Ensure distance above AV has been confirmed pre-op
>10cm HAR
6-9cm LAR
<6cm ULAR
Mechanical bowel prep and PO antibiotics the day before are probably beneficial - especially mech prep if might need to do colonoscopy on-table. However many colorectal surgeons don't do it. Does making the stool more liquid also make it easier for it to leak out?
GA, prep (probably don't need to prep perineum), drape, lithotomy with both arms tucked or left arm out (surgeon at right, assistant at left initially), IV Abx, TEDs + SCDs
Harmonic/Ligasure
IDC
Stand on patient's right - be aware of cables near patient's right neck e.g. Bair hugger as they can be leant on by assistant
Open: long midline incision (around left of umbilicus to give better access to splenic flexure)
Push omentum above liver. Get bowel out of the way - head down, left side up, fold leaflets away like a book, consider extra fan retractor.
Adhesiolysis and mobilisation of sigmoid colon
Lateral to medial when you will be resecting right along the colonic margin (benign)
Incise along white line of Toldt, working up towards splenic flexure
Careful attention to correct plane, first medial to peritoneal sidewall, then anterior to anterior renal fascia (Gerota's)
Medial to lateral when you will be formally ligating IMA (cancer), and provided you can get the bowel out of the way
Tent up sigmoid and identify IMA/IMV, at the sacral promontory, where there is an impression at the CME margin. Iliacs will be just behind.
Identify ureter prior to ligating IMA
Dissect IMA out to 1cm distal from origin and LigaSure/staple/hemolok/suture ligate (LigaSure x3 is a good option, especially in young patients)
Ligate IMV adjacently (this is low ligation IMV)
Continue medial to lateral - tent up doona over head and make a window, looking for ureter. Stay directly underneath IMA to avoid digging under ureter.
Ureter and left gonadal vessel identification, if not already seen
Mobilisation of colon and upper rectum
Incise the retroperitoneal fascia medial to ureter, and work across in the presacral space, in a plane anterior to the left presacral hypogastric nerve.
Carry dissection across sigmoid mesentery as far as necessary
Further mobilisation towards splenic flexure if required
Need enough length to easily bring it down to pelvis
Divide phrenocolic ligament, avoiding spleen and tail of pancreas
Divide adhesions between omentum and colon proximally to mid-transverse colon, entering the lesser sac
Divide IMV high (next to DJ ligament) if more length is required
Dissection and division of rectum
Select a point for division (good blood supply, free of diverticulae). Clear the mesenteric border for approx. 2cm, but stay fairly close posteriorly, to avoid damaging nerves.
TME to 2-5cm below the point of division (if malignancy) - lift sigmoid vertically with Ray-Tec posteriorly, divide the peritoneum on either side. Dissect posteriorly between pre-sacral fascia and mesorectum, preserving the pre-sacral nerves. Dissect anteriorly between seminal vesicles/vagina and rectum to expose the rectovesical fascia. Continue dissecting in avascular plane between mesorectum and pelvic sidewall.
Fire TA linear stapler (green 60) across this point
Colon extraction and division - limited Pfannenstiel or Lanz incision
If converting to open with dissection still to be done, do lower midline
Anastomosis - EEA/sutured
See topics under 'anastomosis' and 'stapling'
Check marginal artery for pulsatile flow at anastomosis site - if not present, need to go proximal
Covering ileostomy if concerns
Leak test
Suturing over defect
Defunctioning stoma
Reconstruction of anastomosis
Consider loop ileostomy and drain
For LAR, reduce risk of leak from 28% to 10% with a covering loop ileostomy
