Task Analysis of Laparoscopic Left Colectomy / Sigmoid Resection:

Dr. Nuaman Ahmed Danawar
General Surgeon
F.MAS & D.MAS course August 2019

General Procedural Task Steps:

A. Exposure

1. operating room setup (position of surgeons, scrub nurse, drapes, etc.)
2. Patient positioning
3. Laparoscopic access (open, Veress needle or other techniques, and insertion of ports).
4. Exposure of operating field (moving of omentum, small bowel, etc.)
B. Dissection of the vascular pedicle
5. Dissection of the vascular pedicle (incision of the peritoneum, creation of window below and above, and dissection with
stapler, clips, ultrasound dissection tool or other techniques)
6. Retrocolic dissection of mesentery (right side toward hepatic flexure, left side toward splenic flexure)
7. Identification of landmark (right side: duodenum, left side: left ureter) C. Mobilization
8. Dissection of flexure (right side: hepatic, left side: splenic)
9. Mesorectal dissection (including total mesorectal excision (TME), only for rectal resections) 10. Dissection of
the bowel (transection, using stapler another similar device)
D. Anastomosis
11. Extraction of the specimen (creation of incision, bringing out the specimen, completion of resection)
12. Anastomosis (intra or extra-corporeal)

Detail Executional Task Steps:

1. Perform a vertical supraumbilical incision within the site of the planned incision for specimen extraction to place
the camera port (10/12 mm) using an open Hasson technique. In certain instances where an infraumbilical
extraction may be possible (based on pathology and patientʼs body habitus), this site may be used.
2. Insert a 30° laparoscope through this trocar and establish pneumoperitoneum to 15-mm Hg with carbon
dioxide.
3. Two other trocars are required: Place one trocar in the right upper quadrant and one in the right lower quadrant
(will be used for endoscopic stapler), both lateral to the rectus muscle.
4. Additional trocars: A third trocar may be placed in the left lower quadrant to aid in the mobilization of the splenic
flexure, surgeon standing in between the legs using the right and left lower quadrant trocars). A left upper
quadrant trocar placed lat- eral to the rectus muscle may be used for additional retraction. This site also provides
an excellent vantage point for laparo- scopic visualization of the anastomosis. A fifth trocar is some- times placed
high in the right upper quadrant if needed.
5. A thorough inspection of the liver and the peritoneal cavity is required for patients with cancer to exclude any
metastatic disease.
6. Place the patient in steep Trendelenburg position with the right side of the table down.
7. Gently bring the small bowel out of the pelvis and sweep it into the right upper quadrant.
A. Lateral-to-Medial Approach
8. Grasp the sigmoid colon with an endoscopic grasper and retract it medially to expose the white line of Toldt.
9.Using either a 5-mm energy device or cautery scissors, incise the peritoneum to mobilize the sigmoid and left
colon to the level of the splenic flexure.
10. Continually grasp and manipulate the left colon/sigmoid as needed to maintain adequate superomedial tract.
This facilitates the dissection as it progresses medially to expose Gerotaʼs fascia, ureter, and sacral promontory
11. Next, reposition the patient in reverse Trendelenburg.
12. Mobilize the splenic flexure and distal transverse colon.
13. Grasp the greater omentum and lift it cephalad. Divide the gastrocolic omentum to the level of the middle colic artery.
14. Grasp the transverse colon with an endoscopic grasper and dissect the transverse colon and splenic flexure
free of the retroperitoneum inferior to the spleen.
15. After complete mobilization, intracorporeally ligate the vascular pedicle.
a. Medially isolate either the superior hemorrhoidal and the
left colic arteries or the inferior mesenteric artery.
b. Anterolateral retraction of the left colon facilitates this
identification.
c. Isolate the vessels by scoring the mesentery and creating
windows in the mesentery on each side.
d. These vessels can be divided using electrothermal bipolar
vessel sealing devices, an endoscopic stapler, or endoscopic clips. Typically, any of these devices are introduced
through the right lower quadrant trocar for an optimal angle.
e. Prior to ligation, visualize the tissue on either side of the vessel and reconfirm the location of the ureter. This is
crucial to ensure that nothing else is incorporated in the ligation. After confirming satisfactory positioning,
perform vessel ligation.
f. Continue dividing the mesentery heading cephalad and identify the inferior mesenteric vein. Isolate and divide
the vein using electrothermal bipolar vessel sealers, clips, or an endoscopic stapler.
g. Typically, only the above-named vessels are divided in this manner.
16. After isolating the smaller vessels in the sigmoid mesentery, control them with clips, electrothermal bipolar
vessel sealers, or ultrasonic shears.
17. Choose the distal extent of resection and circumferentially expose the colonic or rectal wall. This may be
performed using an energy source or a cautery-hook dissector, and at times curved dissector (such as Maryland
forceps) may be useful to develop the plane between the bowel wall and the mesocolon. Bare colon or rectal wall
should be demonstrated circumferentially.
18. Insert a 60-mm linear cutting stapler, encompass the bowel wall between the blades (making sure that
laterally nothing else is incorporated into the blades), and fire the stapler.
19. Once the left colon and sigmoid have been completely mobilized as described, grasp the proximal stapled
colon end with a locking forceps.
20. At the site of the initial trocar (camera trocar) in the infraumbilical position, make a 2- to the 4-cm vertical
incision in the skin and the fascia to allow extraction of the colon. Alternatively, a small Pfannenstiel left lower
quadrant or lower midline incision can be used.
21. Allow the pneumoperitoneum to collapse and place an Alexis® or another similar wound protector (usually, a
small to medium size is required).
22. Deliver the colon through the midline wound, and eviscerate the left colon and sigmoid on the abdominal wall.
23. Perform the proximal resection extracorporeally in conventional fashion. Place a purse-string suture and insert the circular stapling anvil into the proximal end of the bowel. Secure the purse- string suture and replace the
bowel into the abdominal cavity
24. In order to reestablish pneumoperitoneum, we recommend closing the fascia with two running absorbable
sutures (one starting superiorly and one inferiorly) and leaving the ends untied in order to allow replacement of
the Hasson trocar.
The sutures should be fastened to the trocar and should be long
enough so that they can be tied at the end of the operation.
25. Grasp the anvil with a laparoscopic anvil-grasping clamp or alligator clamp. Assess the ability of the anvil to
reach the planned anastomotic site. Further mobilization and/or vascular
division may be needed and should be performed if necessary.
26. Verify the correct orientation (i.e., no twist) for the proximal bowel.
27. Transanally insert a circular stapler and advance it to the distal
staple line. Under direct laparoscopic visual control, extend the spike of the stapler through the distal staple line.
Attach the anvil.
28. Move the laparoscope to the right lower quadrant trocar to best visualize the anvil and stapler head coming
together. Once satisfied, close, fire, and remove the stapler. Inspect the two donuts for completeness.
29. Test the anastomosis by placing an atraumatic clamp across the bowel proximal to the anastomosis. Use the
suction irrigator, fill the pelvis with saline, and immerse the anastomosis. Insufflate the rectum with air using a
bulb syringe, proctoscope, or flexible sigmoidoscope, and observe for air bubbles.
30. Irrigate the abdomen, obtain hemostasis, and close the trocar sites.
31. Remove the Hasson trocar and complete the closure of the small midline incision with the two sutures that
were placed earlier on (in Step 24). Close the fascia of all 10/12-mm trocar sites in the usual fashion.
B. Medial-to-Lateral Approach
32. This approach starts with the identification of the inferior mesenteric artery and its ligation.
33. Using an endoscopic grasper, retract the sigmoid colon supero- laterally and identify the inferior mesenteric
artery.
34. Proceed as described above (Steps 15c–g).
35. Proceed with lateral mobilization of the left colon and sigmoid
as described above (Steps 8–14), followed by Steps 16–31 to complete the procedure.