Keywords

Preference Card

  • Number 10-blade scalpel with handle

  • Abdominal wall retractor (surgeon preference, Bookwalter, Thompson, Balfour, large or extra-large wound protector)

  • Toothed and non-toothed forceps (Adson-Brown, DeBakey, rat tooth, Bonney)

  • Curved Metzenbaum and Mayo scissors

  • Electrocautery, vessel sealing device

  • Kocher, Allis, and Babcock clamps

  • Kelly, mosquito hemostats

  • Retractors (Richardson, Deaver, Army Navy)

  • Needle drivers

  • Suction

  • Sutures

    • 2.0/3.0 polyglactin

    • 3.0 polydioxanone

    • 4.0 polyglecaprone

    • Skin stapler or 2-0 nonabsorbable sutures for skin closure

  • Linear cutting stapler

  • Curved cutting stapler (Contour®)

  • Circular stapler 28–33 mm

  • Flexible sigmoidoscope

Patient Positioning/Operating Room Setup

  • Modified lithotomy position (Fig. 13.1) with legs in stirrups to provide easy access to perineal region, thighs are flexed. Patient’s buttock slightly off the lower edge of the bed to allow access to the rectum.

  • Abduct and secure arms on padded arm boards (max 90°).

  • After standard prep, drape both legs, the underbuttock area, and the abdomen.

  • The surgeon is positioned to patient’s right; the assistant is to the patient’s left; the second assistant can stand either to the left of the first assistant or between the patient’s legs (Fig. 13.2).

  • The scrub nurse is to the right of the surgeon.

  • Foley catheter is inserted.

Fig. 13.1
figure 1

Modified lithotomy position with left arm abducted

Full size image
Fig. 13.2
figure 2

Operating room setup. ANS anesthesiologist, S surgeon, AI first assistant, AII second assistant, N scrub nurse

Full size image

Nodal Points

Type of Incision

  • Midline supraumbilical pubic laparotomy (see Fig. 11.3)

Approach

  • Obtain controlled entry into the abdomen. If previous midline scar, attempt entry in an area above or below the scar to avoid any underlying adhesions.

  • Perform lysis of adhesions if needed to obtain good exposure.

  • Position the abdominal wall retractor and explore the abdomen to assess for any undiagnosed pathology.

  • Culture any fluid if present.

  • Protect and pack the small bowel using moist towels to the right of abdomen.

Dissection, Resection, and Reconstruction Steps

Dissection, resection, and reconstruction steps are similar to the laparoscopic approach, as described in Chap. 12.

The main steps are summarized as follows:

  • Mobilize the sigmoid colon.

  • Isolate and divide the inferior mesenteric artery and vein.

  • Transect the colon distal to the lesion.

  • Complete the division of the mesosigmoid.

  • Transect the colon proximal to the lesion.

  • Create an end-to-end colorectal anastomosis with a transanal circular stapler.

  • Flexible sigmoidoscopy air leak test of the anastomosis.