140

surgicol Procedures lncluding Mlnimol Access Procedures

Gostroiniestlnol Surgery

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lateral attachments are dissected. Care is taken to avoid iniurv to the ureter and duodenum as the disseciio" it coniinued about the terminal ileum, hepatic ff"*or", and proximal transverse colon' livilion ofthe
mesenteric vlssel is then accomplished. Employing ap-

p"optiat" stapling devices, the segment pf colon is resected and the specimen removed via a large port ut-*i"iftp.totomy incision in the right upper quad-

suture or automatic pursestring suture device. The stapler is inserted transanally, and its trocar is extended perforating the stapled end of the rectal segment. Employing a modified anvil grasper to stabilize

laparatomy incision. The staple line placed at the time of division of the colon is,excised and the separated anvil of the stapler secured by hand-sewn pursestring

rant. The anastomosis can then be performed intracorpo""tlb or extracorporeally by.delivering the bowel ;hilgi the minilapiratomy incision' The mesenteric a"?".t'it repaired, and after hemostasis is assured, the

the proximal segment, end-to-end anastomosis is completed in the standard fashion. The tissue rings are inqrected and the anastomosis tested employing a sigmoidoscope or bulb syringe. After hemostasis is

e"""-"p""itoneum is released-. The trocar sites and -minilaparatomy sites are closed. '
o"*La.r"" is similar to a right hemicolectomy' Pneu-*op"til""""m is established, and the ports are plag.e-d o" ift" f"it side (umbilical, left upper quailrant mid.iu"i."tu" line, left para urnbilical, left midclavicullft suprapubic)' lhe table is adjusted i;; iind; ""; ltt. left side up a.ta hter placed in rev,erse Tren*itft

t;ft-H.;icolectomy or Sigmoid

R-esection' This

The left colon is mobilized (avoiding mjuy sp?rmatic or bvarian v,essels, ureter, stomach' ;;;h" r"Jtpt""tt). After dissection has been completed, rei".il"ii ani anastomosis are performed as in right h;;iA;;;"-y. If the distal si$moid colon is included(to follow)' i" lf* '-i;; ""*"tidn, see tow Anterior Resection positioned G;;rior Resection. The patient is

J"i""f"tg.

Ilartmann's Procedure and Reversal of Hartnranrr'p Procedure. The conduction of the Hartnann's procedure is identical to low anterior resection as described above with the exception that the distal rctal segment is closed or on occasion is brought out mto the abdominal wall as a mircous fistula. The prox:rral segment is brought out as an end colostomy. To rererse this proiedure, that is, to restore continuity, the olostomy (proximal colon segment) is anastomosed to tre rectal remnant. The pelvis is inspected and the &ed rectal remna4t identified. If visualization is inedequate, adherent viscera and adhesions must be dis*cted to expose the proximal portion of the rectal segnent. To facilitate identification of the rectal segment, r blunt instrument, large-bore catheter, or sigmoidonope is inserted transanally to "tent" the apex of the agment. When this dissection is complete, the previnsly established colostomy stoma is dissected free ftom the abdominal wall with laparoscopic assistance

assured, the pndumoperitoneum is released and the acess p<irts closed.

in

the anterior abdomen and perineum' Pneumopentoneum is established. Patient is placed in neverse

modified lithotomy possibly providing access to

i;;J;l""burg. Ports are similar to that of left hemiTh"e sigmoid colon and rectum are mobi' "-"1""i.-v ct"e to avoid injury to. gonadal vesti*d, t.iittg

n"etet.]and internal female genitalia' The mesen""t.. .lt".t""es are divided and the specimen resected t"tii ."J a"fi"u"ed through a larg-e-bore port, minilap"*to*y incision, or transanally via.the'distal rec' lal rernnant. Anastomosis is performed employing-an i"i";|"*i""t end-to-end stapler inserted transanallp Til;;;;$;osis is begun b! extracting the proximal bowil via a large-bore post or minirilft"

ifneessary. Any questionably viable coLn is excised. !fu anvil of the intraluminal stapler is placed within &is proximal segment secured by a pursestring suture. !ftis segment with the anvil is replaced intraperi-l"eedrgctal segment. Cire is taken to

....rr" that no tissues or structures overlie the site of the ,lastomqsis. The anastomosis is completed as in a low fuerior resection above.
&aneous

hally. The assistant surgeon then passes the trocar J the intraluminal stapler through the apex of the

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""sected