Patient Education and Consent
Patient instructions
Before surgery, the patient undergoes mechanical bowel preparation under the surgeon’s care, despite the controversy as to whether mechanical cleansing of the intestine is beneficial, necessary, or potentially detrimental.
Elements of informed consent
A thorough discussion of all risks of surgery should at least be mentioned to the patient and recorded on the consent form. The possible need for a diverting stoma should always be mentioned, as should the possible need for open surgery. Thorough informed consents pose no threat to the surgeon or patient; however, incomplete consents foster a breakdown in communication and possible legal problems for the surgeon.
Equipment
The choice of instruments is largely in response to the particular laparoscopic technique being used.
Although numerous laparoscopic graspers and retractors are available, some of them purportedly atraumatic, it is necessary to remember that unlike open manual bowel retractors, laparoscopic graspers focus their point of contact over a small area of the intestinal wall. Therefore, all manipulation of the small or large intestine during laparoscopy creates a higher risk of bowel injury and should be avoided as much as possible by using patient positioning and techniques of dissection that minimize laparoscopic grasping of the bowel wall.
The author uses laparoscopic Babcock graspers, both because they are less expensive than other, more elaborate graspers that are no less traumatic and because they are readily available in any operating room (OR). With any laparoscopic grasper, the surgeon should fill the jaw of the grasper with the tissue to be grasped rather than pinch the bowel; the former displaces the force applied by the grasper jaw over a larger surface area and thus prevents maximal force of closure over a smaller segment of tissue, which is then more likely to be lacerated or crushed.
Energy devices have evolved to use advanced bipolar technology that reliably transects and seals vessels up to 7 mm in diameter, which includes all of the named major nutrient vessels encountered during a left colectomy. The use of these energy devices provides the advantage of less collateral thermal spread as compared with monopolar cautery. These devices can also perform double duty; they can dissect tissue without necessarily grasping tissue in their jaws, thus replacing other laparoscopic dissectors.
Although endoscopic staplers can also be used to ligate major vessels, the use of energy devices not only is more cost-effective but also prevents the extra time and risk of organ injury from additional instrument exchanges that are required to alternate between dissecting tools and staplers.
Laparoscopes come in rigid and flexible forms. With rigid laparoscopes, an angled view is almost a requirement for a procedure such as a left colectomy, in which the dissection involves the entire left abdomen at a minimum rather than a fixed local point. Flexible laparoscopes offer high-definition images with excellent lighting through a trocar as small as 5 mm, and they offer the advantage of a camera tip that can be flexed 90° in four directions.
Especially for single-site surgery, the flexible laparoscope is quite necessary, allowing the camera shaft to be moved away from the operating surgeon while keeping the region of interest centered on the viewing screen. These cameras impose a learning curve on the camera operator, as seen in the example of how rotating the camera results in rotation of the image on the screen. Although this is often a greater than expected challenge for younger surgical residents, it is not an insurmountable one.
Patient Preparation
Anesthesia
Patients should be sent to the anesthesia preoperative clinic, if one is available, to allow a thorough preoperative assessment focusing on tolerance of anesthesia. This also ensures that different views regarding the patient’s ability to tolerate surgery do not arise in the preoperative area, after the patient has already consumed the bowel preparation. In addition, it theoretically may reduce delays in the OR if, for example, the patient is found to be difficult to intubate. Some of these factors can be identified and planned for before the date of the procedure.
Positioning
The patient should be placed in a modified lithotomy position (see the image below). The obvious advantage of this positioning is that it allows access to the anorectum for deployment of an end-to-end anastomosis (EEA) stapler. However, another advantage is that this positioning affords the surgeon or an assistant the option of standing between the patient’s legs, which can be helpful during mobilization of the splenic flexure. For the latter reason, the author uses a modified lithotomy position for all laparoscopic operations on the small or large intestine.
Having the patient firmly secured to the operating room table allows maximal Trendelenburg or reverse Trendelenburg positioning, as well as maximal left and right decubitus tilt. Especially in the absence of intra-abdominal adhesions, these extremes of body positioning improve exposure and limit the degree of tissue handling by the surgeon, serving as additional protection against iatrogenic organ injuries.
To prevent patient movement on the OR table, the author uses a beanbag to which the patient is secured (see the first image below). Silk tape (2 in. [5 cm]) is also used to secure the patient to the bean bag and the OR table. To prevent soft-tissue injury, padding is also applied over the olecranon processes and the dorsal aspects of the hands (see the second image below).
Laparoscopic left colectomy. Padding for upper extremities and shoulders used during patient positioning.
-
Laparoscopic left colectomy. Mobilization of descending colon.
-
Laparoscopic left colectomy. Approach to medial-to-lateral mobilization of sigmoid colon, with ligation of inferior mesenteric artery and identification of left ureter.
-
Laparoscopic left colectomy. Transection of descending colon with endostapler.
-
Laparoscopic left colectomy. Endostapler transection of rectum.
-
Laparoscopic left colectomy. Padding for upper extremities and shoulders used during patient positioning.
-
Laparoscopic left colectomy. Table setup in operating room.
-
Laparoscopic left colectomy. Final table and patient positioning.
-
Laparoscopic left colectomy. Mobilization of splenic flexure: part 1.
-
Laparoscopic left colectomy. Mobilization of splenic flexure: part 2.
-
Laparoscopic left colectomy. Mobilization of splenic flexure: part 3.
-
Laparoscopic left colectomy. Mobilization of splenic flexure: part 4.
