After general anesthesia was obtained, a Foley catheter was inserted, the
abdomen prepped and draped in the usual sterile manner. The patient was
placed in the lithotomy position. A curvilinear skin incision was made
surrounding the umbilicus. Using electrocautery, dissection was continued
through the soft tissues until the anterior abdominal fascia was encountered.
The fascia was then grasped between 2 Kocher clamps and incised, and a 5 mm
trocar introduced. Pneumoperitoneum was then obtained by insufflating with
CO2 under direct visualization. The laparoscopic camera was then placed
through the trocar. Under direct visualization, a second and third 5 mm
trocar were placed in the periumbilical region. The patient was placed in the
left side down, reverse Trendelenburg position. The small bowel was retracted
inferiorly and to the left. The cecum was identified and noted to be somewhat
densely adherent to the lateral pelvic sidewall. The cecum was then
immobilized using blunt dissection and the LigaSure device. Dissection was
then continued, dividing the lateral peritoneal reflection towards the hepatic
flexure. The hepatic flexure was then taken down using the LigaSure device in
a similar fashion until the transverse colon was immobilized to the mid point.
The mesentery to the distal small bowel was then divided with the LigaSure
device and this was taken all the way down to the root. At this point, the
mesentery to the right colon was then divided with the right colic vessels
being taken with the LigaSure device. The remaining portion of the mesentery
was divided to the mid point of the transverse colon. The right colon,
hepatic flexure, and proximal transverse colon were then completely freed at
this point, and the cecum was grasped with a Prestige clamp. The
pneumoperitoneum was released. The periumbilical fascia was divided and an
Alexis wound protector device was placed in the periumbilical region. The
right colon was then brought through the Alexis wound protector and the distal
small bowel was then divided with the GIA stapler. A site was chosen for the
division of the transverse colon, and it was divided with the GIA stapler.
The right colon was then taken off the field as specimen. The distal small
bowel and transverse colon were then laid side to side and anastomosis made
between them by firing a GIA stapler. The transverse anastomosis was closed
with a TA-60 stapler. The anastomosis was noted to be widely patent. The
mesentery was reapproximated with interrupted 2-0 silk sutures. No bleeding
was noted and this anastomosis was then placed back into the abdominal cavity.
The 5 mm trocar was then placed back through the Alexis device and a Penrose
drain was placed and secured with a hemostat. Pneumoperitoneum was able to be
obtained.
Attention was then turned to the left-side of the colon where the patient was
noted to have a colon lesion which had been biopsied and returned positive for
adenocarcinoma. This area was seen and was inked proximally and distally to
the lesion. The laparoscopic camera had been placed back through the trocar
and on direct visualization, a second 5 mm trocar placed in the suprapubic
area, a third 12 mm trocar placed in the right lower quadrant. The patient
was then placed in the Trendelenburg position and right-side down, and the
small bowel was retracted to the right. The sigmoid colon was then mobilized
by dividing the lateral peritoneal reflection. This dissection was continued
superiorly until the splenic flexure was encountered. At this point, the
dissection was then begun with the colon being rolled to the right. The
retroperitoneum was entered and the ureter was identified. The ureter was
noted throughout its length and left in its normal anatomic position. The
peritoneum along the left side of the colon was divided with the LigaSure
device, continuing to the level of the sacral promontory. The colon was then
flipped over to the left side and the peritoneum on the right side of the
colon was divided with the LigaSure device. This dissection was continued
until the colon was completely encircled at the level of the sacral
promontory. The colon was then divided at this level with the GIA stapler.
The mesentery to the sigmoid colon was then divided down to the root with the
LigaSure device, and this division of the mesentery continued superiorly until
a site was chosen that passed the inked lesion. At this point, the colon was
divided 5 to 6 cm proximal to the inked lesion with the Echelon stapler. The
descending colon was noted to be mobilized enough to reach into the pelvis for
the anastomosis, and at this point, the pneumoperitoneum was released. The
specimen was brought through the Alexis wound protector device, and taken off
the field as specimen. The descending colon was then brought through the
Alexis device and the staple line was removed. A auto-pursestring suture was
placed around the colon at this point, and fired. The EEA anvil was then
placed in the colon and the pursestring was secured around the anvil. There
was noted to be adequate blood supply to this segment of colon, and the colon
with the anvil was placed back into the abdominal cavity. The
pneumoperitoneum was then re-obtained, the laparoscopic camera placed through
the trocar. The EEA stapler was then placed into the rectal stump and the tip
was engaged. The tip was then connected to the EEA anvil and the stapler was
then closed and fired. The stapler was removed. The donuts were inspected
and noted to be completely intact. At this point, 3 interrupted 3-0 silk
sutures were placed across the staple line for reinforcement. The staple line
was noted to be intact. The pelvis was irrigated with copious amounts of
normal saline. No active bleeding was noted. The trocars were then removed.
The Alexis wound protector device was removed. The anterior abdominal fascia
in the periumbilical region was then reapproximated with a running, double-
stranded, looped PDS suture. The wound was irrigated with copious amounts of
antibiotic solution and infiltrated with 0.5% Marcaine. The deep soft tissue
was closed with interrupted 2-0 Vicryl suture and the skin closed with 4-0
Monocryl subcuticular suture. Steri-Strips placed, sterile dressing placed,
and the patient was taken to the recovery room in a stable condition.