From the Guidelines
Laparoscopic sigmoidectomy involves several key surgical steps, including patient positioning, pneumoperitoneum establishment, port placement, medial-to-lateral dissection, and anastomosis creation, as described in the most recent and highest quality studies, although the provided evidence does not directly describe these steps 1. The procedure begins with patient positioning in modified lithotomy with arms tucked and appropriate padding.
- The patient is placed in a modified lithotomy position to allow for easy access to the pelvic area.
- The arms are tucked and padded to prevent injury during the procedure. After pneumoperitoneum is established using a Veress needle or open Hasson technique, typically five ports are placed:
- A camera port at the umbilicus to allow for visualization of the surgical site.
- Two working ports in the right lower quadrant to allow for manipulation of instruments.
- Additional ports in the left upper quadrant and suprapubic region to allow for retraction and dissection. The surgeon then performs medial-to-lateral dissection,
- Identifying and preserving the left ureter and gonadal vessels to prevent injury.
- Mobilizing the sigmoid colon along the white line of Toldt to allow for resection. The inferior mesenteric artery is identified, clipped or sealed with energy devices, and divided at its origin or distal to the left colic branch depending on the pathology.
- The inferior mesenteric vein is similarly divided to allow for complete mobilization of the sigmoid colon. After complete mobilization of the sigmoid colon and upper rectum,
- The proximal and distal resection margins are determined to ensure complete removal of the diseased segment.
- The bowel is divided using endoscopic staplers to allow for a secure and efficient division. The specimen is extracted through a small Pfannenstiel incision or extended port site using a wound protector.
- An end-to-end colorectal anastomosis is created using a circular stapler to restore intestinal continuity.
- The anastomosis is tested for integrity with air insufflation while the pelvis is filled with saline to ensure a secure and leak-proof connection. The procedure concludes with irrigation, hemostasis check, and closure of all port sites.
- This minimally invasive approach offers advantages of smaller incisions, less postoperative pain, and faster recovery compared to open surgery, while maintaining oncologic principles when performed for cancer, although the provided evidence does not directly support these advantages 1.
From the Research
Surgical Steps for Laparoscopic Sigmoidectomy
The surgical steps for laparoscopic sigmoidectomy can be outlined as follows:
- Open insertion of the umbilical port 2
- Placement of three operating ports 2
- Dissection/division of the vascular pedicle after identification of the left ureter 2
- Mobilization of the sigmoid and descending colon 2, 3, 4
- Rectal mobilization/division 2
- Exteriorization of the specimen 2
- Circular stapled anastomosis 2
- Intracorporeal anastomosis using a hemidouble stapling technique 5
- Transanal extraction of the specimen 5
Variations in Technique
There are different techniques used in laparoscopic sigmoidectomy, including:
- Straight laparoscopic approach 6
- Hand-assisted approach 6
- Laparoscopic-assisted approach 6
- Single-port laparoscopic approach 3
- Totally laparoscopic sigmoid colectomy with intracorporeal anastomosis 5
Considerations for Specific Patient Populations
For patients with situs inversus totalis, preoperative assessment and preparation are crucial, including: