What equipment is needed to perform laparoscopic left hemicolectomy?

Updated: Apr 13, 2020
  • Author: David B Stewart, Sr, MD, FACS, FASCRS; Chief Editor: Vikram Kate, MBBS, MS, PhD, FRCS, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed)  more...
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Answer

The choice of instruments is largely in response to the particular laparoscopic technique being used.

Although numerous laparoscopic graspers and retractors are available, some of them purportedly atraumatic, it is necessary to remember that unlike open manual bowel retractors, laparoscopic graspers focus their point of contact over a small area of the intestinal wall. Therefore, all manipulation of the small or large intestine during laparoscopy creates a higher risk of bowel injury and should be avoided as much as possible by using patient positioning and techniques of dissection that minimize laparoscopic grasping of the bowel wall.

The author uses laparoscopic Babcock graspers, both because they are less expensive than other, more elaborate graspers that are no less traumatic and because they are readily available in any operating room (OR). With any laparoscopic grasper, the surgeon should fill the jaw of the grasper with the tissue to be grasped rather than pinch the bowel; the former displaces the force applied by the grasper jaw over a larger surface area and thus prevents maximal force of closure over a smaller segment of tissue, which is then more likely to be lacerated or crushed.

Energy devices have evolved to use advanced bipolar technology that reliably transects and seals vessels up to 7 mm in diameter, which includes all of the named major nutrient vessels encountered during a left colectomy. The use of these energy devices provides the advantage of less collateral thermal spread as compared with monopolar cautery. These devices can also perform double duty; they can dissect tissue without necessarily grasping tissue in their jaws, thus replacing other laparoscopic dissectors.

Although endoscopic staplers can also be used to ligate major vessels, the use of energy devices not only is more cost-effective but also prevents the extra time and risk of organ injury from additional instrument exchanges that are required to alternate between dissecting tools and staplers.

Laparoscopes come in rigid and flexible forms. With rigid laparoscopes, an angled view is almost a requirement for a procedure such as a left colectomy, in which the dissection involves the entire left abdomen at a minimum rather than a fixed local point. Flexible laparoscopes offer high-definition images with excellent lighting through a trocar as small as 5 mm, and they offer the advantage of a camera tip that can be flexed 90° in four directions.

Especially for single-site surgery, the flexible laparoscope is quite necessary, allowing the camera shaft to be moved away from the operating surgeon while keeping the region of interest centered on the viewing screen. These cameras impose a learning curve on the camera operator, as seen in the example of how rotating the camera results in rotation of the image on the screen. Although this is often a greater than expected challenge for younger surgical residents, it is not an insurmountable one.


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