I38

o Surgicol Procedures lncluding Minimol Access Procedures

Goslrointestinol Surgery

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multaneously (a second scrub nurse is necessary). For a two-stage procedure the patient is prepared and
draped for the second stage after the abdomen is closed. Isolate all instruments used on the colon in a basin. The scrub person may receive specimen in a basin.

amtomy incision or use of a lar.ge port.,Similarly, creation or eliminatipn of a stoma and procedures in which fostruments may be inserted transanally are.combined
the laparoscopic approach. The selection oftrocar rites will.vary with the patient's habitus, the patholqgr, previous surgery, and preference of the surgeon rad may nded to be repositioned during the course of

rith

Since there are two separate surgical fields, additional care must be exercised to avoid confusion when counting sponges, needles and sharps, and instruments. "Clean" closure of the abdomen requires regowning, regloving, and redraping and a Basic/lVlinor procedures

tray. Using a pouch prevents inadvertent activation of a

second electrosurgical pencil not in use.

qment is deemed to be mobile or'in a redundant loop ind a li-itud procedure is indicated, the segment may
tedelivered extracorporeally via a minilap4rptomy procdure accomplished without further laparoscopic neneuvers. When a small lesion has been identified colnoscopically and requires segmental excision, ethylne blue dye can be injected into the adjacent bowel wall F facilitate identification on laparoscopic exploration. Smilarly, if laparoscopic visualization cannotldentify a lesion.or its regional location is not established respect to deciding procedure of choice, intraoper. colonoscopy can be performed to verify the level of
The
,

fte procedure. If after irlacement

of the camera the irivolved colonic

TAPAROSCOPIGASSISTED COLON
RESECIION

Definition
Excision of a segment of the large intestine incorporat-

ing endoscopic technique and a minilaparotomy incision or large-bore laparoscopic port.

Discussion

rilre

commonly performed laparoscopic (or lap-

pic-assisted) colonic procedures

Most commonly performed procedures on the colon can be technically accomplished by laproscopic or laparoscopic-assisted approach. It is not yet known as to whether a "proper" cancer resection can be performed laparoscopically. The laparoscopic approach may not be appropriate in cases ofsevere obesity, extensive adhesions, severe inflammation, or colonic perforation.

will be des-

again noting yet unresolved controversies ts the ipriety of this approach for malignancy and certain corlditions. Various modifications or combinaof these basic procedures, for example, total abI colectomy with ileorectal anastomosis or ileostomy with proctocolectomy, ,will not be des-

with peritonitis or in malignancy when tle primary tumor is large or assosiated with adjacent organ involvement or when wide dissection is necebsary. If upon assessment ofthe pathology the laparoscopic approach is likely to compromise the proposed procedure or in the case of hemmorhage or if excessive anesthesia time accumulates, the laparoscopic procedure must be
promptly coverted to an open procedure. Procedures may be completed entirely by laparoscopic approach or may be combined with a minilap

*ight

Hemicolectomy. Pneumoperitoneum is es-. through the umbilicus. Three additional 10ll- mm ports are placed: suprapubic;right subcostal > midclavicular line, and right subziphoid. The is adjusted with the right side elevated to allow to assist in the exposure of the immediaie op. area, and later placed ih reverse TrendelenAfter assessment ofthe pathology, the cecum and I ascending colon are placed on traction as the