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Figure 7 In the setting of malignancy or in the heavier patient, the vascular pedicle must be divided intracorporeally A bowel clamp grasps the mesentery adjacent to the ileocecal junction, and by placing traction on this site, the ileocoli vascular pedicle is placed under tension and “bowstrings” it. The avascular mesenteric windows on either side of th base of the ileocolic pedicle can thus be identified; the more superior one (to the right of the pedicle) is adjacent to th duodenum. These mesenteric windows are then opened and the vessels are cleared of overlying fat. The vessels may b clipped and divided with scissors, with the bipolar device, or with a laparoscopic vascular linear stapler.

Figure 7 In the setting of malignancy or in the heavier patient, the vascular pedicle must be divided intracorporeally A bowel clamp grasps the mesentery adjacent to the ileocecal junction, and by placing traction on this site, the ileocoli vascular pedicle is placed under tension and “bowstrings” it. The avascular mesenteric windows on either side of th base of the ileocolic pedicle can thus be identified; the more superior one (to the right of the pedicle) is adjacent to th duodenum. These mesenteric windows are then opened and the vessels are cleared of overlying fat. The vessels may b clipped and divided with scissors, with the bipolar device, or with a laparoscopic vascular linear stapler.

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Table 1 Reported Incidence of Major Vascular and Visceral Injuries Following Laparoscopic Trocar Insertion
Table 1 Reported Incidence of Major Vascular and Visceral Injuries Following Laparoscopic Trocar Insertion
Figure 1 Veress needle. (Reproduced with permission from the Mayo Foundation for Medical Education and Research. All rights reserved.)
Figure 1 Veress needle. (Reproduced with permission from the Mayo Foundation for Medical Education and Research. All rights reserved.)
Figure 2 Placement of a Hasson trocar. Two fascial sutures stabilize the abdominal wall, and the trocar is inserted under direct vision.
Figure 2 Placement of a Hasson trocar. Two fascial sutures stabilize the abdominal wall, and the trocar is inserted under direct vision.
Figure 3 Median umbilical ligament (arrow). The superior clamp has everted the umbilicus and tented up the median umbilical ligament. The inferior Kocher clamp has been placed on the most superficial aspect of the ligament. Two retractors give adequate exposure by inferior and caudad retraction.
Figure 3 Median umbilical ligament (arrow). The superior clamp has everted the umbilicus and tented up the median umbilical ligament. The inferior Kocher clamp has been placed on the most superficial aspect of the ligament. Two retractors give adequate exposure by inferior and caudad retraction.
C. Optical Trocar tip of the trocar as it is passed through the abdominal wall. A skin incision is made and the optical trocar is inserted into the subcutaneous tissue. Direct pressure with simultaneous twisting is performed to advance the trocar through the abdominal wall. Figure 4 Sharp entry into the peritoneal cavity through the median umbilical ligament. The optical trocar technique is performed with a transparent bladeless trocar and a 0° laparoscope, which is inserted to the tip of the trocar (Fig. 5). This allows visualization of the tissue at the
C. Optical Trocar tip of the trocar as it is passed through the abdominal wall. A skin incision is made and the optical trocar is inserted into the subcutaneous tissue. Direct pressure with simultaneous twisting is performed to advance the trocar through the abdominal wall. Figure 4 Sharp entry into the peritoneal cavity through the median umbilical ligament. The optical trocar technique is performed with a transparent bladeless trocar and a 0° laparoscope, which is inserted to the tip of the trocar (Fig. 5). This allows visualization of the tissue at the
Figure 2 Trocar placement in male (A) and female (B) patients.
Figure 2 Trocar placement in male (A) and female (B) patients.
hair (Fig. 2B). Other settings (eg, left lower quadrant plus suprapubic midline port or a port right under the right costal margin) are not recommended because they have functional disadvantages or may be cosmetically inappropriate. Exposure of the Appendix After insertion of the ports, a quick diagnostic laparoscopy is performed to either confirm the diagnosis or assess other pathology (eg, female organs, diverticulitis, inguinal hernias, liver/gallbladder disease, carcinomatosis). The © sur-
hair (Fig. 2B). Other settings (eg, left lower quadrant plus suprapubic midline port or a port right under the right costal margin) are not recommended because they have functional disadvantages or may be cosmetically inappropriate. Exposure of the Appendix After insertion of the ports, a quick diagnostic laparoscopy is performed to either confirm the diagnosis or assess other pathology (eg, female organs, diverticulitis, inguinal hernias, liver/gallbladder disease, carcinomatosis). The © sur-
The surgeon’s left hand operates a Babcock grasper (Ethi- con Endosurgery, Cincinnati, OH) to retract the cecum and subsequently to expose the appendix (if the appendix is in its usual paracecal position). Particularly if the appendix is sig- nificantly inflamed and friable, it is advisable not to grasp geon’s assistant and camera holder then moves to the pa- tient’s left side, cephalad to the surgeon. The patient is brought into the Trendelenburg position with the right side elevated to facilitate the exposure of the right lower quadrant.
The surgeon’s left hand operates a Babcock grasper (Ethi- con Endosurgery, Cincinnati, OH) to retract the cecum and subsequently to expose the appendix (if the appendix is in its usual paracecal position). Particularly if the appendix is sig- nificantly inflamed and friable, it is advisable not to grasp geon’s assistant and camera holder then moves to the pa- tient’s left side, cephalad to the surgeon. The patient is brought into the Trendelenburg position with the right side elevated to facilitate the exposure of the right lower quadrant.
sect the appendix. After transsection, the appendiceal stump mucosa is cauterized carefully (Fig. 5). Stapling Technique
sect the appendix. After transsection, the appendiceal stump mucosa is cauterized carefully (Fig. 5). Stapling Technique
essary. However, if residual contaminated fluid is to be left in the peritoneal cavity or if the appendiceal/cecal stump is of suboptimal quality, placement of a small drain may be pru- dent. It should be brought in through a separate 4- to 5-mm incision in the right lower quadrant, that is, not through one of the trocar sites, and laid along the cecum into the pelvis to drain those dependent areas. The drain can be removed after a few days once the quality of the fluid is serosanguinous. vantage to irrigation but rather risks spreading contaminated fluid throughout the abdomen. Otherwise, with the appen- dix removed, a thorough lavage of the area is performed. In particular, the pelvis has to be well exposed and any residual contaminated fluid should be aspirated and irrigated by re- tracting the sigmoid colon and exposing the pouch of Doug- las. In the overwhelming majority of cases, a drain is not nec-
essary. However, if residual contaminated fluid is to be left in the peritoneal cavity or if the appendiceal/cecal stump is of suboptimal quality, placement of a small drain may be pru- dent. It should be brought in through a separate 4- to 5-mm incision in the right lower quadrant, that is, not through one of the trocar sites, and laid along the cecum into the pelvis to drain those dependent areas. The drain can be removed after a few days once the quality of the fluid is serosanguinous. vantage to irrigation but rather risks spreading contaminated fluid throughout the abdomen. Otherwise, with the appen- dix removed, a thorough lavage of the area is performed. In particular, the pelvis has to be well exposed and any residual contaminated fluid should be aspirated and irrigated by re- tracting the sigmoid colon and exposing the pouch of Doug- las. In the overwhelming majority of cases, a drain is not nec-
When the tip of the appendix is not clearly visible, a retro- grade appendectomy can be performed with the stapler (Fig. 8). The visible base of the appendix is transected after cre- ation of an appropriate window, followed by the mesoappen- dix, and finally the whole appendix is dissected from the base Difficult Appendicitis Retrograde Appendectomy
When the tip of the appendix is not clearly visible, a retro- grade appendectomy can be performed with the stapler (Fig. 8). The visible base of the appendix is transected after cre- ation of an appropriate window, followed by the mesoappen- dix, and finally the whole appendix is dissected from the base Difficult Appendicitis Retrograde Appendectomy
to the tip. This is performed as in open surgery and does not require specific skills. When the surgeon encounters a gangrenous or perforated appendicitis or an appendiceal phlegmon, it can be difficult initially to recognize the appendix. In these circumstances, it
to the tip. This is performed as in open surgery and does not require specific skills. When the surgeon encounters a gangrenous or perforated appendicitis or an appendiceal phlegmon, it can be difficult initially to recognize the appendix. In these circumstances, it
Figure 1 Laparoscopic right colectomy may be performed with the patient in either a supine or modified lithotomy position. My preference, in keeping with simplification and alignment with the open procedure, is for the supin position. A 3- or 4-port technique is used. A supraumbilical cutdown is employed for insertion of a blunt 12-mm port and pneumoperitoneum is established. An initial assessment is made of the extent of any adhesions. If extensiv: adhesions cannot be lysed laparoscopically, early conversion is advised. Adhesions after appendectomy or cholecys tectomy are not prohibitive in most cases. Under direct vision, two 5-mm trocars are placed in the suprapubic midlin and the left lower quadrant. (Staying lateral to the rectus muscle avoids injury to the epigastric vessels.) In malignanc or in a heavier patient, a fourth 5-mm trocar is placed in the right lower quadrant, mirroring the trocar in the left lowe quadrant. The patient is placed in Trendelenburg position, with the patient’s right side tilted up, and the surgeon anc the camera-operator stand on the left side facing the right colon.
Figure 1 Laparoscopic right colectomy may be performed with the patient in either a supine or modified lithotomy position. My preference, in keeping with simplification and alignment with the open procedure, is for the supin position. A 3- or 4-port technique is used. A supraumbilical cutdown is employed for insertion of a blunt 12-mm port and pneumoperitoneum is established. An initial assessment is made of the extent of any adhesions. If extensiv: adhesions cannot be lysed laparoscopically, early conversion is advised. Adhesions after appendectomy or cholecys tectomy are not prohibitive in most cases. Under direct vision, two 5-mm trocars are placed in the suprapubic midlin and the left lower quadrant. (Staying lateral to the rectus muscle avoids injury to the epigastric vessels.) In malignanc or in a heavier patient, a fourth 5-mm trocar is placed in the right lower quadrant, mirroring the trocar in the left lowe quadrant. The patient is placed in Trendelenburg position, with the patient’s right side tilted up, and the surgeon anc the camera-operator stand on the left side facing the right colon.
Figure 2 In slim patients, the right ureter can be identified before opening the peritoneum. In obese patients identification of the ureter is possible only after the peritoneum has been incised. The cecum and appendix are elevatec toward the head, that is, toward the right of the screen. This exposes a “valley” at the base of the cecum and termina ileal mesentery, which marks the junction of the mesentery with the retroperitoneum, covered by peritoneum. The peritoneum around the cecum and terminal ileum is scored along this valley and the correct retroperitoneal plane is thus entered.
Figure 2 In slim patients, the right ureter can be identified before opening the peritoneum. In obese patients identification of the ureter is possible only after the peritoneum has been incised. The cecum and appendix are elevatec toward the head, that is, toward the right of the screen. This exposes a “valley” at the base of the cecum and termina ileal mesentery, which marks the junction of the mesentery with the retroperitoneum, covered by peritoneum. The peritoneum around the cecum and terminal ileum is scored along this valley and the correct retroperitoneal plane is thus entered.
Figure 3 The right lateral peritoneal reflection is opened lateral to the cecum and proximal ascending colon. The plane between the retroperitoneum and the posterior aspect of the ascending colon mesentery is a bloodless plane, and the cecum and proximal ascending colon are mobilized fully toward the midline. This author's preference is for simple monopolar scissors used similarly to electrocautery in an open case, with the tips of the scissors kept together.
Figure 3 The right lateral peritoneal reflection is opened lateral to the cecum and proximal ascending colon. The plane between the retroperitoneum and the posterior aspect of the ascending colon mesentery is a bloodless plane, and the cecum and proximal ascending colon are mobilized fully toward the midline. This author's preference is for simple monopolar scissors used similarly to electrocautery in an open case, with the tips of the scissors kept together.
Figure 4 Moving cephalad, with the patient still in Trendelenburg, the right lateral peritoneal reflection is opened alongside the distal ascending colon. Care must be taken to identify the correct plane between the mesentery and the retroperitoneum, anterior to Gerota’s fascia, in order not to undermine the right kidney.
Figure 4 Moving cephalad, with the patient still in Trendelenburg, the right lateral peritoneal reflection is opened alongside the distal ascending colon. Care must be taken to identify the correct plane between the mesentery and the retroperitoneum, anterior to Gerota’s fascia, in order not to undermine the right kidney.
Figure 5 As the ascending colon is fully mobilized toward the midline, the duodenum and inferior vena cava are exposed. Awareness of these structures as the mobilization proceeds medially is mandatory. These anatomic landmarks also indicate that the appropriate extent of dissection has been reached, with the ascending colon fully mobilized to the midline. The medial peritoneal attachments of the terminal ileum can be divided toward the level of the duodenum to facilitate exteriorization.
Figure 5 As the ascending colon is fully mobilized toward the midline, the duodenum and inferior vena cava are exposed. Awareness of these structures as the mobilization proceeds medially is mandatory. These anatomic landmarks also indicate that the appropriate extent of dissection has been reached, with the ascending colon fully mobilized to the midline. The medial peritoneal attachments of the terminal ileum can be divided toward the level of the duodenum to facilitate exteriorization.
Figure 6 To mobilize the hepatic flexure, the patient is placed in reverse Trendelenburg, with the right side still tilted up, exposing the hepatic flexure. The gastrocolic attachments are grasped close to but not on the bowel and elevated obliquely toward the lower anterior abdominal wall. The tissue can often be seen moving over the underlying plane between the gastrocolic attachments and the retroperitoneum, allowing identification and entry into the correct plane. The duodenum must again be identified and protected. The hepatic flexure should be mobilized sufficiently to be brought down to the level of the umbilicus. If the camera, when focused on the mobilized hepatic flexure, is angled below an imaginary transverse line drawn through the umbilicus, the flexure has been mobilized sufficiently to permit exteriorization. A final check is made by pulling the mobilized right colon over to the left side of the abdomen to ensure that the entire right retroperitoneum is free of residual attachments.
Figure 6 To mobilize the hepatic flexure, the patient is placed in reverse Trendelenburg, with the right side still tilted up, exposing the hepatic flexure. The gastrocolic attachments are grasped close to but not on the bowel and elevated obliquely toward the lower anterior abdominal wall. The tissue can often be seen moving over the underlying plane between the gastrocolic attachments and the retroperitoneum, allowing identification and entry into the correct plane. The duodenum must again be identified and protected. The hepatic flexure should be mobilized sufficiently to be brought down to the level of the umbilicus. If the camera, when focused on the mobilized hepatic flexure, is angled below an imaginary transverse line drawn through the umbilicus, the flexure has been mobilized sufficiently to permit exteriorization. A final check is made by pulling the mobilized right colon over to the left side of the abdomen to ensure that the entire right retroperitoneum is free of residual attachments.
Figure 8 At this point, the bowel is sufficiently mobilized to permit exteriorization via a periumbilical incision. The supraumbilical port site incision may be enlarged around the umbilicus to 4 to 5 cm, and the specimen is exteriorized from the terminal ileum to the mid-transverse colon. This incision overlies the base of the ileocolic pedicle, and the fully mobilized right colon is now a midline structure centered beneath the umbilicus.
Figure 8 At this point, the bowel is sufficiently mobilized to permit exteriorization via a periumbilical incision. The supraumbilical port site incision may be enlarged around the umbilicus to 4 to 5 cm, and the specimen is exteriorized from the terminal ileum to the mid-transverse colon. This incision overlies the base of the ileocolic pedicle, and the fully mobilized right colon is now a midline structure centered beneath the umbilicus.
Figure 9 Mesenteric division and bowel resection may be performed extracorporeally, and the anastomosis can be completed before returning the bowel to the abdominal cavity. The configuration of a side-to-side stapled anastomosis lies over the mesenteric defect, which is not closed. In the setting of benign disease in a slim patient, the ileocolic pedicle does not need to be divided intracorporeally, and the specimen may be exteriorized as soon as the right colon has been mobilized to the midline.
Figure 9 Mesenteric division and bowel resection may be performed extracorporeally, and the anastomosis can be completed before returning the bowel to the abdominal cavity. The configuration of a side-to-side stapled anastomosis lies over the mesenteric defect, which is not closed. In the setting of benign disease in a slim patient, the ileocolic pedicle does not need to be divided intracorporeally, and the specimen may be exteriorized as soon as the right colon has been mobilized to the midline.
Figure 1 After minimally invasive access to the abdominal cavity is achieved, laparoscopic ports are placed in a standard fashion for laparoscopic cholecystectomy (A, laparoscope; B and C, gall bladder retraction; D, working port; E, cholangiogram catheter).
Figure 1 After minimally invasive access to the abdominal cavity is achieved, laparoscopic ports are placed in a standard fashion for laparoscopic cholecystectomy (A, laparoscope; B and C, gall bladder retraction; D, working port; E, cholangiogram catheter).
Figure 2. Following dissection of the gallbladder neck and identification of the cystic duct, a surgical clip is placed on the cystic duct at the level of the gallbladder. A small cystic duct incision is fashioned just below the clip and its lumen is identified. A 5-Fr cholangiogram catheter is inserted percutaneously in a location that will facilitate further access to the cystic duct and common bile duct, if necessary. Most commonly, the catheter will be positioned close to the costal margin, between the mid epigastric and lateral ports. Once in the abdomen, the catheter is flushed with saline to clear it of air. A dissector is used to advance the catheter into the ductotomy and is then secured with a nonocclusive surgical clip.
Figure 2. Following dissection of the gallbladder neck and identification of the cystic duct, a surgical clip is placed on the cystic duct at the level of the gallbladder. A small cystic duct incision is fashioned just below the clip and its lumen is identified. A 5-Fr cholangiogram catheter is inserted percutaneously in a location that will facilitate further access to the cystic duct and common bile duct, if necessary. Most commonly, the catheter will be positioned close to the costal margin, between the mid epigastric and lateral ports. Once in the abdomen, the catheter is flushed with saline to clear it of air. A dissector is used to advance the catheter into the ductotomy and is then secured with a nonocclusive surgical clip.
Figure 5 For common bile duct stones that are too large to be cleared by simple flushing, many surgeons are successfu in removing these stones with a Fogarty balloon catheter. A 4-Fr Fogarty is inserted with graspers transcystically int the common bile duct past the stones. The balloon is then inflated, and the catheter is slowly withdrawn from the cysti duct with the graspers. In many cases, the Fogarty will carry the stones out of the cystic duct and into the abdomen Following a repeat cholangiogram, the gallbladder can be removed and any free stones can be retrieved later with th gallbladder.?
Figure 5 For common bile duct stones that are too large to be cleared by simple flushing, many surgeons are successfu in removing these stones with a Fogarty balloon catheter. A 4-Fr Fogarty is inserted with graspers transcystically int the common bile duct past the stones. The balloon is then inflated, and the catheter is slowly withdrawn from the cysti duct with the graspers. In many cases, the Fogarty will carry the stones out of the cystic duct and into the abdomen Following a repeat cholangiogram, the gallbladder can be removed and any free stones can be retrieved later with th gallbladder.?
Figure 6 Dilation of the cystic duct with an angioplasty balloon catheter.
Figure 6 Dilation of the cystic duct with an angioplasty balloon catheter.
Figure 7 The catheter is then removed, in a Seldinger fashion, leaving the guide wire in place. With the guide wire in place, a plastic sheath approximately 12 Fr in diameter is placed over the wire through the abdominal wall. This allows safe passage of the choledochoscope and other equipment into the abdomen without injuring the scope’s optic fibers. Alternatively, a 3-mm inner cannula, of the type commonly used to pass an endoscopic ligation loop, can be used through a standard laparoscopic port to pass the choledochoscope. The cannula will prevent injury of the scope by the port’s valve and may be less expensive than other sheaths.
Figure 7 The catheter is then removed, in a Seldinger fashion, leaving the guide wire in place. With the guide wire in place, a plastic sheath approximately 12 Fr in diameter is placed over the wire through the abdominal wall. This allows safe passage of the choledochoscope and other equipment into the abdomen without injuring the scope’s optic fibers. Alternatively, a 3-mm inner cannula, of the type commonly used to pass an endoscopic ligation loop, can be used through a standard laparoscopic port to pass the choledochoscope. The cannula will prevent injury of the scope by the port’s valve and may be less expensive than other sheaths.
Figure 8A Following cholangiography, the anterior common bile duct is identified near its junction with the cystic duct The cystic duct is ligated.
Figure 8A Following cholangiography, the anterior common bile duct is identified near its junction with the cystic duct The cystic duct is ligated.
Figure 8B An endoscopic ligating loop should be used for large cystic ducts. The tissue overlying the common bile duc is cleared bluntly or with assistance of ultrasonic dissection. Electrocautery is to be avoided to prevent injury to the common bile duct. The initial ductotomy is made with small, sharp scissors. The incision is extended just far enougt to allow removal of the stones and T-tube insertion.
Figure 8B An endoscopic ligating loop should be used for large cystic ducts. The tissue overlying the common bile duc is cleared bluntly or with assistance of ultrasonic dissection. Electrocautery is to be avoided to prevent injury to the common bile duct. The initial ductotomy is made with small, sharp scissors. The incision is extended just far enougt to allow removal of the stones and T-tube insertion.
Figure 86 Once the choledochotomy is created, the stones are removed with graspers or a Fogarty balloon as describec earlier.
Figure 86 Once the choledochotomy is created, the stones are removed with graspers or a Fogarty balloon as describec earlier.
Figure 9 The choledochoscope can then be inserted to inspect the proximal and distal ducts directly in order to confirm clearance of the duct system. Any additional calculi that are identified can be removed with retrieval baskets.
Figure 9 The choledochoscope can then be inserted to inspect the proximal and distal ducts directly in order to confirm clearance of the duct system. Any additional calculi that are identified can be removed with retrieval baskets.
Figure 10 Once the duct is visually clear, a 10- to 14-Fr T-tube is cut to shape as in an open exploration. The T-tube i: inserted into the ductotomy with graspers. The ductotomy is then closed around the T-tube with 4-0 absorbabk sutures. Intracorporeal suturing and knot tying will reduce trauma to the edges of the choledochotomy. The end of the T-tube is pulled through a lateral port site, and a completion cholangiogram is taken.
Figure 10 Once the duct is visually clear, a 10- to 14-Fr T-tube is cut to shape as in an open exploration. The T-tube i: inserted into the ductotomy with graspers. The ductotomy is then closed around the T-tube with 4-0 absorbabk sutures. Intracorporeal suturing and knot tying will reduce trauma to the edges of the choledochotomy. The end of the T-tube is pulled through a lateral port site, and a completion cholangiogram is taken.
Table 1 Potential Indications for Laparoscopic Nephrectomy benign disease rests on the size of the kidney, the potential for perinephric inflammation, the presence of renal anomalies (eg, horseshoe kidney), and the surgeon’s experience. Char- acteristically, renal anomalies have not precluded laparo- scopic nephrectomy; however, knowledge of aberrant renal vessels, horseshoe kidneys, and other less common renal fu- sion anomalies is warranted preoperatively. Patients with nonfunctioning kidneys secondary to chronic bacterial in- fection, xanthogranulomatous pyelonephritis, and renal tuberculosis are at risk for severe perinephric scarring and inflammation. Although these patients have no absolute contraindication to laparoscopic nephrectomy, the proce- dure can be much more challenging for this group of pa- tients. Likewise, because of the size of the kidney in a patient with autosomal dominant polycystic kidney disease, laparo- scopic nephrectomy can also be more challenging in this group of patients.
Table 1 Potential Indications for Laparoscopic Nephrectomy benign disease rests on the size of the kidney, the potential for perinephric inflammation, the presence of renal anomalies (eg, horseshoe kidney), and the surgeon’s experience. Char- acteristically, renal anomalies have not precluded laparo- scopic nephrectomy; however, knowledge of aberrant renal vessels, horseshoe kidneys, and other less common renal fu- sion anomalies is warranted preoperatively. Patients with nonfunctioning kidneys secondary to chronic bacterial in- fection, xanthogranulomatous pyelonephritis, and renal tuberculosis are at risk for severe perinephric scarring and inflammation. Although these patients have no absolute contraindication to laparoscopic nephrectomy, the proce- dure can be much more challenging for this group of pa- tients. Likewise, because of the size of the kidney in a patient with autosomal dominant polycystic kidney disease, laparo- scopic nephrectomy can also be more challenging in this group of patients.
Operative Technique
Operative Technique
Figure 2 Peritoneal access and port placement. Access to the peri- toneum can be performed via either an open or closed technique. The favored position for placement of the Veress needle (Ethicon Endosurgery, Cincinnati, OH) with the closed access technique is at the umbilicus after the patient has been rotated away from the surgeon into a more supine orientation. When performing an open access technique, the Hasson cannula is commonly positioned at the umbilicus.
Figure 2 Peritoneal access and port placement. Access to the peri- toneum can be performed via either an open or closed technique. The favored position for placement of the Veress needle (Ethicon Endosurgery, Cincinnati, OH) with the closed access technique is at the umbilicus after the patient has been rotated away from the surgeon into a more supine orientation. When performing an open access technique, the Hasson cannula is commonly positioned at the umbilicus.
Figure 3 To aid with retraction of the liver during a right laparo- scopic nephrectomy, an additional 5-mm trocar can be placed at a subxiphoid position in the midline (B).
Figure 3 To aid with retraction of the liver during a right laparo- scopic nephrectomy, an additional 5-mm trocar can be placed at a subxiphoid position in the midline (B).
Figure 4 Colon mobilization. The line of Toldt is incised to enable medial mobilization of the colon from the underlying Gerota’s fascia. On the right, the line of Toldt is released to the level of the hepatic flexure. Because the righ kidney is frequently not completely covered by the ascending colon, the peritoneal incision is carried around the hepatic flexure between the liver and the transverse colon. In this manner, a swatch of peritoneum is often left adherent to the anterior and lateral aspect of the underlying Gerota’s fascia. In addition to full mobilization of the ascending colon, the anterior coronary and triangular ligaments are divided. Furthermore, remaining colorenal attachments mus' be divided to facilitate medial mobilization of the ascending colon and hepatic flexure. By performing a Koche! maneuver, the duodenum is mobilized medially on the right until the vena cava is easily visualized.
Figure 4 Colon mobilization. The line of Toldt is incised to enable medial mobilization of the colon from the underlying Gerota’s fascia. On the right, the line of Toldt is released to the level of the hepatic flexure. Because the righ kidney is frequently not completely covered by the ascending colon, the peritoneal incision is carried around the hepatic flexure between the liver and the transverse colon. In this manner, a swatch of peritoneum is often left adherent to the anterior and lateral aspect of the underlying Gerota’s fascia. In addition to full mobilization of the ascending colon, the anterior coronary and triangular ligaments are divided. Furthermore, remaining colorenal attachments mus' be divided to facilitate medial mobilization of the ascending colon and hepatic flexure. By performing a Koche! maneuver, the duodenum is mobilized medially on the right until the vena cava is easily visualized.
Figure 7, Control of renal hilum. The critical step of laparoscopic nephrectomy is hilar dissection and securing the renz artery and vein. Asa rule, the dissection should be performed as close to the great vessels as safely possible to minimiz the number of potential vessels to be controlled. In addition, one should avoid placement of excessive clips near th hilar structures because this can contribute to endovascular stapler malfunction when controlling the artery and vein The renal vessels should be dissected separately. A significant amount of lymphatic and adipose tissue typically need to be controlled as the renal vein and artery are dissected. After appropriate preparation of the artery and vein, the arter is most commonly divided before the vein.
Figure 7, Control of renal hilum. The critical step of laparoscopic nephrectomy is hilar dissection and securing the renz artery and vein. Asa rule, the dissection should be performed as close to the great vessels as safely possible to minimiz the number of potential vessels to be controlled. In addition, one should avoid placement of excessive clips near th hilar structures because this can contribute to endovascular stapler malfunction when controlling the artery and vein The renal vessels should be dissected separately. A significant amount of lymphatic and adipose tissue typically need to be controlled as the renal vein and artery are dissected. After appropriate preparation of the artery and vein, the arter is most commonly divided before the vein.
Figure 8 Circumferential mobilization of kidney within Gerota’s fascia. Complete mobilization of the specimen i dependent on the type of nephrectomy being performed. When performing a radical nephrectomy, the surgica specimen includes the ipsilateral adrenal gland. To accomplish this goal, the ipsilateral adrenal vein must first b dissected and divided between clips or with an endovascular stapler. On the left side, division of the adrenal vein cat often be circumvented if the renal vein is divided as close as possible to the vena cava. Division of the short right adrena vein can be more challenging during right radical nephrectomy. After control of the adrenal vein, superior and posterio attachments are divided with electrocautery. Small adrenal arteries are also encountered at this time and are likewis' controlled with electrocautery or clips. After release of the adrenal gland, remaining superior attachments are divide: sharply with electrosurgical endoshears. Inferior retraction of the specimen facilitates this dissection.
Figure 8 Circumferential mobilization of kidney within Gerota’s fascia. Complete mobilization of the specimen i dependent on the type of nephrectomy being performed. When performing a radical nephrectomy, the surgica specimen includes the ipsilateral adrenal gland. To accomplish this goal, the ipsilateral adrenal vein must first b dissected and divided between clips or with an endovascular stapler. On the left side, division of the adrenal vein cat often be circumvented if the renal vein is divided as close as possible to the vena cava. Division of the short right adrena vein can be more challenging during right radical nephrectomy. After control of the adrenal vein, superior and posterio attachments are divided with electrocautery. Small adrenal arteries are also encountered at this time and are likewis' controlled with electrocautery or clips. After release of the adrenal gland, remaining superior attachments are divide: sharply with electrosurgical endoshears. Inferior retraction of the specimen facilitates this dissection.
Figure 9 When a simple nephrectomy is performed, the next step after division of the renal hilum is development of a plane between the adrenal gland and kidney within Gerota’s fascia. Similar to the technique performed with radical nephrectomy, this step is facilitated by inferior retraction of the surgical specimen. After all superior attachments are released, the ureter is divided between clips. By using the proximal ureteral stump as a handle, the remaining posterior and lateral attachments of the specimen to the lateral sidewall can be identified and released via electrocautery.
Figure 9 When a simple nephrectomy is performed, the next step after division of the renal hilum is development of a plane between the adrenal gland and kidney within Gerota’s fascia. Similar to the technique performed with radical nephrectomy, this step is facilitated by inferior retraction of the surgical specimen. After all superior attachments are released, the ureter is divided between clips. By using the proximal ureteral stump as a handle, the remaining posterior and lateral attachments of the specimen to the lateral sidewall can be identified and released via electrocautery.
Figure 10 Specimen entrapment and removal. The surgical specimen can be removed intact or in pieces afte morcellation. Regardless of the technique, the specimen is first placed in an entrapment sack to facilitate removal. Tc perform intact extraction, the largest available self-opening bag instrument is favored (Endocatch II, US Surgical Norwalk, CT). The surgical specimen is held with grasping forceps in a position on top of the liver or spleen respectively. The extraction bag device is then brought through the midclavicular line trocar site and deployed. Witk the grasping forceps, the specimen is then manipulated into the bag. The specimen can then be removed by extendins the incision at the midclavicular trocar site and employing a muscle-splitting extraction technique. Alternatively, the specimen can be removed by extending the periumbilical incision and removing the specimen through the midline.
Figure 10 Specimen entrapment and removal. The surgical specimen can be removed intact or in pieces afte morcellation. Regardless of the technique, the specimen is first placed in an entrapment sack to facilitate removal. Tc perform intact extraction, the largest available self-opening bag instrument is favored (Endocatch II, US Surgical Norwalk, CT). The surgical specimen is held with grasping forceps in a position on top of the liver or spleen respectively. The extraction bag device is then brought through the midclavicular line trocar site and deployed. Witk the grasping forceps, the specimen is then manipulated into the bag. The specimen can then be removed by extendins the incision at the midclavicular trocar site and employing a muscle-splitting extraction technique. Alternatively, the specimen can be removed by extending the periumbilical incision and removing the specimen through the midline.
Figure 3 The medial approach to a laparoscopic sigmoid colectomy requires traction of the sigmoid colon toward the anterior abd as the initia ominal wall and incision of the mesentery behind the superior hemorrhoidal artery over the sacral promontory maneuver. The avascular areolar tissue plane behind the superior hemorrhoidal artery anterior to the sacral promontory is then developed laterally and diagonally over the pelvic brim, protecting the iliac artery and vein and the ureter during the dissection. The majority of dissection is performed in a spreading technique, pushing anteriorly toward the anterior abd plane along ominal wall to avoid damage to the posterior structures. If the surgeon maintains the avascular areolar tissue this area, the ureter and vessels can be easily identified and protected and the window established. The surgeon must remember that the patient is in Trendelenburg position and air-planed with the right side down so that dissection is in a diagonal p ane up and away from the midline. As the incision is followed cephalad over the anterior surface of the aorta, the first structure in a vertical direction from the retroperitoneum is the inferior mesenteric artery. The artery can be divided at its origin in a patient with neoplastic disease. This area contains a nerve plexus of sympathetic nerves. Damage to these nerves results in retrograde ejaculation in the male. For this reason, close ligation of the inferior mesenteric artery should only be used in malignant disease when it is absolutely necessary to achieve an extremely high ligation of the vessel. In diverticulitis, the superior hemorrhoidal artery can be ligated at its origin at the bifurcation of the inferior mesenteric artery (away from the aorta) to give an adequate vascular resection. It is my preference to divide the superior hemorrhoidal/inferior mesenteric vessels with the 0.75-mm staple height vascular stapler load. Lab, Norwalk, CT). Care must be taken with each of these devices, and there are potential advantages and disadvan- tages to each one. The majority of a laparoscopic sigmoid colectomies can be performed with cautery scissors. The management of the vessels at their origin can be accom- plished by suture ligation, ligaclips, radiofrequency energy, or vascular-sized staples of an endocutting stapler. The cor- rect staple height (0.75 mm) is necessary for controlling the smaller inferior mesenteric artery and vein and superior hem- orrhoidal vessels. If any of these fail, the surgeon must have an alternate method or rescue method immediately available. A pretied looped suture is helpful once the bleeding vascular stump has been grasped and controlled. A hand-assisted ap- proach adds the advantage of enabling the use of finger pres- sure to achieve immediate temporary control to reduce blood loss while preparing for permanent ligation of the vessel. Instrumentation is also a personalized issue. A 10-mm nontraumatic grasper such as an Endo-Babcock (Ethicon En- dosurgery, Cincinnati, OH) and a 5-mm Hunter or Wavey grasper (Storz, Germany) are very useful. Energy sources include electrocautery scissors or hook cautery, ultrasound harmonic scalpel, or radiofrequency shears (Ligasure; Valley-
Figure 3 The medial approach to a laparoscopic sigmoid colectomy requires traction of the sigmoid colon toward the anterior abd as the initia ominal wall and incision of the mesentery behind the superior hemorrhoidal artery over the sacral promontory maneuver. The avascular areolar tissue plane behind the superior hemorrhoidal artery anterior to the sacral promontory is then developed laterally and diagonally over the pelvic brim, protecting the iliac artery and vein and the ureter during the dissection. The majority of dissection is performed in a spreading technique, pushing anteriorly toward the anterior abd plane along ominal wall to avoid damage to the posterior structures. If the surgeon maintains the avascular areolar tissue this area, the ureter and vessels can be easily identified and protected and the window established. The surgeon must remember that the patient is in Trendelenburg position and air-planed with the right side down so that dissection is in a diagonal p ane up and away from the midline. As the incision is followed cephalad over the anterior surface of the aorta, the first structure in a vertical direction from the retroperitoneum is the inferior mesenteric artery. The artery can be divided at its origin in a patient with neoplastic disease. This area contains a nerve plexus of sympathetic nerves. Damage to these nerves results in retrograde ejaculation in the male. For this reason, close ligation of the inferior mesenteric artery should only be used in malignant disease when it is absolutely necessary to achieve an extremely high ligation of the vessel. In diverticulitis, the superior hemorrhoidal artery can be ligated at its origin at the bifurcation of the inferior mesenteric artery (away from the aorta) to give an adequate vascular resection. It is my preference to divide the superior hemorrhoidal/inferior mesenteric vessels with the 0.75-mm staple height vascular stapler load. Lab, Norwalk, CT). Care must be taken with each of these devices, and there are potential advantages and disadvan- tages to each one. The majority of a laparoscopic sigmoid colectomies can be performed with cautery scissors. The management of the vessels at their origin can be accom- plished by suture ligation, ligaclips, radiofrequency energy, or vascular-sized staples of an endocutting stapler. The cor- rect staple height (0.75 mm) is necessary for controlling the smaller inferior mesenteric artery and vein and superior hem- orrhoidal vessels. If any of these fail, the surgeon must have an alternate method or rescue method immediately available. A pretied looped suture is helpful once the bleeding vascular stump has been grasped and controlled. A hand-assisted ap- proach adds the advantage of enabling the use of finger pres- sure to achieve immediate temporary control to reduce blood loss while preparing for permanent ligation of the vessel. Instrumentation is also a personalized issue. A 10-mm nontraumatic grasper such as an Endo-Babcock (Ethicon En- dosurgery, Cincinnati, OH) and a 5-mm Hunter or Wavey grasper (Storz, Germany) are very useful. Energy sources include electrocautery scissors or hook cautery, ultrasound harmonic scalpel, or radiofrequency shears (Ligasure; Valley-
Figure 4 Division of the inferior mesenteric artery allows the base of the entire mesentery of the left colon to be released anteriorly toward the anterior abdominal wall. Incising the remaining peritoneal surface of the mesentery to the level of the duodenum opens the window between the inferior mesenteric artery and vein. The avascular areolar tissue can be gently pushed aside to expose the ureter and gonadal vessels in the retroperitoneum along the left gutter. A sweeping and lifting motion is adequate for this dissection. The left hand of the operating surgeon on a 10-mm grasper through the right upper quadrant trocar lifting the left colonic mesentery allows the surgeon’s right hand to use the cautery scissors to sweep away the areolar tissue and cauterize the few thin bleeding vessels. The duodenal-jejunal junction at the Ligament of Trietz is subsequently encountered. The small bowel must be retracted from the base of the mesentery to fully expose this junction. The peritoneum along the curve of the junction can be incised to reveal the inferior mesenteric vein in the thickening of the base of the left colonic mesentery as it dives into the splenic vein under the pancreas. The vessel can be encircled and divided at the inferior border of the pancreas with staples, clips, or even radiofrequency energy. This opens the entire left upper quadrant to dissection through a retroperitoneal or retromes- enteric approach. The areolar tissue plane can be followed around the tail of the pancreas over the anterior surface of the kidney up to the splenic flexure. At this point, a wide open space has been created from the pelvic brim all the way to the tail of the pancreas.
Figure 4 Division of the inferior mesenteric artery allows the base of the entire mesentery of the left colon to be released anteriorly toward the anterior abdominal wall. Incising the remaining peritoneal surface of the mesentery to the level of the duodenum opens the window between the inferior mesenteric artery and vein. The avascular areolar tissue can be gently pushed aside to expose the ureter and gonadal vessels in the retroperitoneum along the left gutter. A sweeping and lifting motion is adequate for this dissection. The left hand of the operating surgeon on a 10-mm grasper through the right upper quadrant trocar lifting the left colonic mesentery allows the surgeon’s right hand to use the cautery scissors to sweep away the areolar tissue and cauterize the few thin bleeding vessels. The duodenal-jejunal junction at the Ligament of Trietz is subsequently encountered. The small bowel must be retracted from the base of the mesentery to fully expose this junction. The peritoneum along the curve of the junction can be incised to reveal the inferior mesenteric vein in the thickening of the base of the left colonic mesentery as it dives into the splenic vein under the pancreas. The vessel can be encircled and divided at the inferior border of the pancreas with staples, clips, or even radiofrequency energy. This opens the entire left upper quadrant to dissection through a retroperitoneal or retromes- enteric approach. The areolar tissue plane can be followed around the tail of the pancreas over the anterior surface of the kidney up to the splenic flexure. At this point, a wide open space has been created from the pelvic brim all the way to the tail of the pancreas.
Figure 5 The next step is to release the left colon from its lateral attachment. The left colon and sigmoid colon are retracted medially and an incision is created along the left side wall of the abdomen to expose the underlying previously developed space all the way up to the splenic flexure. Splenic flexure mobilization is the next step and is best accomplished with the patient in reverse Trendelenburg position. The omentum is freed from the anterior surface of the transverse colon around the splenic flexure and toward the mid portion of the transverse colon. To accomplish this, the omentum is lifted toward the abdominal wall by the assistant with graspers through the right trocar sites in the same way that a matador holds his red cape ina bullfight. The surgeon stands between the legs and pulls the colon down with a grapser or hand through the suprapubic site and uses scissors through the left lower quadrant trocar. This dissection ultimately allows entry into the lesser sac cephalad to the mesentery of the colon and behind the stomach wall. The mesenteric attachments of the splenic flexure to the tail of the pancreas and the suspensory attachments to the spleen and the areolar tissue on the anterior surface of the left kidney are the final attachments, which must be divided during this dissection. Once these have been eliminated, the entire left colon falls down to the pelvic brim with no tension. The divided inferior mesenteric vein is at the base of the mesentery of the left colon and allows the proximal left colon and splenic flexure to reach the pelvic brim in most circumstances.
Figure 5 The next step is to release the left colon from its lateral attachment. The left colon and sigmoid colon are retracted medially and an incision is created along the left side wall of the abdomen to expose the underlying previously developed space all the way up to the splenic flexure. Splenic flexure mobilization is the next step and is best accomplished with the patient in reverse Trendelenburg position. The omentum is freed from the anterior surface of the transverse colon around the splenic flexure and toward the mid portion of the transverse colon. To accomplish this, the omentum is lifted toward the abdominal wall by the assistant with graspers through the right trocar sites in the same way that a matador holds his red cape ina bullfight. The surgeon stands between the legs and pulls the colon down with a grapser or hand through the suprapubic site and uses scissors through the left lower quadrant trocar. This dissection ultimately allows entry into the lesser sac cephalad to the mesentery of the colon and behind the stomach wall. The mesenteric attachments of the splenic flexure to the tail of the pancreas and the suspensory attachments to the spleen and the areolar tissue on the anterior surface of the left kidney are the final attachments, which must be divided during this dissection. Once these have been eliminated, the entire left colon falls down to the pelvic brim with no tension. The divided inferior mesenteric vein is at the base of the mesentery of the left colon and allows the proximal left colon and splenic flexure to reach the pelvic brim in most circumstances.
Figure 6 The patient is then returned to both a Trendelenburg and midline position. The dissection is carried into the pelvis over the sacral promontory to allow dissection behind the fascia propria of the rectum, maintaining the envelope of the mesentery of the rectum as far below the sacral promontory as is necessary to reach soft, pliable, normal rectum. This is especially important in the management of diverticular disease because all of the sigmoid colon must be resected to avoid recurrence. Division of the posterior mesorectum can be accomplished with energy sources such as Ligasure or harmonic scalpel with ultrasound. A double firing of the endo-GIA vascular-loaded staple can also accomplish division of the posterior mesorectum without bleeding. The rectum should be transected distal to the rectosigmoid junction with a transverse staple line.
Figure 6 The patient is then returned to both a Trendelenburg and midline position. The dissection is carried into the pelvis over the sacral promontory to allow dissection behind the fascia propria of the rectum, maintaining the envelope of the mesentery of the rectum as far below the sacral promontory as is necessary to reach soft, pliable, normal rectum. This is especially important in the management of diverticular disease because all of the sigmoid colon must be resected to avoid recurrence. Division of the posterior mesorectum can be accomplished with energy sources such as Ligasure or harmonic scalpel with ultrasound. A double firing of the endo-GIA vascular-loaded staple can also accomplish division of the posterior mesorectum without bleeding. The rectum should be transected distal to the rectosigmoid junction with a transverse staple line.
Figure 7 The lateral approach to sigmoid colectomy requires, once again, positioning the patient in a steep Trendelen- burg position and air-planed to the right. The dissection begins at the pelvic brim on the left with the surgeon standing between the legs or to the patient’s right. An incision is made along the congenital adhesion attachments of the sigmoid colon to the pelvic brim. Dissection occurs in the avascular plane and extends medially to free the mesentery and colon from the retroperitoneal structures. The colon is mobilized toward the midline, exposing the gonadal vessels initially and the ureter as it crosses over the iliac artery at the bifurcation between the external and internal iliac arteries. The avascular plane can be developed all the way up to the splenic flexure, freeing the mesentery of the left colon toward the midline off of the anterior surface of the kidney and away from the spleen. This lateral to medial mobilization is the typical way most surgeons are taught to do a left colectomy and, therefore, follows many of the same anatomic landmarks and is more familiar to the majority of surgeons. Visualization of the ureter is a critical step and is a point at which decision for conversion to an open procedure should be entertained. Failure to confidently trace the ureter in its entire course should prompt conversion to an open procedure.
Figure 7 The lateral approach to sigmoid colectomy requires, once again, positioning the patient in a steep Trendelen- burg position and air-planed to the right. The dissection begins at the pelvic brim on the left with the surgeon standing between the legs or to the patient’s right. An incision is made along the congenital adhesion attachments of the sigmoid colon to the pelvic brim. Dissection occurs in the avascular plane and extends medially to free the mesentery and colon from the retroperitoneal structures. The colon is mobilized toward the midline, exposing the gonadal vessels initially and the ureter as it crosses over the iliac artery at the bifurcation between the external and internal iliac arteries. The avascular plane can be developed all the way up to the splenic flexure, freeing the mesentery of the left colon toward the midline off of the anterior surface of the kidney and away from the spleen. This lateral to medial mobilization is the typical way most surgeons are taught to do a left colectomy and, therefore, follows many of the same anatomic landmarks and is more familiar to the majority of surgeons. Visualization of the ureter is a critical step and is a point at which decision for conversion to an open procedure should be entertained. Failure to confidently trace the ureter in its entire course should prompt conversion to an open procedure.
Figure 8 Once the distal portion of the splenic flexure is reached, the patient is positioned in reverse Trendelenburg. Thi surgeon moves to the between-the-legs position. With a left hand on the 10-mm trocar through the suprapubic por and a right hand on a 5-mm scissors through the left flank port, the splenic flexure can be mobilized. The assistant o1 the right side lifts the omentum from the anterior surface of the transverse colon and splenic flexure to allow th operating surgeon to mobilize the colon from the undersurface of the omentum and enter the lesser sac. The fina attachments of the splenic flexure to the tail of the spleen, the anterior surface of the kidney, and the tail of the pancrea are divided with electrocautery and allow the entire colon to move to a midline position. The surgeon should avoic lifting the tail of the pancreas by overextending the posterior dissection. Overly aggressive traction on the omentum anc splenic flexure can occasionally result in splenic capsular tears. Care is needed to avoid injury of the inferior mesenteri vein from a lateral aspect as the dissection progresses medially along the undersurface of the tail of the pancreas.
Figure 8 Once the distal portion of the splenic flexure is reached, the patient is positioned in reverse Trendelenburg. Thi surgeon moves to the between-the-legs position. With a left hand on the 10-mm trocar through the suprapubic por and a right hand on a 5-mm scissors through the left flank port, the splenic flexure can be mobilized. The assistant o1 the right side lifts the omentum from the anterior surface of the transverse colon and splenic flexure to allow th operating surgeon to mobilize the colon from the undersurface of the omentum and enter the lesser sac. The fina attachments of the splenic flexure to the tail of the spleen, the anterior surface of the kidney, and the tail of the pancrea are divided with electrocautery and allow the entire colon to move to a midline position. The surgeon should avoic lifting the tail of the pancreas by overextending the posterior dissection. Overly aggressive traction on the omentum anc splenic flexure can occasionally result in splenic capsular tears. Care is needed to avoid injury of the inferior mesenteri vein from a lateral aspect as the dissection progresses medially along the undersurface of the tail of the pancreas.
Figure 9 The final maneuver is to divide the blood vessels. The patient is returned to the Trendelenburg position. Ar incision is made along the covering peritoneum at the base of the mesentery of the entire left colon, exposing the inferiot mesenteric artery in the midline and the inferior mesenteric vein just to the left of the Ligament of Trietz and the duodeno-jejunal junction. The artery and vein are ligated via the abovementioned techniques with clips, radiofre- quency, ultrasound energy, or stapled suture line. Once again, complete mobility of the splenic flexure is paramount to reach the pelvis. The rectal dissection is similar to the medial approach in that the posterior mesorectum can be divided through the laparoscopic approach with harmonic scalpel, radiofrequency, or stapling. It can be divided through the suprapubic extraction site according to standard suture ligation techniques.
Figure 9 The final maneuver is to divide the blood vessels. The patient is returned to the Trendelenburg position. Ar incision is made along the covering peritoneum at the base of the mesentery of the entire left colon, exposing the inferiot mesenteric artery in the midline and the inferior mesenteric vein just to the left of the Ligament of Trietz and the duodeno-jejunal junction. The artery and vein are ligated via the abovementioned techniques with clips, radiofre- quency, ultrasound energy, or stapled suture line. Once again, complete mobility of the splenic flexure is paramount to reach the pelvis. The rectal dissection is similar to the medial approach in that the posterior mesorectum can be divided through the laparoscopic approach with harmonic scalpel, radiofrequency, or stapling. It can be divided through the suprapubic extraction site according to standard suture ligation techniques.
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