Large bowel obstruction
- 10ml syringe & supply of "white" 19G hypodermic needles
- Low flow suction
- One (occasionally two) 5mm, two 12mm disposable trocars
- Two 5mm fenestrated Johan grasping forceps
- 5mm Harmonic scalpel
- 10mm bowel clamp applicator & bowel clamp
- Medium (purple) Haem-o-Loc Clips
- 12mm linear stapler eg ATG 45 (Green plus vascular cartridges)
- 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 Spakman retractor after having dilated the cervix. This is the best way to elevate the uterus out of the pelvis. NB Warn the patient that they may experience some uterine cramps and/or vaginal bleeding in the immediate postoperative period.
Under direct & open vision site the laparoscopy port approx. 3cm above 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. When you are planning a right hemicolectomy insert the camera port via an open cut-down in the LUQ (as shown).
Decompress the gaseous bowel distension using percutaneous 19G "white" needles, a 10ml syringe (no plunger) and low flow suction; this manoeuvre allows the creation of an operative space.
Pay particular attention to the caecum and transverse colon. Use gravity to aid you ie., lift up individual loops of bowel with a Johan grasper and let the contents settle and then aspirate the gas.
Once you have an operating space insert the remainder of the operating ports. We use 5mm and 12mm RIF ports for the vast majority of our surgery.
NB., If you go for 4 individual 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! Be warned.
Use a medial or lateral approach as findings dictate – DO NOT GET FIXED ON ONE APPROACH as it will limit what you can do. When the small bowel is distended i.e., the ICValve is incompetent we would normally go for a lateral mobilisation first; the mesocolon will keep the small bowel under control.
Use the pelvis to "cradle" loops of bowel e.g., obstructed sigmoid, caecum or small bowel.
In distal LB obstruction (as shown) it is usually necessary to approach the colonic mobilisation in a caudal to cranial mannner after first mobilising the rectum within the TME plane and then in turn transecting the mesorectum (with your preferred energy source) and bowel (Linear stapler).
The first landmark in dissection of the IMA and opening of the TME plane is the sacral prominentry; opening the peritoneum just below here and medial to the right ureter correctly exposes the neuro/vascular elements of the mesentery. Remember, it is easy to dissect behind the hypogastric nerves. Open up the TME plane. Decide on the desired level of transection before dividing the mesorectum with the harmonic scalpel. Divide the rectum with the ATG-45. Elevate the divided bowel out of the pelvis nad towards the patients right hand side to allow division of the left hand peritoneal attachments.
It is vital that you carry out the dissection in the correct plane. If you are in front of Toldt's or Gerota's fascia it is relatively easy to progress as the tissues are generally oedematous.
In these types of cases we would always advocate the use of an ATW-45 for control of the IMA. After applying the endo-stapler to the pedicle, check its position by elevating the stapler and use the Johan forceps to push away the small bowel. When you are sure thatit has been placed correctly, parallell to the aorta "fire".
Retract the IMV forward and to the left dividing any 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, ligate and divide the IMV origin (Vascular staples).
As in open surgery it sometimes helpful to first mobilise the omentum from the transverse colon. When there is a tumour at the splenic flexure it is often necessary to mobilise the perinephric fat off the kidney; it cetainly makes it easier.
Put the patient in reverse -Trendelenburg position whilst maintaining a right-side-down tilt to bring the stomach and transverse colon into view. Open the lesser sac or mobilise the Gt. Omentum to allow easier resection of retroperitoneal attachments of the splenic flexure. Look out for the pancreas. Place a drain around the pancreas at the end of the procedure (identify any potential pancreatic leak).
Retrieve the specimen through the enlarged 12mm umbilicus port site. Incise directly onto the plastic Excel port. You only need a small incision; tumours can be removed "end on".
NB. In general it is the peritoneum that holds things up, not the linea alba! If the bowel is very bulky use a wound retractor system.
Allow as much of the obstructed bowel content to drain into the resected specimen. Make your colotomy and aspirate any liquid bowel content. Divide the colon and insert your purse-string and anvil head.
If there is a lot of liquid bowel content we would recommend using a laparoscopic bowel clamp (MicroFrance); removed via the 12mm operating port. The clamp stops liquid faeces draining through the anvil head stem.
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. The obstructed proximal segment will quickly decompress itself through the anastomosis.
Ensure that all the small bowel has been removed from behind the mobilised colon.
Close the 12mm port site and skin incisions. Allow the patient to eat and drink as they feel able.