Equipment
The operating theatre must be large enough to accommodate the equipment and personnel needed for the operation. Essential equipment includes the basics for any surgical case—namely, a ventilator and other pertinent anesthesia equipment, an operating table, a back-table instrument setup, and a suction and irrigation system. Essential personnel in the operating room (OR) include a surgeon (with or without an assistant), an anesthesiologist or nurse anesthetist, and circulating and scrub nurses.
Laparoscopic surgery requires additional specialized equipment. A video camera and laparoscope are necessary to visualize the intracorporeal environment. The laparoscope is connected to one or more monitors that project the intra-abdominal image in a location that is within the operating staff’s line of sight. The operating surgeon is located on the patient's right for most of the case; therefore, a monitor should be placed at the left foot of the table and at the left head of the table.
Laparoscopes come in various sizes and optical angular views to accommodate different vantage points. In a laparoscopic Hartmann procedure, a 0º scope is commonly used for most of the case, but a 30º or 45º laparoscope may prove beneficial at certain points. The scope angles employed and the sequence in which different angles are used are functions of the surgeon’s technique and level of comfort with certain instruments. A light source is attached to the laparoscope illumination for the intra-abdominal cavity.
A CO2 insufflator provides the level of pneumoperitoneum required to create the appropriate working space. This machine also monitors the intra-abdominal and flow pressures. Normal insufflation pressures may range from 12 to 15 mm Hg.
Laparoscopic instruments are designed with the functional portion of the instrument attached to a shaft that can range from roughly 20 to 45 cm in length; this design allows intracorporeal maneuvers to be carried out in restricted spaces. Each surgical instrument used in an open surgical case has its laparoscopic counterpart (eg, scissors, graspers, needle holders, and electrocautery).
Trocars/cannulas are needed to act as working ports for the laparoscopic instruments. They come in various diameters and lengths, which provide the flexibility required to accommodate the patient's body habitus and the desired task.
In a laparoscopic Hartmann procedure, larger (10-12 mm) ports are needed for passing larger equipment (eg, linear staplers or ultrasonic dissectors) into the field; these instruments are used for resection of the diseased colon segment and ligation of its vasculature in the mesocolon. Smaller (5 mm) ports are sufficient for sites that host only graspers, dissectors, or scissors. Depending on the number of trocar sites available, laparoscopic retractors can be used to assist in exposure during the dissection.
A laparoscopic suction/irrigator, which can be easily connected to the stationary irrigation and suction system in the OR, is needed to achieve appropriate lavage of the abdomen during the operation.
Patient Preparation
Anesthesia
As with all intra-abdominal laparoscopic procedures, general anesthesia is required. Intraoperative monitoring with arterial catheterization is often beneficial. Drainage of the urinary bladder via a catheter helps the surgeon visualize the pelvis during mobilization and facilitates intraoperative assessment of volume status and end-organ perfusion.
Application of a long-acting local anesthetic (eg, bupivacaine) to the port sites before incision helps control postoperative pain. Additional modalities often used in open procedures, such as incisional continuous local anesthesia delivery devices and epidural infusions, are frequently unnecessary in laparoscopic colon surgery.
Positioning
The low lithotomy position, with the upper extremities tucked securely at the patient's side and the lower extremities suspended via stirrups, is the most versatile position for laparoscopic colon surgery. Because the operating surgeon will be on the patient's right side, monitors should be placed at the left foot of the bed and the left head of the bed.
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Illustrated view of intraperitoneal space during mobilization of colon.
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Images demonstrate significant difference in incision size between open and laparoscopic approaches to Hartmann procedure.
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Orientation of laparoscopic instruments within intraperitoneal cavity.
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Illustration of portion of colon that would be removed with diseased or nonviable bowel near splenic flexure.
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Schematic representation of colon and rectum after Hartmann procedure. Distal colon terminates as colostomy and remains in discontinuity with rectal stump.
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Illustration of segment of distal colon that would be removed in setting of low sigmoid disease or perforation.
