of the sigmoid mesocolon along with lymph nodes.

• Division of colon

A sharp suturing device is used to perform a clean division and stapling without opening the digestive tract.
The stapler (blue cartridges) is introduced through trocar C into the right iliac fossa.

• Isolating sigmoid colon

The sigmoid colon is isolated in a plastic airtight extraction bag introduced through trocar C. This permits continuation of the procedure without manipulating the tumor in the abdominal cavity. If the sigmoid colon is too bulky, extraction can be done immediately, before completing mobilization of the left colon.

• Variation

Preservation of the left colic artery:
Division of the IMA distal to the origin of the LCA preserves the vascular supply of the descending colon better and does not prevent it from being lowered. We use it more and more frequently, along with a lymphadenectomy to the origin of the IMA.
The IMV is divided distal to the pancreas, or even lower, resecting the surrounding tissues to remove the lymph nodes. The left colic veins are often divided to facilitate the descent of the left colon.

11. Principles/Mobilization

In the event that a long segment of sigmoid colon is resected, mobilization of the left colon is necessary to allow for a tension-free colorectal anastomosis.
The left colon is freed by division of its posterior and lateral attachments. Occasionally, division of the left colic vessels is required for full mobilization of the left colon.
The vascular supply of the mobilized left colon should be preserved. This is often difficult to assess in laparoscopic surgery.
Mobilization of the splenic flexure is frequently required. This can be achieved in a number of different ways. It is important for the surgeon to be familiar with all these approaches in order to select the approach most suitable for each case.

12. Lateral mobilization

• Freeing the attachments

1. Attachments of omentum to colon
2. Phrenicocolic ligament
3. Toldt’s line
4. Toldt’s fascia
This approach is conventional in open surgery. It is used in simple cases with an easily mobilized splenic flexure. It includes freeing of the lateral and posterior attachments.

• Toldt’s line

An ascending incision is made along the white line of Toldt using scissors introduced via trocar D.

• Phrenicocolic ligament

The phrenicocolic ligament is then divided using scissors introduced through trocar D. Retracting the colon and the splenic flexure toward the right iliac fossa using graspers introduced through trocars C and E helps in this exposure.

• Dividing the attachments

Attachments are incised close to the colon until the omental bursa (lesser sac) is opened. Division of these attachments is pursued as needed toward the right, to facilitate lowering of the left transverse colon.

13. Medial mobilization

• Principles

Medial mobilization is perfectly suited to the laparoscopic approach as the surgeon, situated to the patient’s right, has an excellent view of the anterior surface of the pancreas and the base of the left transverse mesocolon.
It follows the medial posterior freeing of the sigmoid mesocolon, which then continues upward, anterior to Toldt’s fascia.

• Peritoneal incision

The splenic flexure is freed on its posterior surface while remaining close to the left mesocolon. This avoids the risk of a dissection posterior to the pancreas with an attendant injury of the splenic vein. Division of the IMV just below the inferior border of the pancreas facilitates this operative step.

• Posterior freeing

On the anterior inferior border of the pancreas, the base of the transverse mesocolon is identified. This is divided caudad to cephalad and from right to left, opening the omental bursa (lesser sac). Anterior to the pancreatic tail, care must be taken not to injure the pancreas and small mesocolic vessels, which course through the left transverse mesocolon.

14. Extraction/sigmoid

• Principles

Extraction is performed through a mini-incision while protecting the abdominal wall. In cancer, the specimen is isolated and placed in an airtight plastic bag before extracting it.

• Incision

• Principles

The size of the incision, its location, and the extraction technique take into account the volume of the specimen, the patient’s body habitus, and cosmetic concerns.

• Size

The incision should be adapted to the size of tissues to be extracted. Care must be taken not to crush the specimen during extraction.

• Location

The incision is generally performed in the suprapubic region (1), more rarely in the right iliac fossa (2), but never in the left iliac fossa (3). The lowering of the colon in (1) or (2) allows evaluation of the possibilities of mobilization of the colon in the pelvis. If the mobilized colon reaches the extraction area in a tension-free manner, it may be safely assumed the anastomosis will be tension free as well.

• Protection

The wall should be protected to avoid bacterial and cellular contamination (risk of cancer cells). This protection is made up of a waterproof plastic-coated drape with a ring (7 or 11 mm in diameter).
The same plastic-coated protection is also used during intracorporeal anastomosis to ensure the airtightness of the abdominal cavity before its final closure.

• Extraction

• Principles

The extraction of the specimen is performed using an airtight plastic bag. In current practice, protection of the incision by a plastic-coated drape with a ring is added, to ensure that the abdominal cavity is airtight during the intracorporeal colorectal anastomosis, which follows the extraction.

• Waterproof drape

After introduction of the waterproof plastic-coated drape in the abdominal incision, the bag containing the resected sigmoid colon is withdrawn from the abdomen. The bag is then opened to extract the colon avoiding abdominal contamination.

• Waterproof bag

After placing the sigmoid colon in an airtight waterproof plastic-coated bag, the extraction is done directly through the abdominal opening.

15. Preparation/anastomosis

• Preparation

The colorectal anastomosis is a delicate step. We always use a mechanical circular stapling device to transfix the rectal stump.
Performing the anastomosis includes an extra-abdominal preparatory step and an intra-abdominal step performed laparoscopically
The extra-abdominal step takes place after exteriorization of the left colon through the incision protected by the plastic-coated drape.

• Placement of anvil

If necessary, the colon is cut again in a healthy, supple and well-vascularized zone. The anvil (at least 28 mm in diameter) is then introduced into the colonic lumen and closed with a purse string. The left colon with the anvil is then reintroduced into the abdominal cavity.

• Closure of abdominal incision

The closure ensures the airtightness of the abdominal cavity required to perform the anastomosis under laparoscopic guidance. The closure is achieved either by primary closure of the abdominal wall or by introducing a plastic-coated drape with an airtight ring. The second option is more attractive because it leaves the surgeon the possibility of exteriorizing the colon if necessary.

16. Anastomosis

• Principles

The intra-abdominal step is performed entirely under laparoscopic guidance after reinflation of the abdominal cavity. It includes transfixing the rectal stump and performing the colorectal anastomosis with a circular mechanical stapler.

• Transfixing the rectal stump

After ensuring that the abdominal cavity is airtight, the pneumoperitoneum is reestablished. The circular stapler is introduced into the rectum through the atraumatically dilated anus. The rectal stump is then transfixed with the tip of the head of the circular stapler.
To avoid ischemic risks, the stapler can be introduced in the middle or at one of the ends of the rectal stump staple line while avoiding leaving lateral ear-shaped flaps.
In women, the posterior vaginal wall should be retracted anteriorly.

• Anastomosis

Once the anvil has been clicked onto the proximal part of the circular stapler, it is mandatory to ensure that the proximal part of the colon is not twisted. The stapler is then closed; the surgeon should check that no neighboring organs are incarcerated before stapling in accordance with the manufacturer’s recommendations.
The stapler is then loosened and withdrawn through the anus.

• Testing the anastomosis

Verification of the anastomosis is mandatory. This includes checking for the circular aspect of the amputated rectal and colon rings, optional air test and for some authors, endoscopic transanal evaluation of the anastomosis.

17. Conclusions

Laparoscopic sigmoid colon resection for cancer has been described in a standardized manner. It enables the surgeon to perform a reproducible oncological procedure (Köckerling et al., 1998). Its morbidity, the risk of recurrence on the trocar sites and risks of local recurrence do not seem higher than the results of conventional surgery (Franklin et al., 1996; Leung et al., 1996; Milsom et al., 1998).
Although no studies have demonstrated the usefulness of the guidelines which have often been quoted as references by some authors (Balli et al., 2000), and even though other authors (Wexner and Cohen, 1995) recommend using the safety guidelines of Scientific Societies which are not obtainable in an official form, it is wise to comply with certain rules and to agree to participate in controlled studies to perform this surgical technique.

The smooth performance of laparoscopic sigmoidectomy for early stage cancer depends on:
- the quality of the equipment;
- perfect knowledge of surgical anatomy;
- respecting the operative strategy (medial approach);
- the experience of the surgical team.
Surgeons learning the technique must do so with a skilled, experienced team. The ideal learning strategy is to start by reproducing the various steps of the procedure with an open approach but under the same conditions as those in laparoscopic surgery.

18. Reference

Allardyce R, Morreau P, Bagshaw P. Tumor cell distribution following laparoscopic colectomy in a porcine
model. Dis Colon Rectum 1996;39:S47-52.
Ayoub SF. Arterial supply to the human rectum. Acta Anat 1978;100:317-27.
Balli JE, Franklin ME, Almeida JA, Glass JL, Diaz JA, Reymond M. How to prevent port-site metastases in
laparoscopic colorectal surgery. Surg Endosc 2000;14:1034-6.
Franklin ME, Rosenthal D, Abrego-Medina D, Dorman JP, Glass JL, Norem R et al. Prospective
comparison of open vs. laparoscopic colon surgery for carcinoma. Five-year results. Dis Colon Rectum
1996;39:S35-46.
Geis WP, Coletta AV, Verdeja JC, Plasencia G, Ojogho O, Jacobs M. Sequential psychomotor skills
development in laparoscopic colon surgery. Arch Surg 1994;129:206-12.
Kockerling F, Reymond MA, Schneider C, Wittekind C, Scheidbach H, Konradt J et al. Prospective
multicenter study of the quality of oncologic resections in patients undergoing laparoscopic colorectal
surgery for cancer. The Laparoscopic Colorectal Surgery Study Group. Dis Colon Rectum 1998;41:963-
70.
Kwok SP, Lau WY, Carey PD, Kelly SB, Leung KL, Li AK. Prospective evaluation of laparoscopic-assisted
large bowel excision for cancer. Ann Surg 1996;223:170-6.
Milsom JW, Bohm B, Hammerhofer KA, Fazio V, Steiger E, Elson P. A prospective, randomized trial
comparing laparoscopic versus conventional techniques in colorectal cancer surgery: a preliminary report.
J Am Coll Surg 1998;187:46-54; discussion 54-5.
Nano M, Levi AC, Borghi F, Bellora P, Bogliatto F, Garbossa D et al. Observations on surgical anatomy for
rectal cancer surgery. Hepatogastroenterology 1998;45:717-26.
Shafik A, Mostafa H. Study of the arterial pattern of the rectum and its clinical application. Acta Anat
1996;157:80-6.
Wexner SD, Cohen SM. Port site metastases after laparoscopic colorectal surgery for cure of malignancy.
Br J Surg 1995;82:295-8.

Username
Password
	Remember me (needs cookies)