The lateral approach to laparoscopic sigmoid colon resection

Abstract

Laparoscopic sigmoid colon resection has been tradi- tionally performed using an anterior approach with the patient placed in a modified lithotomy position. The dissection of the splenocolic ligament and transverse co- lon is often difficult, especially in the case of a high splenic flexure. From our experience using the lateral approach for laparoscopic nephrectomy and adrenalec- tomy, we have found that the lateral position provides excellent visualization of the splenic flexure, and the en- tire left colon can be mobilized easily without the need for excessive retraction. In this study, we report our ex- perience and describe our technique for laparoscopic sigmoid colon resection using a lateral approach. Technique The patient is placed in the right lateral decubitus posi- tion. The right leg is placed in a 30-degree flexed posi- tion and the left leg is kept extended. A pillow is placed between the legs. The left arm is secured to a Mayo stand. The table is flexed and the kidney rest is elevated to maximize the working space. The surgical area requir- ing exposure extends from the left nipple down to the pubic symphysis and from the umbilicus to the posterior axillary line. Easy access to the anus must be ensured to facilitate placement of the rigid sigmoidoscope and the circular stapler. Two video monitors are required. One is positioned at the head of the table to the left of the patient, and the other is placed at the foot of the table. A 10-mm trocar is inserted in the subcostal area at the level of the anterior axillary line, and another 10-mm trocar is inserted under the 11th rib at the level of the midaxillary line (Fig. 1). A 5-mm trocar is inserted at the level of the midclavicular line 2 to 3 cm above the level of the umbilicus. If a fourth trocar is needed for an extra instrument, it is placed in the suprapubic area. A 10- mm, 45-degree-angle laparoscope is used during the procedure. Mobilization of the colon and rectum is performed in two stages. The first stage includes mobilization of the left colon, identification of the left ureter, and dissection of the splenic flexure. It is best performed with the sur- geon standing on the right side of the table and facing the upper monitor. The patient is placed in a 30-degree