Laparoscopic Sigmoid Colon Resection:Supine and Lateral

George Ferzli, MD, FACSProfessor of Surgery, SUNY Downstate Health Science Center, Brooklyn, NY

How is it done?

1. Lateral approach

2. Anterior approach

Patient with Large Ventral Hernia

Lateral Patient Position

• Patient positioned on right side

• Hand rotated in semicircle over sigmoid for trocar placement (more like triangle)

Trocar Placement: Lateral Position

Lateral PositionSplenic Flexture Mobilization

Lateral ApproachInferior Mesenteric Artery

Lateral Position

Lateral trocar cuts sigmoid

Repair - Lateral Position

If proximal colon can be brought through lateral incision tension-free, the repair will be tension free.

End to End Anastomosis

Lap. Sigmoidectomy - Lateral Position

Lateral Approach

Advantages• Easy mobilization of

splenic flexture

• Easier identification of ureter

• Small bowel out of the way in case of ventral hernia

Disadvantages• Inability to evaluate liver

• Poor access to adhesions or lesions on the right side of the recto-sigmoid

• In females, ovary may interfere

QuickTime™ and aVC Coding

Anterior Approach

• Patient supine

• Position hand over sigmoid and rotate in semi-circle to place trocars (3)

Trocar Placement: Anterior Position

Anterior Position

1

2

Trocar in inguinal crease cuts sigmoid

Repair – Anterior Position

If proximal colon can be brought through inguinal crease trocar incision, tension free repair will be successful.

Anterior Approach

QuickTime™ and aVC Coding

Medial to Lateral LCR

From Jan 1999 to Dec 2004, 100 consecutive patients underwentthree trocar, M-L segmental laparoscopic colon resection.LCR’s included sigmoid (55%), right (34%), left (6%) andtransverse (5%). All conversions to open surgery (3%) occurred during the early learning curve.

Early LCR patients experienced greater morbidity (21% vs 12%)and mortality (5% vs 2%).

Significant and consistent improvement in the learning curve occurred after 38 LCR’s.

Kim J. et al Medial to Lateral Laparoscopic colon resection: a view beyond the learning curve. Surg Endosc, 2006

Questions?

Laparoscopic Sigmoid Colectomy

Total (n) = 62 pts Lateral (24) Anterior (38)Age 48 (32 - 70) 46 (27 - 86)

Sex, M:F 23:1 35:3

Indications:

• Diverticulitis 16 (2 abscess) 20 (4 abscess)

• Polyp 3 6

• Carcinoma 5 12

Complications 1 hematoma flank,

1 re-op for SBO,

1 leak (cut.drainage)

1 leak (re-op hartman)

Hospital Stay 2.2 (2 - 10) 2.4 (2 - 9)

OR Time 142 (98 – 216) 147 (110 – 279)

Ferzli G et al. (2000 – 2001) Unpublished Data