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, St Marks retractor)

  • Needle drivers

  • Linear cutting stapler

  • Curved cutting stapler (Contour®)

  • Circular stapler 28–33 mm

  • Flexible sigmoidoscope

  • Ileostomy rod and stoma appliance

  • Suction

  • Sutures

    • 2.0/3.0 polyglactin or catgut

    • 3.0 polydioxanone

    • 1 looped polydioxanone

    • 4.0 polyglecaprone

    • 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, thighs are flexed; patient’s buttock slightly off the lower edge of the bed to allow access to the rectum (see Fig. 11.1).

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

  • Prep and 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.

  • The scrub nurse is to the right of the surgeon (see Fig. 11.2).

  • Foley catheter is inserted.

Nodal Points

Type of Incision/Port Locations

  • Midline laparotomy (see Fig. 12.2)

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 for any undiagnosed pathology.

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

Dissection, Resection, and Reconstruction

Dissection, resection, and reconstruction steps are similar to the laparoscopic approach as described in Chap. 16.

Main steps are summarized as follows:

  • Mobilization of the descending colon

  • Mobilization of the splenic flexure

  • Identification and ligation of the inferior mesenteric artery and vein at their origin

  • Total mesorectal excision

  • Resection of rectum and descending colon at designated points

  • Creation of the colorectal anastomosis

  • Creation of loop diverting ileostomy