Laparoscopic High Anterior Resection
- One (occasionally two) 5mm, two 12mm disposable trocars
- Two 5mm fenestrated Johan grasping forceps
- 5mm Harmonic scalpel
- 5mm needle holder
- Medium (purple) Haem-o-Loc Clips
- 12mm linear stapler eg ATG 45 (Green cartridge)
- Electric operating table
We use gravity as much as possible (200steep head down and slight right lateral tilt). A warming blanket and catheterisation (remove at end of procedure) are essential. There should be minimal hip flexion. We always use a 300 scope.
In the case of a female patient with a uterus in situ, insert a Sprakman retractor after having dilated the cervix. This is the best way to elevate the uterus out of the pelvis.
Site the laparoscopy port approx. 3cm above/lateral to the umbilicus in a "short" abdomen (short distance from umbilicus to the symphysis pubis) or a mass is palpable or as in most cases, through the umbilical tube (as shown). We use 5mm and 12mm RIF ports for the vast majority of our surgery.
If you go for 4 12mm operating ports and two 5mm exposure ports you need very good assistants! Inexperienced assistants can't manage operating a 300 scope as well as holding an instrument.
Use a medial or lateral approach as findings dictate – if there is very little space/too much small bowel/very large tumour/sigmoid diverticulitis we would always start the dissection laterally. If the tumour is fixed/tethered start medially. DO NOT GET FIXED ON ONE APPROACH as it will limit what you can do. Sometimes (in complicated diverticulitis) you will need to approach in a caudal to cranial mannner after mobilising the TME plane and transecting the bowel..
The first landmark in dissection of the IMA is the sacral prominentry; opening the peritoneum here medial to the left ureter correctly exposes the neuro/vascular elements of the mesentery. Remember, it is easy to dissect behind the hypogastric nerves.
When dissecting behind the sigmoid mesentery, watch out for the gonadal vein as much as the ureter. If you make a hole in it reduce the venous pressure with steep head down tilt and clip it. Adapt the level of transection of the IMA (preserving the LCA in some cases) to the individual anatomical circumstance and quality of colonic vascularisation. In the majority of cases we would advocate the use of a 3 Haem-o-Lok clips for the IMA (leaving two on the IMA base).
Retract the IMV forward and to the left dividing attachments to the DJ flexure. Identify the origin and the inferior border of the pancreas. Mobilise the mesocolon off the retroperitoneum. Don't stray in and out of Gerota's fascia; keep in front of it! Once the colon has been mobilised off the kidney, clip and ligate the IMV origin (3 clips again). When access is poor e.g., dilated small bowel, large bowel obstruction use a vascular stapler for control of these two vessels.
Put the patient in reverse -Trendelenburg position whilst maintaining a right-side-down tilt to bring the stomach and transverse colon into view.
The medial approach to the splenic flexure uses an initial dissection, after division of the IM vein through the transverse mesocolon to allow entery into the lesser sac. The next step is to divide the posterior attachments of the transverse mesocolon at the lower border of the pancreas. Potential dangers include; dissecting behind the pancreas (don't follow the IMV too far and make the hole through the TV mesocolon early). Do not mistake the splenic vein for the IMV and don't stray into the mesentery and damage the marginal vessels. It is rare to damage the spleen; you only really see it when you dissect the lateral peritoneal attachments.
The lateral approach is the same as in open surgery ie mobilised off Gerota's fascia. As in open surgery it sometimes helpful to first mobilise the omentum from the transverse colon.
Open the lesser sac or mobilise the Gt. Omentum to allow easier resection of retroperitoneal attachments of the splenic flexure.
Retract the rectum upward and forward, identify the loose areolar plane between the mesorectum and the presacral fascia (with the hypogastric nerves lying on it). The right and left nerves should now be clearly visualised on the presacral fascia. Divide the mesorectum with the harmonic scalpel using "slow burn" and the active tip away from the bowel.
Use an atraumatic forcep to occlude the bowel lumen to allow distal cytocidal rectal washout from below. Finally divide the rectum with an endostapler e.g., ATG45 (green reload).
Retrieve the specimen through a TV Left upper quadrant incision lateral to the rectus in bad Diverticulosis (sufficient length to avoid a diverticulum in the anastomosis). Alternately use the 12mm LIF port site or as we now prefer, bring it out via the umbilicus (as shown).
Return the bowel with staple head inserted, close the umbilical incision and insert a 12mm camera port through the suture line. Pull the suture tight (no need to tie at this stage. Staple the two ends of the bowel together.
Ensure that all the small bowel has been removed from behind the mobilised colon.
Close the 12mm port site and skin incisions.