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

  • Linear cutting stapler

  • Suction

  • Sutures

    • 0 polyglactin ties

    • 2/3.0 polyglactin

    • 3.0 polydioxanone

    • 1 looped polydioxanone

    • Skin stapler or 4.0 absorbable sutures for skin closure

Patient Positioning/Operating Room Setup

  • Modified lithotomy position with legs in stirrups to provide easy access to perineal region (in case an intraoperative colonoscopy is needed); thighs are flexed (see Fig. 11.1).

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

  • Prep and drape the abdomen.

  • The perineal region does not need to be prepped, but easily accessible.

  • The surgeon is positioned to the 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 (see Fig. 11.2).

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

  • Insert Foley catheter.

Nodal Points

Type of Incision

  • Midline skin incision (see Fig. 11.3) above and below the umbilicus, using 10-blade scalpel, extending cranially or caudally if needed

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 for any undiagnosed pathology.

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

Dissection, Resection, and Reconstruction

Dissection, resection, and reconstruction steps are similar to the laparoscopic approach as described in Chap. 14.

Main steps are summarized as follows:

  • Mobilize the cecum and ascending colon to the hepatic flexure.

  • Mobilize the proximal transverse colon by dividing the gastrocolic ligament and entering the lesser sac.

∗∗ It is important to visualize the posterior part of the stomach to ensure that the lesser sac has been entered∗∗

  • Identify and ligate the ileocolic vessels at their origin – if cancer operation.

  • Divide the mesentery, including the right colic and right branch of the middle colic artery, preserving the middle colic artery.

  • Transect the terminal ileum (10 cm proximal to the ileocecal valve) and the proximal transverse colon (proximal and distal margin).

  • Create an isoperistaltic or antiperistaltic ileocolic anastomosis (surgeon preference).