Technical tips for laparoscopic left colectomy in the obese patient

Obesity may pose certain technical difficulties for the laparoscopic surgeon in terms of positioning, exposure, and dissection. We believe that the surgical outcome might be equalized between obese and non-obese patients if the appropriate key operative steps are respected. Here we show certain tips that we believe will help achieve this goal.

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Technical tips for laparoscopic left colectomy in the obese patient

Authors

J Leroy, M Simone, J Marescaux

Abstract

Obesity may pose certain technical difficulties for the laparoscopic surgeon in terms of positioning, exposure, and dissection. We believe that the surgical outcome might be equalized between obese and non-obese patients if the appropriate key operative steps are respected. Here we show certain tips that we believe will help achieve this goal.

Classification

tips and tricks

Keywords

Technical tips, laparoscopic left colectomy, obese patient

Media type

Surgical video

Duration

07'00''

Publication

2005-08

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E-publication

WeBSurg.com, Aug 2005;5(08).
URL: http://www.websurg.com/doi-vd01en1670.htm

Technical tips for laparoscopic left colectomy in the obese patient

1. Clinical history 00'12''

Morbid obesity is becoming more predominant in our society. As surgeons, we will see a commensurate rise in our practices as well. Several studies have shown that obese patients fare worse compared to their non-obese counterparts in several surgical outcome variables. We believe that surgical outcomes can be equalized between obese and non-obese patients if the appropriate positioning, exposure and surgical strategies are utilized in the laparoscopic left colectomy. The positioning of the patient is similar to that of a non-obese patient but it cannot be over-emphasized obtaining 15 to 20 degrees of Trendelenburg as well as 10 to 15 degrees of right lateral tilt are often utilized. The retraction of the greater omentum and small bowel are improved with proper positioning of the patient.

2. Patient positioning 01'04''

Exposure is often a troublesome task in obese patients due to their visceral obesity whereby the mesentery has significant adipose disposition functionally creating less operative space in the abdomen as well as a shortened mesentery. Any additional benefit from positioning is critical to the successful completion of the procedure. Trocar length is variable depending on many factors. However, longer length shafts are available for patients with significant subcutaneous disposition.

3. Retraction of greater omentum 01'35''

Operative time can be improved with the maintenance of the trocars in their position and not inadvertently removed during the procedure. The optical port is placed supra- or infra-umbilical dependent upon torso size.

4. Trocar placement 01'47''

The 2 operative ports are placed along the right mid-clavicular line and 2 to 3 ports are necessary for retraction to aid in dissection. We have identified each port site with a letter. Ports B and C are the operative ports, E and D are utilized for retraction. Additionally, D can be used as an operative port in the dissection of the lateral attachments of the splenic flexure, and dependent upon difficulty with retraction, a 6th port will be denoted as the letter F to aid in the retraction of omentum and transverse colon. We have noted more frequently in obese patients short mesentery. We first give an example of long mesentery in a non-obese patient. Note the relative ease of mobilization in this patient. This obese patient has short mesentery. It is much more difficult to mobilize out of the way. As you can see, it takes some time to mobilize the small bowel.

5. Exposure of small bowel 03'40''

We are utilizing a closed grasper placed lateral to the proximal jejunum to drape the proximal small bowel. This maintains it in place. The root of the mesentery can now be seen. The significant adipose disposition also aids to a smaller working space environment making it critical to make the most of the small bowel retraction. The remaining distal small bowel is retracted to the right side of the abdomen out of the way. We now note the midline of the abdomen, as well on the left of the screen the ligament of Treitz. Dissection is ready to begin. With our surgical strategy, we feel a stagnant operative field can reduce small bowel injury as well as reduce the operative time. The key tip we believe that allows for a successful performance of a left colectomy in an obese patient is the use of the medial approach. Our prospective randomized study from a different institution also has shown benefits when compared to the lateral approach. Utilizing the inherent gravitational traction provided by the lateral attachments of the colon, dissection with the use of the retractors proves to be easier than the lateral approach as seen here. In cases of malignancy adequate proximal division of the mesentery is obtained along with the ‘no touch’ technique. As you can see, injury to the colon is also avoided during dissection as it is not in the operative field. This illustration reinforces this approach with identification of the IMA and its branches also easier to find with the medial approach. Another strategy we employ is the use of the Ligasure device. Several studies have shown the significant time savings as well as the safety of the device in colonic mesentery. Not only it is used for coagulation and cut functions but it is also used as a blunt dissector acting as a finger in dissecting through the tissue planes.

6. Surgical strategy 06'30''

Advancing to the splenic flexure in our dissection, we gain entrance into the lesser sac with this approach. This allows us to be able to free the colon medially. We will follow with the release of the lateral attachments. In summation, the success of a laparoscopic left colectomy can be achieved in the obese patient using the tips we have presented: trocar and patient positioning, exposure and dissection techniques that we have illustrated.