The document discusses different approaches for performing a laparoscopic sigmoid colon resection surgery. It describes the lateral and anterior patient positioning approaches. For the lateral approach, the patient is positioned on their right side and trocars are placed in a triangular configuration. This approach allows for easy mobilization of the splenic flexure but has disadvantages like poor access to the right side of the rectosigmoid area. The anterior approach involves positioning the patient supine and placing trocars in a semicircular configuration above the sigmoid colon. Both approaches aim to bring the proximal colon through the incision sites to allow for a tension-free anastomosis repair. Data on outcomes from 62 patients undergoing either the lateral or anterior approach are also presented.

1. Laparoscopic Sigmoid Colon Resection: Supine and Lateral George Ferzli, MD, FACS Professor of Surgery, SUNY Downstate Health Science Center, Brooklyn, NY

2. How is it done? 1. Lateral approach 2. Anterior approach

3. Patient with Large Ventral Hernia

4. Lateral Patient Position Patient positioned on right side Hand rotated in semicircle over sigmoid for trocar placement (more like triangle)

5. Trocar Placement: Lateral Position

6. Lateral Position Splenic Flexture Mobilization

7. Lateral Approach Inferior Mesenteric Artery

8. Lateral Position Lateral trocar cuts sigmoid

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

10. End to End Anastomosis

11. Lap. Sigmoidectomy - Lateral Position

12. 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

14. Anterior Approach Patient supine Position hand over sigmoid and rotate in semi-circle to place trocars (3)

15. Trocar Placement: Anterior Position

16. Anterior Position 1 2 Trocar in inguinal crease cuts sigmoid

17. Repair – Anterior Position If proximal colon can be brought through inguinal crease trocar incision, tension free repair will be successful.

18. Anterior Approach

20. Medial to Lateral LCR From Jan 1999 to Dec 2004, 100 consecutive patients underwent three trocar, M-L segmental laparoscopic colon resection. LCR’s included sigmoid (55%), right (34%), left (6%) and transverse (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

21. Questions?

22. Laparoscopic Sigmoid Colectomy Ferzli G et al. (2000 – 2001) Unpublished Data 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)