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Jean-LouisDulucqTipsandTechniquesinLaparoscopicSurgery Jean-LouisDulucqTipsandTechniquesinLaparoscopicSurgeryInCollaborationwithPascalWintringerForewordbyJacquesPérissatWith281ColoredFigures123 Dr.Jean-LouisDulucqInstitutdeChirurgieLaparoscopiqueHôpitalBagatelleMSPB203RoutedeToulouse33401BordeauxTalence,FranceCollaborator:Dr.PascalWintringerInstitutdeChirurgieLaparoscopiqueHôpitalBagatelleMSPB203RoutedeToulouse33401BordeauxTalence,FranceTitleoftheoriginalFrenchedition:Techniquesetastucesenchirurgielaparoscopique©Springer-VerlagFrance,Paris,2003ISBN2-287-59749LibraryofCongressControlNumber:2004104705ISBN3-540-20902-6SpringerBerlinHeidelbergNewYorkThisworkissubjecttocopyright.Allrightsarereserved,whetherthewholeorpartofthematerialisconcerned,specificallytherightsoftranslation,reprinting,reuseofillustrations,recitation,broadcasting,reproductiononmicrofilmorinanyotherway,andstorageindatabanks.DuplicationofthispublicationorpartstherofispermittedonlyundertheprovisionoftheGermanCopyrightLawofSeptember9,1965,initscurrentversion,andpermissionforusemustalwaysbeobtainedfromSpringer-Verlag.ViolationsareliableforprosecutionundertheGermanCopyrightLaw.SpringerisapartofSpringerScience+BusinessMediaspringeronline.com©Springer-VerlagBerlinHeidelberg2005PrintedinGermanyTheuseofdesignations,trademarks,etc.inthispublicationdoesnotimply,evenintheabsenceofaspecificstatement,thatsuchnamesareexemptfromtherelevantprotectivelawsandregulationsandthereforefreeforgeneraluse.Productliability:Thepublishercannotguaranteetheaccuracyofanyinformationaboutdosageandapplicationcontainedinthisbook.Ineveryindividualcasetheusermustchecksuchinformationbyconsultingtherelevantliterature.Editor:GabrieleSchröder,Heidelberg,GermanyDeskeditor:StephanieBenko,Heidelberg,GermanyProductioneditor:IngridHaas,Heidelberg,GermanyCover-Design:FridoSteinen-Broo,Pau,SpainTypesetting:Fotosatz-ServiceKöhlerGmbH,Würzburg,GermanyPrinting:DruckhausMitte,Berlin,GermanyBookbinding:Stein&Lehmann,Berlin,GermanyPrintedonacid-freepaper.24/3150ih-543210 ForewordPerformingasurgicaloperationcouldbecomparedtonavi-gatinginsidethehumanbody.Twoessentialrequirementsarenecessaryforasuccessfulapprenticeship:Aperfectunderstandingoftheroadmap,theanatomyRegulartrainingwithexpertsurgeonteachersshowingstrat-egies,tactics,manoeuvres,andgesturestomakethejourneysafe,efficientandfastFordecadesthiswasthewaytakenbyapprentice-surgeonsandalsobysurgeonsalreadyinpracticeconcernedaboutupdat-ingtheirknowledge.Foryearstheironlytravellingcompanionswerebooks,drawings,andpictures.However,printedmediumcannotsatisfactorilyandproperlyreproducethemovementsofamanoeuvringsurgeon.Inopensurgery,onlythetwofirstas-sistantscanpreciselycapturebydirectvisionwhatishappen-inginthedepthoftheoperatingfield.Therefore,thedurationofapprenticeshipislongandrestrictedtoasmallnumberofpeopleperteacher.Theintroductionofmoviecamerasintotheoperatingroomsimprovedthequalityofsurgicaleducation.Butfilminginopensurgeryisnotsoeasy.Thecamerapersonhastobewelltrainedtocatchgoodtakesinthedepthofapitbetweentheheads,shoulders,andfingersofthesurgeonandassistants.Mostofthetime,thoseconstraintsdisturbtheoper-ator’smanoeuvres,alteringtheirpedagogicalvalue.Withtheintroductionoflaparoscopicsurgery(LS),usingavideocameraprovidingimagesinrealtimeonatelevisionscreen,everythingchanged.Now,thesurgeoncanusetheim-agetoperformhisoperation.Withimagesbeingtheoperatingfield,therearenolongeranyconstraintsduetomovietaking.LSisarealrevolutionintheconceptofsurgicaleducation;how-ever,thetwofundamental,above-mentionedrequirementsarepersisting:Aperfectknowledgeofanatomymustbereinforced.Themagnificationduetothelaparoscopepermitsabetterde-terminationoftheplanesofsofttissuebetweentheorgans. VIForewordItismandatorytofollowthoseplanespreciselytoavoidtheopeningofdozensofmicrobleederswhichalterthelightandcouldobligetoconvertinopensurgery.Regulartrainingwithexpertsbecomesofmucheasieraccessandinvolvesalargernumberofparticipants.Theysharethesamevisionoftheoperatingfieldswiththesurgeonandhisassistants.Theteachercandemonstrateperfectlyhispro-gression,havingpermanentaudiovisualcontactwiththeau-diencetoprovideadditionalexplanationsondemand.Suchlive,interactivedemonstrationscanbebroadcastallaroundtheworld.Therecordingiseasy,allowingthestorageofplen-tyofdocumentsthatcanbeusedtosetuplibrariesofvideotapes,CD-R,etc.ThisaudiovisualaidisnowtheprincipalcompanionofthesurgeontravellingthepathofLSlearning.Dr.J.L.Dulucqunderstoodthatissueveryquickly.HeisamongthetensurgeonsintheworldwhoopenedthegatesofLSin1988–1989.Hewasimmediatelyaterrificoperatorandheisstillridingonthefrontwaveofthedevelopersofthatsurgery.Hecreatedasfarbackas1993aninstitutefortheteachinganddevelopmentofLSconcerningthetreatmentofdigestive,en-docrine,andvasculardisorders.Thisinstitute,namedI.L.S.,isnowknownworldwideandrecognizedasacentreofexcel-lenceinLSteaching.Inadditiontoregularcoursesheldattheinstitute,I.L.S.isconnectedbyasatellitetransmissionsystemtosimilarcentresinEuropeandabroad.TheI.L.S.libraryiseasilyaccessibleviaInternetandmaintainspermanentcontactwithbothcurrentandformertrainees.Havingbeenpartofthedevelopmentofthecentre,Ithoughtthatcombiningallthosemodernmediacouldreplacethetraditionalprintedmaterial.Butwiththecourseoftime,Ihavechangedmymindanden-couragedJ.L.Dulucqtowriteabooksummarizingthebestofhisteaching.Andhereisthatbook:seventeendifferentprocedurescon-cerningthecureofdigestive,adrenalgland,groinherniadis-orderspresentedin280pagesinanoriginalway.Thestyleissoberandprecise,assurgicalmanoeuvreshavetobe.Thewrit-ingoutlinesonlythemainpoints.Oppositethetext,excellentdesignsandintraoperativepicturesaredisplayedasimmediateillustrations.Thewholepresentationisascloseaspossibletorecreatingtheatmosphereofasurgeoninaction.Thisbookgathersthebest-ofinnovationsandtricksofJ.L.Dulucq.Becauseofthelargerangeofdescribedprocedures, ForewordVIIfromappendectomytocolorectalsurgery,thebookwillbeuse-fultobeginnersaswellasmoreexpertsurgeons.Althoughthebookdoesnotstrivetobesufficienttotrainacompletelaparo-scopicsurgeon,itisthebestkeytoopenthedoorofatrainingcentreandtoguidethestepsofthelearner.Havealookatthebookbyvisitingtheshow-caseofI.L.S.ontheInternetatwww.e-laparoscopy.com.Andbepreparedtowelcomeabrotherbookonotheradvancedtechniquesonoesophageal,gastric,liver,andpancreasLS.Thisbookhonours“l’EcoleBordelaise”oflaparoscopicsur-gery,whichwassoinstrumentalinthelaunchingofLSduringtheformerdecade.JacquesPérissat,M.D.,F.A.C.S.ProfessorofSurgery,VictorSegalenUniversity,Bordeaux,FrancePresident,IFSES(InternationalFederationofSocietiesofEndoscopicSurgery) PrefaceThepurposeofthisworkisadescriptivedemonstrationoflapa-roscopictechniquesapproachedinaverypracticalway.Everyintervention,summarizedinsixstages,iscarefullyillustratedwithanoperatingclichéandaplanthatshowstheprogressofthephasesoftheintervention.The17operatingchapterspresentedinthisworkrepresentthebasicknowledgeofeverylaparoscopicsurgeon.Thisworkisintendedtobeahandbookcompanionforeverysurgeoninter-estedinthissurgicaldomain.Aspecialchapterisdedicatedtotheanalysisofknowledgeofthelast6yearsinlaparoscopicsur-gery.Overall,thebookoffersanaccountofmorethan10yearsofexperienceinlaparoscopicsurgery.Ihopethisbookofsurgi-caltechniqueswillbeausefulhandbookforthenovicesurgeonandareferencefortheconfirmedsurgeon.IwouldreallyliketothanktheteamoftheInstituteofLapar-oscopicSurgeryofBordeaux,PascalWintringerandJacquesPérrisat,whoenabledmeduringthesemanyyearstodevelopapracticaleducationintheserviceofourfellowsurgeons.IalsowouldliketothankthesurgeonswhohaveparticipatedinthetrainingprogramattheInstituteofLaparoscopicSurgeryofBordeaux.Thesesurgeons,whocomefromallcornersoftheworld,havecontributedtothedynamicsofoureducationandtotherealizationofthisbookofsurgicaltechniques.Anidenticalworkinadvancedlaparoscopicsurgerywillbepublishedsoon.Ihopethisbookisabletomeettheexpectationsoflaparo-scopicsurgeons.Goodreading.JeanLouisDulucq,M.D. ContentsPart1·UpperGastrointestinalTractProcedures....11LaparoscopicCholecystectomy.............32LaparoscopicCommonBileDuctSurgery.......233LaparoscopicFundoplicationforGERD:LaparoscopicNissenandToupetFundoplication..414LaparoscopicGastricBandingforMorbidObesity..575LaparoscopicHellerEsophagomyotomyforAchalazia.......................776LaparoscopicSplenectomy...............91Part2·ColorectalProcedures...............1017LaparoscopicAppendectomy..............1038LaparoscopicLeftColectomy..............1199LaparoscopicRightColectomy.............13710LaparoscopicTotalColectomy.............14911LaparoscopicRectopexyforRectalProlapse.....153Part3·InguinalHerniaandRetroperitonealProcedures......................16912TotallyExtraperitonealApproach(TEPA)forLaparoscopicHerniaRepair.............17113LaparoscopicRightAdrenalectomy..........18914LaparoscopicLeftAdrenalectomy...........203Part4·ProceduresforPelvicFloorDisorders......20715LaparoscopicPosteriorColpopexy...........20916LaparoscopicAnteriorColpopexy...........22117LaparoscopicBurchColposuspension.........233SubjectIndex.......................243 AbbreviationsCBDCommonbileductERCPEndoscopicretrogradecholangiopancretographyGERDGastro-esophagealrefluxdiseaseLAGBLaparoscopicadjustablegastricbandingOROperatingroomTEPATotallyextra-peritonealapproach PART1UpperGastrointestinalTractProcedures1LaparoscopicCholecystectomy32LaparoscopicCommonBileDuctSurgery233LaparoscopicFundoplicationforGERD:LaparoscopicNissenandToupetFundoplication414LaparoscopicGastricBandingforMorbidObesity575LaparoscopicHellerEsophagomyotomyforAchalazia776LaparoscopicSplenectomy91 1LaparoscopicCholecystectomy1.1OperatingRoomSetup:PositionofthePatientThepatientisplacedsupineinthereverseTrendelenburgposition.Lateralrota-tiontotheleftcanbeuseful.Thesurgeonstandsbetweenthepatient’slegs,hisfirstassistantisonthepatient’srightside,thesecondassistantcanbeplacedonthepatient’sleftside(>Fig.1.1).Non-woven,selfadhesivedrapesareused.Instrumentbagsareveryuseful.Themonitorisplacedatthepatient’shead,slightlyontheleftside.43assistant1assistant221surgeonFig.1.1.ORsetup–trocarposition 41LaparoscopicCholecystectomy1.2RecommendedInstruments▬Two10-mmtrocars▬Three5-mmtrocars▬A0°endoscope▬Twonon-traumaticgraspingforceps▬Apairofcoagulating5-mmshears,straightorcurved▬Astrong5-mmgraspingforceps▬A5-mmsuctionandirrigationcannula▬A5-mmclipapplicator▬Aspecimenretrievalbag▬A5-mmneedleholder1.3PneumoperitoneumandInsertionoftheTrocars:ExposureandExplorationoftheAbdominalCavityPneumoperitoneumiscreatedwithaVeressneedle.Thefirst10-mmportisinsert-edatthesuperiormarginoftheumbilicuswithaslightlyobliqueroutetopreventsubsequentincisionalhernias.Five-millimetertrocarsareintroducedunderdirectvision.Onetrocarisplacedbetweentheumbilicusandthexiphoidprocessslightlytotheleft,onerightsubcos-tal,andoneintherightupperquadrant,slightlyabovetheumbilicus(>Fig.1.1).Atthisstage,theperitonealcavityisthoroughlyexploredwiththeendoscope.Thesmallbowelismobilized.Theleftlobeoftheliverisliftedtoexposethegallbladder.Theimportanceofinflammatoryadhesionsisassessed(>Fig.1.2).Thegallbladderisgraspedwithanon-traumaticforceps.Thecoagulatingscissorsareintroducedinthemidlineporttostartthedissection.Alldissectionismadeinclosecontacttothegallbladderwall.Inaveryinflammatorysituation,dissectionisperformedwiththesuctioncannulaandwiththecoagulatingscissorsalternatively.1.4ExposureofCalot’sTriangleandDissectionoftheCysticDuctAlateraltractionisexertedonthegallbladderexposingCalot’striangle.Perito-neumisincisedclosetothegallbladderneckbygentledissectionofperitonealelements.Thecysticductisidentified,freedwithadissectorfor1cmandclosedproximallywithaclip(>Figs.1.3–1.5). 1.4ExposureofCalot’sTriangleandDissectionoftheCysticDuct5Fig.1.2.FreeingomentaladhesionsFig.1.3.Dissectionofcysticduct 61LaparoscopicCholecystectomyFig.1.4.DissectionofcysticductcompletedT4T3T2Fig.1.5.Dissectionofcysticductcompleted 1.5Intra-operativeCholangiography71.5Intra-operativeCholangiographyThecysticductisincisedwithscissorsclosetotheclip(>Fig.1.6).Acholangi-ographycatheterisinsertedintothecysticductandheldinplacewithagraspingforceps(>Fig.1.7).Aradioscopiccontrastcholangiographyisperformed.Ifthecholangiographyisconsiderednormal,thecholangiographycatheterisremovedandthecysticductisclosedwithaclip.Thecysticductistransected,leavingalongenoughstomp(>Fig.1.8).Alternatively,cholangiographycanbereplacedbylaparoscopicultrasound,butismoredifficultandlesssensibleinthisindication(>Figs.1.9,1.10).Fig.1.6.Incisionofcysticduct 81LaparoscopicCholecystectomyFig.1.7.CholangiographyFig.1.8.Transectionofcysticduct 1.5Intra-operativeCholangiography9Fig.1.9.LaparoscopicultrasoundprobeFig.1.10.Laparoscopicultrasound 101LaparoscopicCholecystectomy1.6VascularControlDissectionofCalot’striangleiscarriedon,andthecysticarteryisusuallyfoundeasily.Theliverretractorisrepositioned.Thecysticarteryorseveralbranchesareindividualized,farenoughfromtherighthepaticartery.Oneortwoclipsareusedtocontrolthearteryandoneclipisplaceddistally.Thearteryisthensectionedbetweentheclipsandretrogradecholecystectomyisthefurtherstep(>Figs.1.11–1.13).Fig.1.11.Dissectionofcysticartery 1.6VascularControl11Fig.1.12.CysticarteryclippedpriortotransectionT4T2T3Fig.1.13.FinaldissectionofCalot’striangle 121LaparoscopicCholecystectomy1.7FreeingtheGallbladderTheperitoneumisprogressivelyincisedanteriorlyandposteriorly,andthegallbladderisfreedfromitshepaticattachmentswiththecoagulatingscissors.Usually,onlysmallvesselsareencountered,andtheyareeasilycoagulated.Ifnecessary,alargevesselcanbeclipped.Dissectioniscarriedonstepbysteppullingonthegallbladderwithagrasp-ingforceps.Hemostasisisachievedwiththecoagulatingshears(>Figs.1.14,1.15).1.8SpecimenRetrievalThegallbladder,totallyfreedfromtheliver,istemporarilyleftaside.Theoperativefieldischeckedforbleedingandathoroughlavageisperformed.(>Fig.1.16).Thegallbladderisretrieved,eitherdirectlyorwithaprotectivebag,dependingonthedegreeofinflammation.Thegallbladdercanberetrievedthroughtheumbilicalportafterplacingtheendoscopeintheleftparamedianport.A5-mmgraspingforcepsisintroducedthroughtheumbilicalport.Incaseoflargestones,thegallbladderhastobeemptiedpriortoitsretrieval.Thegallbladderisopenedandthestonesarecrushedinsidewithastronggraspingforceps.Incaseofalargewideningoftheum-bilicalport,theaponeurosishastobesuturedwithabsorbablesutures.Atthisstep,thepneumoperitoneumisreleased.Asuctiondraincanbeplacedsubhepaticallythroughtherightlateralport.Skinincisionsaresuturedusingabsorbablesutures.Fig.1.14.Cholecystectomy 1.8SpecimenRetrieval13Fig.1.15.CholecystectomynearcompletionFig.1.16.Peritoneallavage 141LaparoscopicCholecystectomy1.9TipsandComments▬Clipsonthearteryshouldalwaysbedoubleforextrasafety.▬Thedissectionshouldalwaysstartattheinfundibulumofthegallbladder,en-ablinganeasylocationofthecysticduct.▬Theuseofaspecificdissectorhelpsinfreeingthecysticductforalong-enoughlengthtoeasilyperformthecholangiographyandtoclosethecysticductwithclipsthereafter.▬Werecommendthatthedissectionofthecysticarteryshouldbeperformedafterdissectionandcontrolofthecysticduct.Doingthis,theoriginofthearteryorarteriesismoreclearlyvisible.Inthecaseofananteriorcysticartery,ofcourse,arterialcontrolisdonefirst(>Figs.1.17–1.20).▬Insevereacuteinflammation,itcanbehelpfultoemptythegallbladderbynee-dlepuncture,thegallbladderbeingotherwisetoothicktobegraspedproperly.▬Incaseofsevereacuteinflammation,dissectionisbestcarriedoutbybluntdis-sectionwithametallicsuctioncannula.▬Alargecysticductmayexceedthesizeofusualclips.Inthatcase,thecysticductshouldbeclosedwithaligatureusingintracorporealknots.▬Inobesepatients,omentumandthesmallbowelcanbekeptoutofthewaybyusinganextratrocarinaleftsubcostalposition.▬Hepaticsteatosisisbestcontrolledwithanautostaticretractorintroducedthroughtherightsubcostalport.▬Thescarsfromlaparoscopiccholecystectomycanevenbereducedto3or2mm,andtherightorleftlateralportscanbeplacedonbothaxillarylinesforlessvisiblescars.Thistechnique,withoutseriouslyhinderingthehandlingoftheinstruments,hastheadvantageofshiftinglaterallythetwo5-mmincisions.Thisreducesthescarstoaminimum.Inthiscase,itshouldbenotedthatthecholangiographyisperformedthroughtheleftport. 1.9TipsandComments15Fig.1.17.DissectionofanteriorcysticarteryFig.1.18.Dissectionofanteriorcysticarterywithcurveddissector 161LaparoscopicCholecystectomyFig.1.19.ClippinganteriorcysticarteryFig.1.20.Anteriorcysticarterytransected 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201LaparoscopicCholecystectomyMcEnteeG,GracePA,Bouchier-HayesD(1991)Laparoscopiccholecystectomyandthecommonbileduct.BrJSurg78:385–386MoosG(1986)Dischargewithin24hoursofelectivecholecystectomy:thefirst100patients.ArchSurg121:1159–1161MoosaAR,MayerAD,StabileB(1991)Iatrogenicinjurytothebileduct:who,how,where?ArchSurg125:1026–1031MotsonRW,WetterlA(1990)Operativecholedochoscopy:commonbileductexplorationisincom-pletewithoutit.BrJSurg77:975–982MouretP(1991)Fromthefirstlaparoscopiccholecystectomytothefrontiersoflaparoscopicsurgery:thefutureprospectives.DigestSurg8:124–125NagyAG,JamesD(1989)Diagnosticlaparoscopy.AmJSurg157:490–493NatansonLK,EasterDW,CushieriA(1991)Laparoscopiccholecystectomy:theDundeetechnique.BrJSurg78:155–159NeugebauerE,TroidlH,SpangenbergerW,DietrichAetal(1991)Cholecystectomystudygroup.Conventionalversuslaparoscopiccholecystectomyandtherandomizedcontrolledtrial.BrJSurg78:150–154NouailleJM(1990)Àproposdelacholecystectomiesouscoelioscopie.Lapressemédicale19:337NowzaradanY,WestmoreladJC(1991)Laparoscopiccholecystectomy:newindications.SurgLapa-roscEndosc1:71–76O’KellyTJ,BarrH,MalleyWR(1991)Cholecystectomytrougha5cmsubcostalincision.BrJSurg78:762OlsenDO(1991)Laparoscopiccholecystectomy.AmJSurg161:339–344OlsenDO,AsbunHJ(1991)Laparoscopiccholecystectomyforacutecholecystitis.Problemsingen-eralsurgery.LaparoscSurg8:426–431Paterson-BrownS,GardenOJ,CarterDC(1991)Laparoscopiccholecystectomy.BrJSurg78:131–132PérissatJ(1990)Lacholécystectomieparcoelioscopie,unetechniqued’avenir.PressMé19:337PérissatJ,VitaleGC(1991)Laparoscopiccholecystectomy:gatewaytothefuture.AmJSurg161:408PérissatJ,ColletD,BelliardRetal(1990)Lithiasevésiculaire:traitementlaparoscopique.Lithotritieintracorporelle(LIC)suiviedecholécystostomieoucholécystectomietechniquepersonnelle.ActualitésDigestives12:64–67PetelinJB(1991)Laparoscopicapproachtocommonductpathology.SurgLaparoscEndosc1:33–41PetersJH,EllisonEC,InnesJTetal(1991)Safetyandefficacyoflaparoscopiccholecystectomy:aprospectiveanalysisof100initialpatients.AnnSurg213:3–12PetersJH,GibbonsGD,InnesJT(1991)Complicationsoflaparoscopiccholecystectomy.Surgery11:769–778PhillipsEH,CarrollB(1991)Newtechniquesforthetreatmentofcommonbileductcalculien-counteredduringlaparoscopiccholecystectomy.Problemsingeneralsurgery.LaparoscSurg8:387–394PonskyJL(1991)Complicationsoflaparoscopiccholecystectomy.AmJSurg161:393–395QuattelbaumJK,DorseyH,FlandersHD(1991)Laparoscopictreatmentofcommonbileductstones.SurgLaparoscEndosc1:26–32RaleighBK(1991)Subcutaneousemphysemaandhypercarbiafollowinglaparoscopiccholecystec-tomy.ArchSurg126:1154–1156ReddickEJ(1991)Laparoscopiclasercholecystectomy:techniqueandresults.DigestiveSurg8:79–83ReddickEJ,OlsenDO(1990)Outpatientlaparoscopiclasercholecystectomy.AmJSurg160:485–498ReddickEJ,OlsenD,SpawAetal(1991)Safeperformanceofdifficultlaparoscopiccholecystectomy.AmJSurg161:377–381 Literature21ReinerDS,ReinerMA(1991)Asimplemethodfordrainplacementincoelioscopiccholecystectomy.SurgeryGynecolObstr173:57–58ReyJF,GreffM(1992)Traitementendoscopiquedelalithiasecholédocienne.XIVèJournéesdePathologieDigestive,NiceRoseauE(1991)Cholécystectomieparcoelioscopie,soncoûtetsonavenir.PressMéd20:6243RoseauE(1991)Cholécystectomieparcoelioscopie:unenseignementindispensable.PressMéd18:100–101RoseauE(1991)Lacholécystectomieparcoelioscopie,unetechniqued’exception.PressMéd18:1528RubioPA,RoweG,FesteJR(1989)Endoscopiclasercholecystectomy.HoustonMedicine5:124–126SackierJM,BerciG,PhillipsEetal(1991)Theroleofcholangiographyinlaparoscopiccholecystec-tomy.ArchSurg126:1021–1026SaltzsteinEC,MercerLC,PeacockJBetal(1991)Twenty-fourhourhospitalizationaftercholecystec-tomy.GynecolObstSurg173:367–370SchirmerBD,EdgeSB,DixJ(1991)Laparoscopiccholecystectomy.AnnSurg213:665–677SoperNJ,DunneganDL(1991)Laparoscopiccholecystectomy.SurgLaparoscEndosc1:156–161SpawAT,ReddickEJ,OlsenDO(1991)Laparoscopiclasercholecystectomy:analysisof500proce-dures.SurgLaparoscEndosc1:2–7SpiroHM(1992)Diagnosticlaparoscopiccholecystectomy.Lancet339:167–168StiegmannGV,GoffJS,MansourAetal(1992)Precholecystectomyendoscopiccholangiographyandstoneremovalisnotsuperiortocholecystectomy,cholangiography,andcommonductexplora-tion.AmJSurg163:227–230StokerME(1991)Laparoscopiccommonductexploration,3rdinternmeetingofSMITBoston,NovemberStrasbergSM,ClavienPA,SanabriaJ(1991)Laparoscopiccholecystectomy.SemRoentgenol26:232–238TalaminiMA,GadaczTR(1991)Traditionalversuslaparoscopiccholecystectomy.Problemsingen-eralsurgery.LaparoscSurg8:279–283TerblancheJ(1991)Laparoscopiccholecystectomy:anewmilestoneoradangerousinnovation?Sur-gery3:177–180TestasP,CholletJM,DeWattevilleJC(1990)Essaid’évaluationdelacholécystectomieparabordcoelioscopique:àproposde2.266malades.Chirurgie116:844–847TheSouthernSurgeonsClub(1991)Aprospectiveanalysisof1518laparoscopiccholecystectomies.NEnglJMed324:1073–1078TroidlH(1991)Laparoscopiccholecystectomyinviewofmedicaltechnologyassessment.Problemsingeneralsurgery.LaparoscSurg8:495–501UngerSW,EdelmanDS,ScottJSetal(1991)Laparoscopictreatmentofacutecholecystitis.SurgLaparoscEndosc1:14–16VelezM,MuleJ,BrandonJetal(1991)Laparoscopicrepairofacholecystectoduodenalfistulae.SurgEndosc5:224VitaleGC,ColletD,LarsonGMetal(1991)InterruptionofprofessionalandhomeactivityafterlaparoscopiccholecystectomyamongFrenchandAmericanpatients.AmJSurg161:396–398VoylesRC,PetroAB,MeenaALetal(1991)Apracticalapproachtolaparoscopiccholecystectomy.AmJSurg161:365–370WalshTN,RusselRCG(1992)Cholecystectomyandgallbladderconservation.BrJSurg1:4–5WalterP,LedetJ(1990)Ambulatorycholecystectomywithoutdisability.ArchSurg125:1434–1435WhistonRJ,EggersKA,MorrisRW(1991)Tensionpneumothoraxduringlaparoscopiccholecystec-tomy.BrJSurg78:1325WilkinsonLH(1991)Laparoscopiccholecystectomyforasuspectedcaseofgallbladdercarcinoma.AmJGastro86:1851 221LaparoscopicCholecystectomyWilsonP,LeeseT,MorganWPetal(1991)Electivelaparoscopiccholecystectomyfor»all-comers«.Lancet338:795–797WolfeBM,GardinerBN,LearyBF(1991)Laparoscopiccholecystectomy:aremarkabledevelopment.JAMA265:1573–1574WolharnR,CoburgAG,WieneltN(1991)Borderlineindicationsforlaparoscopiccholecystectomy.DigestSurg8:101–103ZuckerKA,BaileyRW,GadaczTR(1991)Laparoscopicguidedcholecystectomy.AmJSurg161:36–44 2LaparoscopicCommonBileDuctSurgery2.1OperatingRoomSetup:PositionofthePatientThepatientisplacedsupine.Thesurgeonstandsbetweenthepatient’slegs.Thefirstassistantisonthepatient’srightsidewhilethesecondassistantisontheleft(>Fig.2.1).Twovideomonitorsetsarerequiredforthisprocedure;onefortheactuallaparoscopicpartandthesecondforcholangioscopy.Thelaparoscopicmonitorisplacedleftofthepatient’shead,whilethecholangioscopymonitorisontheright.SomereverseTrendelenburgpositionisrequired,andslightleftrotationattimes.Fig.2.1.ORsetup–trocarposition 242LaparoscopicCommonBileDuctSurgery2.2RecommendedInstrumentsTwo10-mmtrocarsTwo5-mmtrocarsA0°endoscopeThreeJohan5-mmfenestratedforcepsA5-mmstraightgraspingforcepsFive-millimetreshearsA5-mmretractableknifeA5-mmneedleholderA5-mmdissectorTwocholangioscopes:size2.8mmforatranscysticapproachandsize4.8mmforacholedochotomyapproachAspecific10-mmcholangioscopegraspingforcepsAspecificprotectivetrocarfortheflexiblecholangioscopeAplasticretrievalbagAtitaniumclipapplicator,5or10mmFogartyballooncathetersVariousDormiabaskets,3and4stranded,10and20mmAflexiblefiberlithotriptor2.3TrocarPlacementandExposurePneumoperitoneumiscreatedwithaVeressneedle,andthefirsttrocarisintro-ducedobliquelyattherightlateralmarginoftheumbilicus.Theabdominalcavityisexploredandtheoperationsiteisexposed.A5-mmrightpara-umbilicaltrocarisintroducedabout8cmlateralfromthefirstport.A5-mmfenestratedforcepsgoesinthere.Asecond10-mmportisinserted5cmabovetheumbilicus,slightlytotheleftofthemidline.Thisallowsinsertionoftheoperatinginstruments,forinstancecoagulatingshears.Twosubcostaltrocarsareinserted,oneontheaxillarylineallowingtheinsertionofasecondfenestratedforcepsorretractor.Thetrocarforthecholangioscopeispositionedsubcostallyslightlytotherightofthemidline(>Fig.2.1).Theperitonealcavityisvisuallyexplored(>Fig.2.2).Therightlateralfenestratedforcepsgraspsthegallbladderafterpositioningasmoothretractorintherightsubcostalspace.2.4DissectionofCalot'sTriangleandCBD(>Fig.2.3)Lateraltractionontheinfundibulumstraightenstheanteriorandposteriorperi-toneallayers(>Fig.2.4).Theyareincisedwithcoagulatingshearsandthecysticductisexposed. 2.4DissectionofCalot'sTriangleandCBD25Fig.2.2.ExposureofgallbladderFig.2.3.ExposureCalot’striangle 262LaparoscopicCommonBileDuctSurgeryFig.2.4.ExposureofCBDThedistalcysticductisdissectedfreedowntothecommonbileduct(CBD).TheanteriorpartoftheCBDispreparedoveradistanceof2–3cm(>Fig.2.7).Thedistalpartofthecysticductisthusclearlyidentified.Thecysticductiscontrolledproximallywithaclip.2.5IntraoperativeCholangiographyIntraoperativecholangiographyisthenperformedwithasiliconcatheterintro-ducedwithafenestratedforceps(>Figs.2.5,2.6).Thecysticductisincisedclosetotheclip.Thecatheterisintroducedaftercarefulfillingandremovingofairbubbles.FluoroscopyoftheCBDisperformed.2.6RemovalofCBDStonesCholangiographyclearlyidentifiesCBDstones,andthenumberofstonesandtheirsizecanbeassessed.Basicallytwosituationsareencountered.IfstonesaresmallerthanthecysticductandarelocatedinthedistalCBD,transcysticextractionispossible.Asinglestoneisthebestindication.Otherwise,acholedochotomyispre-ferred,especiallyincaseofmultiplestones. 2.6RemovalofCBDStones27Fig.2.5.CholangiographyFig.2.6.Cholangiography 282LaparoscopicCommonBileDuctSurgery2.7TranscysticExtraction2.7.1Step1:PreparationofCysticDuctTheopeningofthecysticcanbeslightlydilated.Thisisdonemoreeasilybyinsert-ingaflexiblewireguide.Ureteraldilatationbougiesmaybenecessary.Caremustbetakenherenottoexertexcesstractionontheinstruments.Theentirecysticductmustbedissected.ThistranscysticapproachcanbedoneonlyifthecysticductenterstheCBDlaterally,andnotincaseofaposteriorimplantation.2.7.2Step2:TranscysticExtractionCholangiographyisperformed;aDormiabasketisintroducedthroughaflexiblecatheter.Thestonemaybeextractedaftercatchingitwiththebasketunderfluoro-scopicguidance.ItissometimesnecessarytousethesmallflexiblecholangioscopeandtointroducetheDormiabasketthroughtheoperatingchannel.Thestoneiscaughtandremovedunderdirectvision.OncethelowerpartoftheCBDseemsempty,acontrolcholangioscopyoftheCBDisperformedtoensureitisactuallyempty.Cholangioscopicinspectionoftheintrahepaticductsisusuallyimpossi-blebythisroute.Afinalcontrolcholangiographycheckscompleteclearanceofstones.2.7.3Step3:ClosureofCysticDuctOncetheCBDisclearedofstones,thecysticductisclosedwithtwoclips.Incaseofmajorinflammation,oranydoubt,biledrainageisperformedwithatranscysticdrain.Thedrainistightenedtothecysticductwithanabsorbableligature.Thisveryligatureisespeciallyimportantinpreventingeitherpostoperativeleakageorcatheterdisplacement.Ifthesetranscysticmanoeuvresfail,acholedochotomyisalwayspossible.2.8Choledocholithotomy:CBDStoneExtractionThroughCholedochotomy2.8.1Step1:ExposureofCBDExposureisdonebytractionwitharightsubcostalforcepsontheinfundibulum.Thecysticductisclosedwithtwoclips.Theleftlobeoftheliverissuspendedbyatranscutaneoussutureontheanteriorligament.Anextra5-mmtrocarisinsertedleftsubcostallytolowertheduodenumandthesmallbowel.Itishandledbythe 2.8.2Step2:StoneExtractionandCheckingforResidualStones29Fig.2.7.ExposureofanteriorCBDsecondassistant.CoagulationofsmallvesselsontheanteriorpartoftheCBDisperformedwithcoagulatingshears(>Fig.2.7).Choledochotomyisdonewitharetractableblade,eitherlongitudinallyortransversally(incaseofasmallCBDorsmallstones)(>Fig.2.8).Dormiabasketsandballooncathetersareintroducedthrougharightlateralroute.2.8.2Step2:StoneExtractionandCheckingforResidualStonesOncetheCBDhasbeenopened,aretrievalbagisplacedintherightsubhepaticpositioninordertorecoverallCBDstones.ThefirstmanoeuvreconsistsofgentlepressurewithaforcepsontheCBDfromdistallytopresentstonesatthecholedoch-otomysite.Stonesareremovedandcounted(>Figs.2.9–2.11).Otherwise,Fog-artyballooncatheterandDormiabasketscanbeused.Theyareinserteddirectlyintothecholedochotomy,orunderdirectvisionthroughtheoperatingchannelofthecholangioscope.Animpactedstonemaybedestroyedbyacontactlitho-tripsycatheter(Lithoclast)insertedthroughtheoperatingchannelofthecholan-gioscope.Thefragmentsarethenextractedwiththeabove-mentionedtechniques(>Fig.2.14).Theflexiblecholangioscopeisintroducedthroughaprotectivecan-nulatocheckthattheCBDisemptyinbothitsextra-andintrahepaticportions(>Figs.2.15–2.17).ThelowerCBDisfullyexplored. 302LaparoscopicCommonBileDuctSurgeryFig.2.8.CholedochotomywithretractablebladeFig.2.9.Choledochotomycompleted 2.8.2Step2:StoneExtractionandCheckingforResidualStones31Fig.2.10.SpontaneousstonedischargeFig.2.11.Gentlestoneexpression 322LaparoscopicCommonBileDuctSurgeryFig.2.12.StonepresentingatcholedochotomysiteFig.2.13.Cholangioscopy 2.8.2Step2:StoneExtractionandCheckingforResidualStones33Fig.2.14.Cholangioscopy:lithotripsyofalargestoneFig.2.15.Cholangioscopy:papilla 342LaparoscopicCommonBileDuctSurgeryFig.2.16.Cholangioscopy:intrahepaticbileductsFig.2.17.Cholangioscopy:intrahepaticbileducts 2.9Cholecystectomy352.8.3Step3:ClosureandDrainageofCBD(>Fig.2.18)Thecholedochotomyisclosedwitha5/0absorbablecontinuoussuture.AT-tubeoratranscysticdrainmaybeleftifthereismajorinflammation.Inlessinflamma-torycases,primaryclosureoftheCBDwithoutdrainageispossible(>Figs.2.19–2.21).2.9Cholecystectomy(>Fig.2.22)Cholecystectomyisperformedlast.Thecysticductisdivided.Thecysticarteryisdissected,clippedanddivided(>Fig.2.23).Thegallbladderisfreedfromitshepaticattachmentswithcoagulatingshears.Fig.2.18.ClosureofCBD:beginningofsuture 362LaparoscopicCommonBileDuctSurgeryFig.2.19.ContinuoussutureonCBDFig.2.20.Precisestitching 2.9Cholecystectomy37Fig.2.21.EndofsutureonCBDFig.2.22.Cholecystectomy 382LaparoscopicCommonBileDuctSurgeryFig.2.23.FinalcheckofCBDsuture2.10RemovalofGallbladderandCBDStonesThegallbladderandtheCBDstonesareremovedwitharetrievalbag.Theperito-nealcavityiscleanedwithsaline.Subhepaticdrainageismandatory.Thebiliarydrain,ifpresent,isextractedthroughoneofthelateralports.Pneumoperitoneumisreleased.Theportwoundsarecleanedwithsalineandclosedwithevertingab-sorbablesutures.2.11TipsandCommentsKeepingcholecystectomyfortheendallowsbetterexposureofCBDbylateraltractionduringcholedocholithotomy.Completedissectionofthedistalcysticductmakestranscysticmanoeuvreseasier.DissectionoftheCBDatthesiteofcholedochotomymustbecomplete.HaemostasisoftheCBDincisionshouldbedonewithlow-setcoagulatingshearsduringcholedochotomy.Thelengthofthecholedochotomymustbeadaptedtothediameterofthechol-angioscopeinordertoavoidexcessiveleakage.Theincisioncanbewidenedaccordingtothesizeofthestones. Literature39GentlepressureontheCBDshouldbethefirstattemptatstoneextraction.Failuretoextractstonesmayleadtoconversiontoopensurgery.Incaseofknownresidualstones,abiliarydrainislefttohelpsubsequentpostoperativeERCP.ThecholangioscopeshouldbehandledthroughitsprotectiveTefloncannula.Evenspecificallymanufacturedforcepsremaintraumaticandmaydamagetheendoscope.Anextradedicatedinstrumenttableshouldbeusedforthecholangioscopymaterial.Thecontinuoussutureofthecholedochotomyterminatesonthreeleads.LiteratureAlipertiG,EdmundowiczSA,SoperNJ(1991)Combinedendoscopicsphincterotomyandlaparo-scopiccholecystectomyinpatientswithcholedocholithiasisandcholecystolithiasis.AnnInter-nationalMed115:783–785BagnatoVJ,McgeeGE,HattenLEetal(1991)Justificationforroutinecholangiographyduringlapa-roscopiccholecystectomy.SurgLaparoscEndosc1:89–93BaumelH,DomergueJ(1991)Cholécystectomiecoelioscopique.PressMed20:678BelghitiJ,SauvanetA(1990)Lacholangiographieperopératoireat-ellevécue?Actualitésdigestives3:115–117CorbittJD,CantwelleD(1991)Laparoscopiccholecystectomywithoperativecholangiogram.SurgLaparoscEndosc1:229–232DuboisF,IcardP,BerthelotGetal(1990)Approchechirurgicalesimplifiéedelalithiasecholédo-cienne,réduisantlacomplexitéetlagravitédecettechirurgie;153cas.AnnChir44:19–23GigotJF,NavezB(Personalcommunication)Techniquesetrésultatsdutraitementcoelioscopiquedelalithiasecholédocienneencoursdecholécystectomielaparoscopique.TheBelgiangroupforendoscopicsurgeryHandyJE,RoseSC,NievesASetal(1991)Intraoperativecholangiography:useofportablefluoros-copyandtransmittedimages.Radiology181:205–207Hauer-JensenM,KaresenR,NygaardKetal(1986)Consequencesofroutineperoperativecholangi-ographyduringcholeclystectomyforgallstonedisease:aprospective,randomizedstudy.WorldJSurg10:996–1002HoudartR,BrissetD,PerniceniTetal(1990)Lacholangiographieintra-veineuseestinutileavantcholécystectomiepourlithiasenoncompliquée:etudeprospectivede100cas.GastroenterolClinBiol14:652–654HuguierM,BornetP,CharpakY(1991)Prédictiond’unelithiasedelavoiebiliaireprincipale(VBP).AnnChirurgie45:938HunterJG(1992)Laparoscopictrancysticcommonbileductexploration.AmJSurg163:53–58JakimowiczJ(1991)Intraoperativevs.postoperativebiliaryendoscopy:intraoperativeultrasonogra-phyvs.sonographyduringlaparoscopiccholecystectomy.Problemsingeneralsurgery.LaparoscSurg8:442–457JoyceWP,KeaneR,BurkeGJ(1991)Identificationofbileductstonesinpatientsundergoinglaparo-scopiccholecystectomy.BrJSurg78:1174–1176MalletG(1976)Lacholangiographieopératoiredanslapressechirurgicaleanglo-saxonne.LyonChirurgical72:369–374MillsJL,BeckDE,HarfordFJetal(1985)Routineoperativecholangiography.SurgGynecolObstetric161:343–345 402LaparoscopicCommonBileDuctSurgeryMoreauxJ,HoriotA(1982)Ladésobstructiondelavoiebiliaireprincipaleparvoietrancystique.JChir(Paris)119:193–194MotsonRW,WetterA(1990)Operativecholedoscopy:commonbileductexplorationisincompletewithoutit.BrJSurg77:975–982PetelinJB(1991)Laparoscopicapproachtocommonductpathology.SurgLaparoscEndosc1:33–41PhillipsEH,CarrollB(1991)Newtechniquesforthetreatmentofcommonbileductcalculien-counteredduringlaparoscopiccholecystectomy.Problemsingeneralsurgery.LaparoscSurg8:387–394PonchonT,ValettePJ,HenryLetal(1992)Cholédoscopiepercutanée.XIVèJournéesdepathologiedigestive,NiceSackierJM,BerciG,PhillipsEetal(1991)Theroleofcholangiographyinlaparoscopiccholecystec-tomy.ArcSurg126:1021–1026SchivelyEH,WiemanTJ,AdamsAL(1990)Operativecholangiography.AmJSurg159:380–385SpawAT,ReddickEJ,OlsenDO(1991)Laparoscopiclasercholecystectomy:analysisof500proce-dures.SurgLaparoscEndosc1:2–7StokerME(1991)Laparoscopiccommonductexploration;3rdInternmeetingofSummit,BostonThompsonJE,BennionRS(1988)Intraoperativeendoscopyofthebiliarytract.SurgEndosc2:172–175UngerSW,EdelmanDS,ScottJSetal(1991)Laparoscopictreatmentofacutecholecystitis.SurgLaparoscEndosc1:14–16 3LaparoscopicFundoplicationforGERD:LaparoscopicNissenandToupetFundoplication3.1OperatingRoomSetup:PositionofthePatientThepatientundergeneralanaesthesiaisplacedsupinewithaslight10°reverseTrendelenburgposition.Thesurgeonstandsbetweenthepatient’slegs.Thefirstassistantisonthepatient’srightsideandthesecondassistantonthesurgeon’srightside(>Fig.3.1).Themonitorandlaparoscopyrackareplacedleftofthepatient’shead.Fig.3.1.ORsetup–trocarposition 423LaparoscopicFundoplicationforGERD:LaparoscopicNissenandToupetFundoplication3.2RecommendedInstrumentsA0°straightendoscopeOne10-mmtrocarFour5-mmtrocarsTwo5-mmJohanfenestratedgraspingforcepsStraightorcurved5-mmcoagulatingshearsAstraight5-mmgraspingforcepsA5-mmneedleholderA5-mmsuctioncannulaHooked5-mmgraspingforcepsA36FFauchertubeHarmonicscalpel,ifavailable3.3TrocarPlacementandExposure:DissectionofHiatusThe10-mmtrocarisplacedinthemiddleofthexipho-umbilicalline.Theleftoper-atingtrocarisplaced5cmlateraltotherightofthefirsttrocar.Therightoperatingtrocarisplacedintheleftsubcostalregion.Athird5-mmleftlateralsubcostaltro-carisplacedforpurposesofexposure.Afinal5-mmrightmediansubcostaltrocarallowsretractionoftheliver.Inobesepatients,thelattertrocarisplacedclosertothexiphoidprocess.Thehiatusisdefinedbythetwopillarsofthediaphragm.Operativestrategyconsistsofopeningthevisceralperitoneummediallyaroundthepillars,irrespec-tiveofthesizeofthehiatalenlargement.Thefirststepistoreducethestomachbygentletractionwiththeleftlateralforcepsplacedontheanteriorpartofthestomach.Theleftlobeoftheliveristhenreclinedbytherightsubcostalforceps(>Fig.3.2).Itiskeptinplacebyattachingittothediaphragmatthetopoftherightpillar.A5-mmadjustableretractormaybeusedforthis.Theparsflaccidaofthelesseromentumisopenedwithcoagulatingshears.Therightpillaristhusexposed.Alefthepaticartery,ifpresent,mustbepreserved(>Fig.3.3).Therightcrusisfreedfromitsperitonealadhesionsfrombottomtotop.Medi-astinaldissectionisbegunandtheoesophagusislowered(>Fig.3.4).TheVshapeofthehiatusisreached,andthestartoftheleftcrusisidentified(>Figs.3.5–3.7)andthenfreedwhilstpullingthestomachtotheright.Thisexposesthegastro-phrenicligament,whichisgraduallyresected.Theexposureisagainmodifiedbyleftwardstractiononthestomach.Thedis-sectionoftheinferiorpartoftheleftcrusiscontinueduntiltheV-shapedoriginofbothcruraisdissected(>Fig.3.8).Lateraldissectionoftheleftcruscreatesaretro-oesophagealwindow(>Figs.3.9,3.10). 3.3TrocarPlacementandExposure:DissectionofHiatus43Fig.3.2.ExposurewithliverretractorFig.3.3.Openingoflesseromentum 443LaparoscopicFundoplicationforGERD:LaparoscopicNissenandToupetFundoplicationFig.3.4.ExposureofrightcrusFig.3.5.Dissectionofrightcrus 3.3TrocarPlacementandExposure:DissectionofHiatus45Fig.3.6.ExposureofleftcrusFig.3.7.Completedanteriordissection 463LaparoscopicFundoplicationforGERD:LaparoscopicNissenandToupetFundoplicationFig.3.8.DissectionoflowerpartofleftcrusbehindtheoesophagusFig.3.9.Creatingaretro-oesophagealwindow 3.4OesophagealDissection47Fig.3.10.Retro-oesophagealwindowDissectionofthehiatusisthencomplete.Thisdissectioncanbeperformedwiththecoagulatingshearsortheharmonicscalpel.Theoesophagusiscentredonthehiatus.Iftherewerealargehiataldefect,avisceralperitonealcollarwouldbeseenontheoesophagus.3.4OesophagealDissection(>Fig.3.11)Dissectioniscontinuedinsidethemediastinumbybluntlyopeningtheweb-liketissue.Thepleuraarepushedback.Thevagusnervesareleftinclosecontactwiththeoesophagus(>Fig.3.12).Theoesophagusisfreedfor5–10cmtogainintra-peritoneallength. 483LaparoscopicFundoplicationforGERD:LaparoscopicNissenandToupetFundoplicationFig.3.11.DissectionofoesophagusinsidethemediastinumFig.3.12.Exposureofrightvagusnerve 3.6ClosureoftheHiatalDefect493.5MobilizationoftheFundusThefundusisgraduallyfreedfromitsdiaphragmaticattachments,especiallybycompletesectioningofthegastrophrenicligament(>Fig.3.13).Ifthefunduscan-notbemobilized,controlofshortgastricvesselsiscarriedoutwithclipsor,better,withtheharmonicscalpel.Exposureisensuredbytractiononthestomachandgastrophrenicligament.Thestomachisthussufficientlymobilizedandthefundusisgraspedbehindtheoesophagusthroughtheretro-oesophagealwindowwithafenestratedforcepsintroducedfromtherightside(>Figs.3.14–3.16).Aretro-oesophagealwrapiscreated.3.6ClosureoftheHiatalDefectThehiatusshouldalwaysbeclosedbysuturingbothcrura.Exposureisobtainedbytractiononthegastricwrapwithaleft-sidedforceps.Twoorthreeinterruptedsuturesofnonabsorbablemultifilamentareplacedontheinferiorpartofthecrura(>Fig.3.17).Intracorporealknottingisbest.Fig.3.13.Freeinggastrophrenicattachments 503LaparoscopicFundoplicationforGERD:LaparoscopicNissenandToupetFundoplicationFig.3.14.SelectingthewrapFig.3.15.Pullingthewrapbehindtheoesophagus 3.6ClosureoftheHiatalDefect51Fig.3.16.PlacingthewrapFig.3.17.Suturingthecrura 523LaparoscopicFundoplicationforGERD:LaparoscopicNissenandToupetFundoplication3.7CreatinganAnti-refluxWrapTwotypesofgastricvalvemaybecreated.Mostcasesrequirea270°partialposte-riorvalveaccordingtoToupet.Incaseofalargeormodifiedhiatus,however,wepreferacomplete360°Nissen-typevalve.3.8Toupet270°FundoplicationTheleftlateralgraspingforcepsexposestheesogastricjunction.Usuallythelastsuturemayfixthegastricvalveposteriorlyonthecrura(>Fig.3.18).Therightpartofthegastricvalveissuturedtotheoesophaguswiththreeorfourinterruptedsuturesofnonabsorbable2/0multifilament,afterlocatingthevagusnerveontheoesophagealwall(>Fig.3.19).Theleftpartofthegastricvalveissuturedinanidenticalandsymmetricalman-ner,whilerespectingtheanteriorvagusnerve.Theanteriorpartoftheoesophagusisleftfreefor2cm(>Figs.3.20,3.21).Fig.3.18.Thewrapissuturedposteriorlytotheclosedcrura 3.8Toupet270°Fundoplication53Fig.3.19.Toupet:creatingtherightpartofthewrapFig.3.20.Toupet:creatingtheleftpartofthewrap 543LaparoscopicFundoplicationforGERD:LaparoscopicNissenandToupetFundoplicationFig.3.21.Toupetcompleted3.9Nissen360°Valve(>Fig.3.22)Thegastricvalveiscompletelywrappedaroundtheabdominaloesophagus.Theposteriorpartissuturedtothecrura.Bothvalvesofthewrappedfundusandtheanteriorpartoftheoesophagusaresuturedtogetherwithfourorfivenonabsorb-ablemultifilamentstitches.Theposteriorvagusnerveisleftclosetotheoesopha-gusinsidethevalve.Theanteriorvagusnerveshouldbeavoidedwhilesuturingthewraptotheoesophagus.A36FFauchertubecalibratestheoesophagus.3.10FixingtheValve:DrainageItisimportanttofixthevalvecorrectlybothinNissenorToupetprocedure.Thevalveisalwayssuturedtothecruraposteriorly(>Fig.3.18).Therightpartofthevalvecanalsobesuturedtotherightcrus.Subhepaticsuctiondrainageisoptional. 3.11TipsandComments55Fig.3.22.CompletedNissen3.11TipsandCommentsAlwaysinsertthetrocarsaftercompleteinflation;orientatetheminthedirec-tionofthehiatus.Thelivermaybereclinedbyanautostaticretractorandaspecificinstrument,especiallyinpresenceofsteatosisorhypertrophyoftheleftlobe.Alefthepaticarteryisfrequentlyencountered.Thedecisiontokeepitornotdependsonitssize.Gianthiatalherniasaretreatedthesameway.Completeremovaloftheperito-nealsacisachievedbycircularincision.Theresectedperitoneumisleftcollar-likearoundtheoesophagus.Tractiononthestomachthroughtheleftlateraltrocarmaybeensuredbytheautostaticdevice.Inthiscase,nosecondassistantisneeded.SuturingofthecruramaybereinforcedwithTeflonpledgets.U-shapedsuturesarethenperformed,takinginthesesupports.Incaseofalargehiatalopening,oneortwofinalsuturesshouldbedoneante-riorlytoavoidstrictureontheoesophagus.Thebestgastricvalveistheupperpartofthefundus,atthejunctionbetweentheanteriorandposteriorwallsofthestomach.Lookingthroughtheretro-oesophagealwindow,ifproperlydissected,makesthebestchoicevisible.A36FFauchertubeuponterminationoftheprocedurecalibratestheoesopha-gusandoutlinesthequalityoftherepair. 563LaparoscopicFundoplicationforGERD:LaparoscopicNissenandToupetFundoplicationLiteratureAnvariM,AllenC,BormA(1995)LaparoscopicNissenfundoplicationisasatisfactoryalternativetolongtermomeprazoletherapy.BrJSurg82:938–942CadiereGB,HoubenJJ,BruynsJ,HimpensJ,PanzerJM,GelinM(1994)LaparoscopicNissenfun-doplication:techniqueandpreliminaryresults.BrJSurg81:400–403CatteyRP,HenryLG,BielefieldMR(1996)LaparoscopicNissenfundoplicationforgastroesophagealre-fluxdisease:clinicalexperienceandoutcomeinthefirst100patients.SurgLaparoscEndosc6:430–433CosterDD,BowerWH,WilsonVT,BrebrickRT,RichardsonGL(1997)Laparoscopicpartialfun-doplicationvs.laparoscopicNissen-Rossettifundoplication:short-termresultsof231cases.SurgEndosc11:625–631CuschieriA,HunterJ,WolfeB,SwanstromLL,HutsonW(1993)Multicenterprospectiveevaluationoflaparoscopicantirefluxsurgery:preliminaryreport.SurgEndosc7:505–510DallemagneB,WeertsJM,JehacsC,MarkiewidS,LombardR(1991)LaparoscopicNissenfundopli-cation:preliminaryreport.SurgLaparoscEndosc1:138–143FontaumardE,EspalieuP,BoulezJ(1995)LaparoscopicNissen-Rossettifundoplication.SurgEn-dosc9:869–873GeageaT(1994)LaparoscopicNissen-Rossettifundoplication.SurgEndosc8:1080–1084GotleyDC,SmithersBM,MenziesB,BranickiFJ,RhodesM,NathansonL(1996)LaparoscopicNis-senfundoplicationandpostoperativedysphagia:canitbepredicted?AnnAcadMedSingapore25:646–649GotleyDC,SmithersBM,RhodesM,MenziesB,BranickiFJ,NathansonL(1996)LaparoscopicNissenfundoplication:200consecutivecases.Gut38:487–491HallerbackB,GliseH,JohanssonB,RadmarkT(1994)LaparoscopicRossettifundoplication.SurgEndosc8:1417–1422HunterJG,SwanstromL,WaringJP(1996)Dysphagiaafterlaparoscopicantifrefluxsurgery:theimpactofoperativetechnique.AnnSurg224:51–57JamiesonGG,WatsonDI,Britten-JonesR,MitchellPC,AnvariM(1994)LaparoscopicNissenfun-doplication.AnnSurg220:137–145LaycokWS,TrusTL,HunterJG(1996)NewtechnologyforthedivisionofshortgastricvesselsduringlaparoscopicNissenfundoplication:aprospectiverandomizedtrial.SurgEndosc10:71–73LegettPL,Churchman-WinnR,AhnC(1998)Resolvinggastrooesophagealrefluxwithlaparoscopicfundoplication:findingsin138cases.SurgEndosc12:142–147NisssenR(1956)EineeinfacheOperationzurBeeinflussungderRefluxoesophagitis.SchwetMedWochenschr86:590–592PattiMG,ArceritoM,FeoCV,DePintoM,TongJ,GantertW,TyrrellD,WayLW(1998)Ananalysisofoperationsforgastroesophagealrefluxdisease.ArchSurg133:600–607PetersJH,DeMeesterTR,CrookesP,ObergS,deVosShoopM,HagenJA,BremnerCG(1998)ThetreatmentofgastroesophagealrefluxdiseasewithlaparoscopicNissenfundoplication:prospec-tiveevaluationof100patientswith„typical“symptoms.AnnSurg228:40–50RattnerDW,BrooksDC(1995)Patientsatisfactionfollowinglaparoscopicandopenantirefluxsur-gery.ArchSurg130:289–294RossettiM,HellK(1977)Fundoplicationforthetreatmentofgastroesophagealrefluxinhiatalher-nia.WorldJSurg1:439–444SwanstromLL,PenningsJL(1995)Laparoscopiccontrolofshortgastricvessels.JAmCollSurg181:347–351WatsonDI,JamiesonGG(1998)Antirefluxsurgeryinthelaparoscopicera.BrJSurg85:1173–1184WatsonDI,GourlayR,GlobeJ,ReedMWR,JohnsonAG,StoddardCJ(1995)Prospectiverandomizedtrialoflaparoscopic(LNF)versusopen(ONF)Nissenfundoplication[Abstract].Surgery118:58WatsonDI,PikeGK,BaigrieRJ,MathewG,DevittPG,Britten-JonesR,JamiesonGG(1997)Pro-spectivedouble-blindrandomizedtrialoflaparoscopicNissenfundoplicationwithdivisionandwithoutdivisionofshortgastricvessels.AnnSurg226:642–652 4LaparoscopicGastricBandingforMorbidObesity4.1OperatingRoomSetup:PositionofthePatientThepatientisplacedsupinewithlegsapart.Bothlegsareflexedandextrasupportisgivenonthethighs.ReverseTrendelenburgpositionmustbegenerous,withthepatientinanear-sittingposition.Thesurgeonstandsbetweenthepatient’slegs.Thefirstassistantisattherightofthepatient,andthemonitorisontheleftsideofthepatient.Asecondassistantstandsontheleftofthepatient(>Fig.4.1).Fig.4.1.ORsetup–trocarposition 584LaparoscopicGastricBandingforMorbidObesity4.2RecommendedInstruments(>Fig.4.2)Five-millimetreinstrumentsCoagulatingshearsThreeJohannfenestratedforcepsAspecific10-mmdissectioninstrument,withangulationmechanismAuto-staticendoscopeholdersFive-millimetrehepaticretractorsSiliconbandingdeviceandaccessport,ofvarioussizesdependingontissuethicknessandmodelsTwo10-mmtrocarsThree5-mmtrocarsA15-mmtrocarA30°endoscopeA5-mmneedleholderA2/0nonabsorbablesuture,with26-mmneedleFig.4.2.Instruments 4.3PositionoftheTrocarsandExposure594.3PositionoftheTrocarsandExposure(>Fig.4.3)PneumoperitoneumiscreatedwithaVeressneedle.Thefirst10-mmtrocarisin-sertedinthemiddleofthexipho-umbilicalline.Thegeneraldirectionofthetrocarshouldbeobliquetowardsthehiatus.Theleftlobeoftheliverisreclinedthrougharightsubcostaltrocar,slightlyrightofthexiphoidprocess.A5-mmtrocarisplaced5cmfromthefirstontheright.A10-mmtrocar,placedintheleftparame-dianpositionattwofingerwidthsfromthecostalrim,enablestheinsertionoftheright-handoperatinginstrument.Amorelateral4-cmsubcostalincisionenablesthefuturepositioningoftheaccessportandtheinsertionofthelast15-mmoper-atingtrocar.ExposureisperformedusingtheJohannforcepsinsertedthroughtheleftlat-eraltrocartoseizetheanteriorpartofthefundus.Aliverretractorisinserted(>Fig.4.4).Aspecificinflatablegastrictubewitha25-mlballoonisintroducedbytheanesthesiologist.Theballoonisinflatedto25mlandplacedbytractionbelowtheoesophagealgastricjunction(>Fig.4.5).Incisionofthelesseromentumisstartedandmarkedbyelectrocautery,closetothegastricwall,attheequatoroftheballoon.Theballoonisdeflatedandthegastrictuberemoved.Thegastrophrenicligamentisidentified.Fig.4.3.Positionoftrocars 604LaparoscopicGastricBandingforMorbidObesityFig.4.4.LiverretractorFig.4.5.Balloonmeasuringgastricpouch 4.4RetrogastricChannel614.4RetrogastricChannel(>Fig.4.6)Thedissectionandcoagulationofthelesseromentumisstarted.Thiscontinuesincontactwiththegastricwalloveradistanceof1cm.AJohannforcepsintroducedfromtheleftdissectsthisretrogastricplaneasfaraspossible.Thefundusisgraspedbytheleftlateralinstrument.Thegastrophrenicligamentisgraspedbytheleftlateralinstrumentandbythecoagulatingscissorsinsertedthroughtheleftparamediantrocar.Theesogastricangleanditsdiaphragmaticattachmentsaredissectedbysuccessivecoagulation.Theretrogastrictunnelingcanbeperformedusingthespecificinstrumentin-sertedthroughthe10-mmleftparamediantrocar.Thisinstrumentisplacedintheretrogastricpositionandgentlypushedforward.Exposureisprogressivelyresumed,pushingbackthefundusandrevealingtheesogastricangle.Oncethedissectorisseen,itisangulatedandpushedforward,completingtheretrogastrictunnel.Fig.4.6.Para-gastricdissection 624LaparoscopicGastricBandingforMorbidObesity4.4.1PreferredOptionThespecificangulatedinstrumentformakingtheretrogastrictunnelisintroducedafteropeningtheparsflaccida(>Fig.4.7),anddissectingtherightcrusofthedia-phragm.Theinstrumentthuscreatesahighretrogastricchannelatthelevelofthe"V"ofthetwodiaphragmaticcruraandtheesogastricjunction(>Figs.4.8,4.9).Asecondpositioningoftheinstrumentstartsatthepreviouslymarkedretrogas-tricchannel,towardstheesogastricjunction.Thistwo-stepprocedureplacesthebandinghigher,andleavesvagusnerveandlesseromentumoutsidethebanding.4.5PlacementoftheGastricBanding(>Fig.4.10)Thegastricbandingisrinsedwithsalineandintroducedintotheabdomenthroughthe15-mmleftlateraltrocar.ThecatheterofthegastricbandingisfittedwithitsTeflontab(>Fig.4.11).Thisendiseithergraspedwithaforcepsorwiththespe-cificangulatinginstrument.Thecatheteristhenpulledthroughtheretrogastricchannel(>Figs.4.12–4.14).UsingaleftparamedianJohannforceps,thebandispassedintotheretrogastricposition;thisoccasionallyrequiresadditionalcoagula-tionduetothenarrownessofthechannel(>Figs.4.15–4.19).Fig.4.7.Incisionofthelesseromentum 4.5PlacementoftheGastricBanding63Fig.4.8.Retro-oesophagealdissectionFig.4.9.Retro-oesophagealtunnelling 644LaparoscopicGastricBandingforMorbidObesityFig.4.10.IntroducingthebandingdeviceFig.4.11.Bandinsidetheabdomen 4.5PlacementoftheGastricBanding65Fig.4.12.GraspingthebandcatheterbehindtheoesophagusFig.4.13.Passingthecatheterbehindtheoesophagus 664LaparoscopicGastricBandingforMorbidObesityFig.4.14.BandcatheterpassedbehindtheoesophagusFig.4.15.Tunnellingthroughthelesseromentum 4.5PlacementoftheGastricBanding67Fig.4.16.CatheterpassedthroughthelesseromentumFig.4.17.Cathetersecurelypassedthroughthelesseromentum 684LaparoscopicGastricBandingforMorbidObesityFig.4.18.BandplacementbehindtheoesophagusFig.4.19.Bandpassedthroughthelesseromentum 4.7SuturingtheStomachtoFixtheBand694.6FittingoftheBand(>Figs.4.20–4.22)Beforeclosingtheband,thegastrictubeisintroducedagainandtheballoonisin-flatedto20ml.Thebandisclosedaroundthestomach,creatinga20-mlpouch.4.7SuturingtheStomachtoFixtheBandTheanteriorwallofthefundusisusedtocreateagastricvalvearoundtheex-posedpartoftheband.Thisisessentialtopreventpostoperativeslippageoftheband.Interruptednonabsorbable2/0multifilamentsuturesarerequired.Thebandcatheterismaintainedonthesideofthelessercurvaturewiththeleftfenestratedforceps.Thefirstsuturesareplacedwiththeballoonstillinflated.Continuoussu-turesareoptional.Incaseofinterruptedsutures,fourstitchesareusuallyneeded(>Figs.4.23–4.26).Fig.4.20.Bandinplacearoundstomach 704LaparoscopicGastricBandingforMorbidObesityFig.4.21.ClosureofbandFig.4.22.Bandclosedafterpouchmeasurement 4.7SuturingtheStomachtoFixtheBand71Fig.4.23.BandwrappedwiththegastricwallstartingontheleftFig.4.24.Wrappingthebandcontinued 724LaparoscopicGastricBandingforMorbidObesityFig.4.25.WrappingcompletedFig.4.26.Finallaparoscopicview 4.8PlacementoftheAccessPort734.8PlacementoftheAccessPort(>Fig.4.27)Thegastricbandisinplace.Thehepaticretractorisremoved.ThedistalendofthecatheterofthegastricbandisgraspedwithaJohannforcepsinsertedthroughthe15-mmtrocar.Thepneumoperitoneumisreleased.Thecatheterisconnectedtotheaccessportthathasbeenpreviouslyfilledwithsaline.Asubcutaneousspaceiscreated(>Fig.4.28).Theaccessportisplacedsubcutaneouslyandportwoundsareclosed.Fig.4.27.Accessportattached 744LaparoscopicGastricBandingforMorbidObesityFig.4.28.Accessportisplacedsubcutaneously4.9TipsandCommentsGiventheparietalthickness,thetrocarsmaybeextralong.Trocarsmustbeinsertedaftercompleteinflationoftheabdomen,towardsthehiatusinthegeneralworkingdirectionbecauseofthethicknessoftheobeseabdominalwall.Theretrogastricchannelmustbemadewiththeleftparamedianinstrumentforacorrectdirectionoftheretrogastrictunnel.Theproposedoptionofaretrogastricchannelnearthefootofthecruramustbeperformedwiththerightparamedianfenestratedforceps.Thesecondtunnelexcludingthelesseromentummustbeperformedwiththespecificangulatedinstrumentinsertedintheleftparamedianposition.Thelockingmechanismofthegastricbandispositionedincontactwiththelesseromentum,enablingalargeranteriorgastricvalveandmakingfuturebandremovaleasier.Theuseofthe30°endoscope,whilenot100%useful,isnonethelessstronglyrecommendedforBMI'sover50kg/m2.Thebandisneverinflatedimmediately,butusually6weekspostoperatively. 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5LaparoscopicHellerEsophagomyotomyforAchalazia5.1OperatingRoomSetup:PositionofthePatientThepatientisplacedsupinewithaslight10°reverseTrendelenburgposition.Thesurgeonstandsbetweenthepatient’slegs.Thefirstassistantisontherightofthepatientandasecondassistantisontheleftofthepatient.Themonitorisplacedbehindandtotheleftsideofthepatient’shead(>Figs.5.1,5.2).Fig.5.1.ORsetup 785LaparoscopicHellerEsophagomyotomyforAchalazia5.2RecommendedInstrumentsA0°endoscope(a30°endoscopecanbeuseful)A10-mmtrocarFour5-mmtrocarsTwoJohanfenestratedgraspingforcepsFive-millimetrestraightorcurvedcoagulatingshearsAstraight5-mmgraspingforcepsA5-mmneedleholderA5-mmsuctioncannulaA5-mmhookedgraspingforcepsA10-mmoesophagealdilatationballoonHarmonicscalpelifavailable5.3TrocarPlacementandExposure(>Fig.5.2)The10-mmtrocarispositionedinthemiddleofthexipho-umbilicalline.Theleftoperatingtrocarispositioned5cmtotherightofthisfirsttrocar.Theright-handoperatingtrocarispositionedintheleftmediansubcostalposition.Athird5-mmtrocarintheleftlateralsubcostalpositionisessentiallyusedforexposure.Afinal5assistant12314assistant26surgeonFig.5.2.Positionoftrocars 5.4DissectionoftheHiatus79rightmediansubcostal5-mmtrocarenablesretractionoftheliver.Dependingonthedegreeofobesityofthepatient,thislatterportwillbepositionedclosertothexiphoid.Dissectionstartswithopeningtheparsflaccidawhilepullingfromtheleftonthestomach.Hepaticnervesintheparsflaccidacanbesectioned.Alefthepaticarteryshouldbestbepreserved.5.4DissectionoftheHiatusTherightcrusofthediaphragmisexposed(>Fig.5.3).Theperitoneumisopenedmediallytotherightcrus,startingfromthemiddle,andtoptobottom,torespecttheposteriorpartofthehiatus.Afteropeningtheperitoneum,themediastinaldissectionisstarted.ThetopofthehiatusattheleveloftheupperVofthecruraisreached.Theleftcrusisrapidlyrecognized(>Fig.5.4).Theperitoneummedialtotheleftcrusisopenedtothemiddlepart.Thehiatusisthusdissectedinitsanteriorhalf,asisexposedtheanteriorwallofthemedias-tinaloesophagus(>Fig.5.5)Fig.5.3.Exposureofrightcrus 805LaparoscopicHellerEsophagomyotomyforAchalaziaFig.5.4.ExposureofleftcrusandlowermediastinumFig.5.5.Exposureofmediastinaloesophagus 5.6EsophagealMyotomy815.5DissectionoftheOesophagusTheanteriorwalloftheoesophagusisgentlydissected,usingabluntinstrumentandproceedingwiththegreatestcare.Exposureofatleast10cmofmediastinaloesophagusisnecessary.Therightandleftpleuraarereclined.Duringthisstageoftheoperation,exposureisoptimizedbyagraspingforcepsliftingtheupperVofthehiatus(>Fig.5.6).5.6EsophagealMyotomyThemyotomystarts1cmabovethegastro-oesophagealjunction,usingtheco-agulatingshears(>Fig.5.7).Thelongitudinalmuscularfibresareincisedinthemiddleoftheanteriorwalloftheoesophagus.Theendoscopeshouldzoominascloseaspossibletotheoperativefield.Thecircularfibresappear.Theyaredeli-catelytransected.Thesubmucosalplaneisexposed(>Fig.5.8).Themyotomyiscarriedon.Afenestratedforcepsdelicatelyexploresthedissec-tionplanebetweenthemucosaandthemuscularlayers(>Fig.5.9).Themuscularfibersareresectedwiththecoagulatingscissorsoveradistanceof6–7cmalongthemediastinaloesophagus(>Figs.5.10,5.11).Fig.5.6.Mediastinaldissection 825LaparoscopicHellerEsophagomyotomyforAchalaziaFig.5.7.AnteriorvagusFig.5.8.Startofmyotomy 5.6EsophagealMyotomy83Fig.5.9.ResectionofcircularmuscleFig.5.10.Upperlimit 845LaparoscopicHellerEsophagomyotomyforAchalaziaFig.5.11.SubmucosallayerofoesophagusexposedThemyotomyiscontinuedtowardstheesogastricjunction.Thedissectionbe-comesincreasinglydelicateandthemuscularfibresaredissectedprogressively(>Figs.5.12,5.13).Resectionisperformedwiththecoagulatingscissors.Thisiscontinuedafurther2cmdownwardsfromthegastro-oesophagealmucosaljunc-tion,andmustalwaysbemonitoredbyanintraoperativegastroscopy(>Fig.5.14).Themyotomyischeckedforleakagebyinstillationofmethyleneblue.5.7RefectionoftheAngleofHis:Anti-refluxValveAnanterioranti-refluxvalveismadewiththefundus.Ifthehiatusisnotenlarged,thegastricvalveissuturedtoleftsideofthemyotomy,justrecreatingthenormalanatomyoftheangleofHis(>Fig.5.15).Theanteriorvalve,however,maybetotal,coveringthemyotomy,performedbysuturingthegastrictissuetotherightedgeofthemyotomywithfourtofiveintracorporealsuturesusing2/0nonabsorbableligatures(>Fig.5.16).Therightpartoftheanteriorvalvecanbesuturedtotherightcruswithtwoorthreestitches(>Fig.5.17). 5.7RefectionoftheAngleofHis:Anti-refluxValve85Fig.5.12.InferiorpartofmyotomyFig.5.13.Myotomynearcompletion 865LaparoscopicHellerEsophagomyotomyforAchalaziaFig.5.14.EndoscopiccontrolofesogastricjunctionFig.5.15.Gastricwraponleftedgeofthemyotomy 5.7RefectionoftheAngleofHis:Anti-refluxValve87Fig.5.16.GastricwrapontherightedgeofthemyotomyFig.5.17.Suturingthegastricwraptothecrura 885LaparoscopicHellerEsophagomyotomyforAchalazia5.8AdditionalSurgeryontheHiatus:PeritonealLavage–DrainageIntheabsenceofalargehiataldefect,andasithasnotbeentotallydissected,noextraclosureisrequired.However,alargewideningofthehiatusrequiressutur-ingthepillarsofthediaphragm.Thisisusuallyperformedintheupperpartofthecrura,byinterruptedintracorporeal2/0nonabsorbablestitches(>Fig.5.18).Theoperativefieldischeckedforbleeding.Asuctiondrainagemaybeleft.5.9TipsandCommentsAlwayspositionthetrocarsaftercompletionofthepneumoperitoneumanddirecttheminthedirectionofthehiatus.Myotomycanbefacilitatedbyanoesophagealdilatationcatheterinflatedtoamoderatepressureof18French.Harmonicscalpelcanprovehelpfulinthetransectionofthemuscularfibres.Themucosalplane,however,mustnotbeexposedtotheactivebladeoftheinstrument.Aretro-oesophagealpresentationlacecanbepositionedtobetteroutlinetheoesophagealgastricjunctionandtotractontheabdominaloesophagus.Fig.5.18.Closureofthecrura Literature89Thelivermaybereclinedbyanauto-staticretractorandaspecificinstrument,especiallyinthepresenceofsteatosisorhypertrophyoftheleftlobe.Alefthepaticarteryisfrequentlyencountered.Itshouldbepreserved,depend-ingonitssize.Anadditional5-mmtrocarcanbepositionedtoexposethetwoedgesofthemyotomy,thusachievingasymmetricalexposure,eitherbytractiononthein-strumentsorbytheplacementoftwopresentationsutures.LiteratureAbidS,ChampionG,RichterJEetal(1994)Treatmentofachalasia:thebestofbothworlds.AmJGastroenterol89:979–985AmarelJF(1994)Laparoscopicmyotomiesusinganultrasonicallyactivatedscalpel.SurgEndosc8:463AnconaE,PeracchiaA,ZaninottoGetal(1993)Hellerlaparoscopiccardiomyotomywithantirefluxanteriorfundoplication(Dor)inthetreatmentofesophagealachalasia.SurgEndosc7:459AndreolloNA,EarlamRJ(1987)Heller‘smyotomyforachalasia:isanaddedanti-refluxprocedurenecessary?BrJSurg74:765–769AnselminoM,HinderRA,FilipiCJ,WilsonP(1993)LaparoscopicHellercardiomyotomyandthora-coscopicoesophageallongmyotomyforthetreatmentofprimaryoesophagealmotordisorders.SurgicalLaparoscopyandEndoscopy3:437–441BonavinaL,NosadiniA,BardiniR,BaessatoM,PeracchiaA(1992)Primarytreatmentofoesophagealachalasia.ArchSurg127:222–227BuessG,CuschieriA,MannekeK,SchneiderHJ,BeckerHD(1993)Techniqueandpreliminaryre-sultsoflaparoscopiccardiomyotomy.EndoscopicSurgery1:76–81CrookesPF,WilkinsonAJ,JohnstonGW(1989)Heller‘smyotomywithpartialfundoplication.BrJSurg76:98–99CsendesA,BraghettoI,HenriquezA,CortesC(1989)Lateresultsofaprospectiverandomisedstudycomparingforcefuldilatationandoesophagomyotomyinpatientswithachalasia.Gut30:299–304CuschieriA(1993)Endoscopicoesophagealmyotomyforspecificmotilitydisordersandnon-cardiacchestpain.EndoscopicSurgery1:280–285CuschieriA,NathansonLK,ShimiSM(1992)Thoracoscopicoesophagealmyotomyformotilitydisorders.In:CuschieriA,BuessG,PerissatJ(eds)Operativemanualofendoscopicsurgery.Springer,BerlinHeidelbergNewYork,pp141–148CuschieriA,ShimiSM,NathansonLK(1992)Laparoscopiccardiomyotomyforachalasia.In:Cusch-ieriA,BuessG,PerissatJ(eds)Operativemanualofendoscopicsurgery.Springer,BerlinHeidel-bergNewYork,pp298–302DallemagneB(1993)Endoscopicapproachestooesophagealdisease.Baillière’sClinicalGastroen-terology7:795–822DePaulaAl,HashibaK,BafuttoM(1995)Laparoscopicapproachtoesophagealachalasia.SurgEndosc9:220DorJ,HumbertP,FigarellaJ(1962)L’intérêtdelatechniquedeNissenmodifiéedanslapréventiondurefluxaprèscardiomyotomieextra-muqueusedeHeller.Mémoiresdel’AcadémiedeChirur-gie88:877–883EllisFH(1991)Functionaldisordersoftheesophagus.In:ZuidemaGD,OrringerMB(eds)Shackel-ford’ssurgeryofthealimentarytract,3rdedn.WBSaunders,Philadelphia,pp146–163EllisFH(1993)Oesophagomyotomyforachalasia:a22-yearexperience.BrJSurg80:882–885EllisFH,CrozierRE,GibbsSP(1986)Reoperativeachalasiasurgery.JThoracCardiovascSurg92:859–865 905LaparoscopicHellerEsophagomyotomyforAchalaziaJaakkolaA,OvaskaJ,IsolauriJ(1991)Esophagocardiomyotomyforachalasia.EurJSurg157:407–410KatzP(1994)Achalasia:twoeffectivetreatmentoptions–letthepatientdecide.AmJGastroenterol89:969–970MercerCD,HillL(1986)Reoperationafterfailedesophagomyotomyforachalasia.CanJSurg29:177–180MonsonJRT,DarziA,CareyPD,GuillouPJ(1994)ThoracoscopicHellers’scardiomyotomy:anewapproachforachalasia.SurgicalLaparoscopyandEndoscopy4:6–8MucioM(1994)Achalasia:laparoscopictreatment.SurgEndosc8:463PaiGP,EllisonRG,RubinJW,MoorHV(1984)TwodecadesofexperiencewithmodifiedHeller’smyotomyforachalasia.AnnThoracSurg38:201ParicioPP,MartinezdeHaroL,OrtizA,AguayoJL(1990)Achalasiaofthecardia:resultsofoesophag-omyotomyandposteriorpartialfundoplication.BrJSurg77:1371–1374ParkmanHP,ReynoldsJC,OuyangAetal(1993)Pneumaticdilatationoresophagomyotomytreat-mentforidiopathicachalasia:clinicaloutcomesandcostanalysis.DigDisSci38:75–85PellegriniC,WetterLA,PattiMetal(1992)ThoracoscopicEsophagomyotomy.AnnSurg216:291–299PellegriniCA,LeichterR,PattiMetal(1993)Thoracoscopyesophagealmyotomyinthetreatmentofachalasia.AnnThoracSurg56:680–682RosatiR,FumigalliU,BonavinaAetal(1994)LaparoscopicHeller-Dorprocedurewithintraopera-tiveballoondilatationofthecardia.SurgEndosc8:463SauerL,PellegriniCA,WayLW(1989)Thetreatmentofachalasia.ArchSurg124:929–932SchwartzHM,CahowCE,TraubeM(1993)Outcomeafterperforationsustainedduringpneumaticdilatationforachalasia.DigDisSci38:1409–1413ShimiS,NathansonLK,CuschieriA(1991)Laparoscopiccardiomyotomyforachalasia.JRCollSurgEdinb36:152–154SpencerJ(1994)Cardiomyotomy.In:BallantyneGH,LeahyPF,ModlinIM(eds)Laparoscopicsur-gery.WBSaunders,Philadelphiapp400–416SwanstromLL,PenningsJ(1995)Laparoscopicesophagomyotomyforachalasia.SurgEndosc9:286–292ToupetA(1936)Techniqued’oesophago-gastroplastieavecphréno-gastropexieappliquéedanslacureradicaledeshernieshiatalesetcommecomplementdel’opérationdeHellerdanslescar-diospasmes.Mémoiresdel’AcadémiedeChirurgie89:394–401YangHK,DelGuercioLouisRM,SteichenFM(1995)ThoracoscopicBelsey-MarkIVfundoplication.SurgEndosc9:622 6LaparoscopicSplenectomy6.1OperatingRoomSetup:PositionofthePatientThepatientisplacedsupine,withslightreverseTrendelenburgposition,andwitharightrotationof30°.Thesurgeonstandstotherightofthepatient,andthefirstassistanttothesurgeon’sleft.Asecondassistantmaybeplacedtotheleftofthepa-tient(>Fig.6.1).Thevideomonitorispositionedtotheleftofthepatient’shead.Fig.6.1.ORsetup–positionoftrocars 926LaparoscopicSplenectomy6.2RecommendedInstrumentsOneortwo10-mmtrocarsThree5-mmtrocarsA0°endoscopeTwoJohanfenestratedgraspingforcepsFive-millimetrestraightorcurvedcoagulatingshearsAbluntpaddleAstraight5-mmgraspingforcepsA5-mmdissectorA5-mmneedleholderA5-mmclipapplicatorA5-mmsuctioncannulaVascularlinearstaplersHarmonicscalpelifavailable,orLigaSureAstrongspecimenretrievalbag6.3TrocarPlacementandExposureThepneumoperitoneumiscreatedwithaVeressneedle.Thefirst10-mmtrocarisinsertedattheleftmarginoftheumbilicus.Theskinincisionmustmatchthesizeofthetrocar.Insertionisoblique,throughthemuscle,inthedirectionofthespleentoavoidsubsequentincisionalhernias.Theotherthree5-mmoperatingtrocarsarepositionedasfollows:thefirsttro-carisonthemedianline,8cmabovetheumbilicus;asecondoperatingtrocarinaleftsubcostalpositionontheaxillarylineenablesgastroepiploicmobilization;aleft5-mmoperatingtrocarispositionedintheleftlateralposition,10cmfromtheumbilicus.Theperitonealcavityisexplored,especiallylookingforaccessoryspleens(>Fig.6.1).6.4ApproachoftheSpleenTheleftcolicomentumisopenedusingtheharmonicscalpel(>Fig.6.2).Withthe5-mmsubcostalinstrument,bluntpaddleorfenestratedforceps,thestomachandomentumarereclinedrightwards(>Fig.6.3).Thebodyandtailofthepancreasareeasilyvisualizedatthisstage.Thesplenicarteryiseasilyfound.Itisdissecteddownwards.The5-mmdissectorenablesaprecisedissectionandelectivecontrolofthesplenicarteryusingclips,ligatureorstapling.Controlofthesplenicveinisperformedinthesamewaydistaltothecaudalpartofthepancreas(>Figs.6.4–6.6). 6.4ApproachoftheSpleen93Fig.6.2.TakingdownthesplenicflexureFig.6.3.Freeingtheshortgastricvessels 946LaparoscopicSplenectomyFig.6.4.ExposureofthesplenicvesselsFig.6.5.Dissectionofthesplenicvessels 6.6ControlofShortGastricVessels95Fig.6.6.Controlofthesplenicvein6.5FreeingtheSplenicCapsuleTheparietalattachmentsofthelowerpoleofthespleenarefreedusingthecoagu-latingshearsorharmonicscalpel(>Fig.6.7).Anextraarterialbranchisfrequentlyfoundinthisareaandiscontrolledbyclips.6.6ControlofShortGastricVessels(>Fig.6.8)Dissectioncontinuesmedially.Shortgastricvesselsarecontrolledeitherbyhar-monicscalpelorclipsorbylinearstapling.Thelastdiaphragmaticattachmentsontheupperpoleofthespleenaretransectedbycoagulationorwithclips. 966LaparoscopicSplenectomyFig.6.7.ReleaseofthelowercapsularattachmentsFig.6.8.Ligatureoftheshortgastricvesselswithharmonicscalpel 6.8SpecimenRetrieval:Drainage976.7DissectionofFinalSplenicCapsularAttachments(>Fig.6.9)Thespleencanbemobilized,allowingexposureofthelateralandupperattach-ments.Thesearetransectedwiththeharmonicscalpelorwiththecoagulatingshears.6.8SpecimenRetrieval:DrainageAlateral5-mmportisenlargedto2cmandastrongretrievalbagisintroduced.Thespleeniscaughtandthebagextracted(>Fig.6.10).Thesplenicparenchy-macanbefragmentedinsidethebagusingKellyforceps.Theperitonealcavityiscleanedwithsaline.Theoperativefieldischeckedforbleeding(>Fig.6.11).Asuctiondrainisinstalled.Fig.6.9.Dissectionofthefinalspleniccapsularattachments 986LaparoscopicSplenectomyFig.6.10.SpleeninretrievalbagFig.6.11.Checkingforbleeding Literature996.9TipsandCommentsPositioningofthepatientintheposterolaterallumbarpositionresultsinchang-ingtheplaceofthesurgeonforaleftlateralposition.Thisisamatterofchoice.Wepreferpositioningthepatientasindicated,withamaximum30°leftrota-tion.Theuseofametallicsuctioncannulaasabluntdissectorintheperisplenicfatisstronglyrecommended.Hand-assistedtechniquesmayproveusefulincaseofaverylargespleenatthestageofvasculardissectionorextraction.ThespecimenretrievalincisioncanbeaPfannenstielincision.Laparoscopicvascularclampsmustbereadyincaseofneed.LiteratureBaccaraniU,CarrollBJ,HiattJR,DoniniA,TerrosuG,DeckerR,ChandraM,BresadolaF,Phil-lipsEH(1998)ComparisonoflaparoscopicandopenstaginginHodgkindisease.ArchSurg133:517–522BruntLM,LangerJC,QuasebarthMA,WhitmanED(1996)Comparativeanalysisoflaparoscopicsplenectomyversusopensplenectomy.AmJSurg172:596–601CarrollBJ,PhillipsEH,SemelCJ,FallasM,MorgensternL(1992)Laparoscopicsplenectomy.SurgEndosc6:183–185DeckerG,MillatB,GuillonF,AtgerJ,LinonM(1998)Laparoscopicsplenectomyforbenignandmalignanthematologicdiseases:35consecutivecases.WorldJSurg22:62–68DelaitreB,MaignienB(1992)Laparoscopicsplenectomy:technicalaspects.SurgEndosc6:305–308DukeBJ,ModinGW,SchecterWP,HornJK(1993)Transfusionsignificantlyincreasestheriskforinfectionaftersplenicinjury.ArchSurg128:1125–1132FlowersJL,LeforAT,SteersJ,HeymanM,GrahamSM,ImbemboAL(1996)Laparoscopicsplenec-tomyinpatientswithhematologicdiseases.AnnSurg224:19–28FriedmanRL,HiattJR,KormanJL,FacklisK,CymermanJ,PhillipsEH(1997)Laparoscopicoropensplenectomyforhematologicdisease:whichapproachissuperior?JAmCollSurg185:49–54GlasgowRE,YeeLF,MulvihillSJ(1997)Laparoscopicsplenectomy:theemergingstandard.SurgEndosc11:108–112GlasteinE,GuernseyJM,RosenbergSA(1969)ThevalueofstaginglaparotomyandsplenectomyinthestagingofHodgkin‘sdisease.Cancer24:709–718ParkA,GagnerM,PompA(1997)Thelateralapproachtolaparoscopicsplenectomy.AmJSurg173:126–130RegeRV,MerriamLT,JoehlRJ(1996)Laparoscopicsplenectomy.SurgClinNorthAm3:459–468RhodesM,RuddM,O‘RourkeN,NathansonL,FieldingG(1995)Laparoscopicsplenectomyandlymphnodebiopsyforhematologicdisorders.AnnSurg222:43–46SchlinkertRT,MannD(1995)Laparoscopicsplenectomyoffersadvantagesinselectedpatientswithimmunethrombocytopenicpurpura.AmJSurg170:624–627SmithCD,MeyerTA,GoretskyMJ,HyamsD,LuchetteFA,FegelmanEJ,NussbaumMS(1996)Lapa-roscopicsplenectomybythelateralapproach:asafeandeffectivealternativetoopensplenectomyforhematologicdiseases.Surgery120:789–794TaragonaEM,EspertJJ,BalagueC,PiulachsJ,ArtigasV,TriasM(1998)Splenomegalyshouldnotbeconsideredacontraindicationforlaparoscopicsplenectomy.AnnSurg228:35–39 1006LaparoscopicSplenectomyTaragonaEM,EspertJJ,BalangueC,SugranesG,AyusoC,LomenaF,BoschF,TriasM(1998)Re-sidualsplenicfunctionafterlaparoscopicsplenectomy.ArchSurg133:56–60TerrosuG,DoniniA,SilvestriF,PetriR,AnaniaG,BarillariG,BaccaraniU,RisalitiA,BresadolaF(1996)Laparoscopicsplenectomyinthemanagementofhematologicaldiseases:surgicaltech-niqueandoutcomeof17patients.SurgEndosc10:441–444TerrosuG,DoniniA,BaccaraniU,VianelloV,AnaniaG,ZajaF,PasqualucciA,BresadolaF(1998)Laparoscopicversusopensplenectomyinthemanagementofsplenomegaly:ourpreliminaryexperience.Surgery124:839–843WatsonDI,CoventryBJ,ChinT,GillG,MalychaP(1997)Laparoscopicversusopensplenectomyforimmunethrombocytopenicpurpura.Surgery121:18–22 PART2ColorectalProcedures7LaparoscopicAppendectomy1038LaparoscopicLeftColectomy1199LaparoscopicRightColectomy13710LaparoscopicTotalColectomy14911LaparoscopicRectopexyforRectalProlapse153 7LaparoscopicAppendectomy7.1OperatingRoomSetup:PositionofthePatientThepatientisplacedsupineina15°Trendelenburgposition.Rotationtotheleftcanbeuseful.Thesurgeonstandsonthepatient’sleftside.Thefirstassistantstandsonthesurgeon’sleft.Asecondassistantmaystandbetweenthepatient’slegs.Themonitorisonthepatient’srightside(>Fig.7.1).Fig.7.1.ORsetup–positionoftrocars 1047LaparoscopicAppendectomy7.2RecommendedInstrumentsA10-mmtrocarwitha5-mmreducerTwo5-mmtrocarsTwoJohan5-mmfenestratedforcepsFive-millimetrecoagulatingshearsA5-mm,straight0°endoscopeAlinearstapleronoccasionSpecimenretrievalbagThree-millimetreinstrumentsand3-mmtrocarsinpaediatriccases7.3TrocarPlacementandExposure(>Fig.7.1)ThefirsttrocarisintroducedatthelowermarginoftheumbilicusaftercreatingthepneumoperitoneumusingaVeressneedle.Insertionshouldbeinaslightlyobliquemannertopreventincisionalhernias.Theintraperitonealpressureissetto12,withamaximumof14mmHginadults.Inchildren,maximumpressureequalsage.Theabdomenisvisuallyexplored.Asecond5-or3-mmsuprapubictrocarisinsertedfortheworkinginstruments.Fig.7.2.Explorationofperitonealcavity 7.4.1TheAppendixIsInflammatory,butNarrowandEntirelyFree105Fig.7.3.ExposureThepatientisplacedintheTrendelenburgposition,tobettermobilizethesmallbowel,gentlywithanon-traumaticforceps.Theileocaecalregionisvisualized.Theappendixisidentifiedandthedegreeofillnessisassessed(>Figs.7.2,7.3).7.4ThreeSituationsCanBeDefined,LeadingtoDifferentWaystoMobilizeandResecttheAppendix7.4.1TheAppendixIsInflammatory,butNarrowandEntirelyFree,andWithoutThickeningoftheMesoappendixTheappendixcanusuallybegraspedwithaforcepswithoutanyadditionaltro-car(>Figs.7.4–7.9).Completemobilizationcanbeachievedbygentlepulling.Thetipoftheappendixisextractedthroughtheumbilicalportusinga5-mmfor-ceps.Pneumoperitoneumisthenreleased.Ligatureisdoneextracorporeally,withabsorbablesuturesasinconventionalappendectomy.Theappendicealstumpisreintroduced,andpneumoperitoneumisresumed(>Fig.7.10). 1067LaparoscopicAppendectomyFig.7.4.AppendicealdissectionFig.7.5.Appendixgraspedwithumbilicalforceps 7.4.1TheAppendixIsInflammatory,butNarrowandEntirelyFree107Fig.7.6.ExtractionthroughumbilicusaftermobilizationFig.7.7.Ligatureofmesentery 1087LaparoscopicAppendectomyFig.7.8.ClampingofappendixFig.7.9.Resectionofappendix 7.4.2TheAppendixIsHighlyInflammatory,withThickeningoftheMesoappendix109Fig.7.10.Laparoscopiccontrolofappendicealstump7.4.2TheAppendixIsHighlyInflammatory,withThickeningoftheMesoappendix,andAdherenttotheAdjacentStructuresAthirdoperatingtrocarisessentialandcanbeintroducedeitherintherightiliacfossaorintheleftiliacfossa.However,weevenpreferplacementintherightup-perquadrantforbetterinstrumenthandling(>Figs.7.11,7.12).Astheappendixisimpossibletomobilize,priordissectionwithcoagulatingshearsandafenestratedforcepsiscarriedout.Themesoappendixisopenedatthebaseoftheappendix,andtwosuturesaretiedintracorporeallyonbothmesoandappendix.Theappen-dixisthenextractedthroughtheumbilicalportafterpositioningtheendoscopeinthesuprapubicregion.Optionally,intracorporealsectioningoftheappendixenablesspecimenretrievalwithaprotectiveplasticbag. 1107LaparoscopicAppendectomyFig.7.11.MobilizationofappendixFig.7.12.Dissection:appendicealabscess 7.4.3TheAppendixHasaTumour-likeAppearanceorIsTotallyAbscessed1117.4.3TheAppendixHasaTumour-likeAppearanceorIsTotallyAbscessedInsertionofathirdoperatingtrocarcan’tbemissed.Onetrocarsiteisenlargedtoa12-mmporttoallowtheuseofendostaplers.Astheappendixiseitherabscessedortumour-likewithimportantcaecalinflammation,dissectionisdonewithtwooperatingtrocarsusinga5-mmfenestratedforcepsand5-mmcoagulatingshears.A5-mmirrigationandsuctioncannulaisoftenuseful,workingasabluntdissectorwhileaspirating.Pusiscollectedforbacteriologicalwork-out.Thecaecumiscare-fullyfreedfromallinflammatoryadhesions,andtheoriginoftheappendixcanbeidentified.Resectionisdonewithendo-staplers(>Figs.7.13–7.17).Theresectedspecimenisremovedwitharetrievalbag(>Fig.7.18).Fig.7.13.Staplingincaseofabscess 1127LaparoscopicAppendectomyFig.7.14.StaplingthemesoappendixFig.7.15.Staplingagangrenousappendix 7.4.3TheAppendixHasaTumour-likeAppearanceorIsTotallyAbscessed113Fig.7.16.StaplingtheappendixFig.7.17.Controlofstaplelinesaftercompletedresection 1147LaparoscopicAppendectomyFig.7.18.Retrievalofgangrenousappendixwithabag7.5PeritonealCleaningandCheckingforBleeding:InspectionofthePeritonealCavityInallcases,afterresumingthepneumoperitoneum,theabdomenischeckedforbleeding.Additionalhaemostasisisachievedwithelectrocauteryorsutures.Theperitonealcavityiscleanedwithsaline.Thepelviccavityisthoroughlyexplored,asaretherightandleftdiaphragmaticareas.Incaseofgeneralperitonitis,anad-ditionaltrocarmaybeinsertedintheleftupperquadrantforbettersubphreniclavage.TheterminalileumischeckedforMeckel’sdiverticulumoranymesenteryorbowelinflammation.7.6DrainageandClosureofPortsAsuctiondrainmaybeleftinthesuprapubicposition.Amultitubulardrainisusuallyplacedthroughalateralport(2>Fig.7.19).COisreleasedandtrocarsareremoved.Theportwoundsarecleanedwithiodineandclosedwithevertingab-sorbablesutures. 7.7TipsandComments115Fig.7.19.Suctiondrain7.7TipsandCommentsMinimaladhesionscanbereleasedbygentletractionontheappendixusinga5-or3-mmsuprapubicforceps.Inthepresenceofsevereinflammation,useofametallicsuctioncannulaen-ablesquickdissectionofinflammatorytissue,especiallyinthecaseofabscess.Peritoneallavagemaybehelpedwiththeinsertionofasponge,enablingreaspi-rationoffluidsmoreeasily.Whileremovingtheappendixthroughtheumbilicus,pressureontheabdomi-nalwallmayhelpinextractingthecaecumforbettercontrolandligature.Surgeon’splacementbetweenthepatient’slegsfacilitatesintraperitonealla-vageofbothupperquadrants.Ifno5-mmendoscopeisavailable,a10-mmsuprapubicportisneededatthetimeofumbilicalextraction.Theuseofanendoscopewithanoperatingchannelcanbeanoption. 1167LaparoscopicAppendectomyLiteratureAdamekHE,MaierM,BenzC,HuberT,SchillingD,RiemannJF(1966)Schwerwiegendekomplika-tionenderdiagnostischenlaparoskopie.MedKlein91:694–697AddissGD,ShafferN,FowlerS,TauxeRV(1990)Theepidemiologyofappendicitisandappendec-tomyintheUnitedStates.AmJEpidemiol132:910–925AnderssonRE,HuganderA,ThulinAJG(1992)Diagnosticaccuracyandperforationrateinap-pendicitis:associationwithageandsexofpatientandwithappendicectomyrate.EurJSurg158:37–41ArnbjörnssonE(1984)Smallintestinalobstructionafterappendectomy:anavoidablecomplication?CurrSurg354–355ArnbjörnssonE,Andrén-SandbergA,BengmarkS(1983)Appendicectomyintheelderly,incidenceandoperativefindings.AnnChirGyn72:223–228AttwoodSEA,HillADK,MurphyPG,ThorntonJ,StephensRB(1992)Aprospectiverandomizedtrialoflaparoscopicvs.openappendicectomy.Surgery112:497–501BirkenfeldA,BrzezinskiA,SchenkerJG(1982)Postmechanicalsterility.ActaEurFertil13:173–176BlindPJ,DahlgrenST(1986)Thecontinuingchallengeofthenegativeappendix.ActaChirScand152:623–627BonjerHJ,HazebroekEJ,KazemierG,GiuffridaMC,MeijerWS,LangeJF(1997)Openvs.closedestablishmentofpneumoperitoneuminlaparoscopicsurgery.BrJSurg84:599–602BorgsteinPJ,GordijnRV,EijsboutsQAJ,CuestaMA(1997)Acuteappendicitis:aclear-cutcaseinmen,aguessinggameinwomen.SurgEndosc11:923–927CangFC,HogleHH,WellingDR(1973)Thefateofthenegativeappendix.AmJSurg126:752–754ChampaultG,CazacuF,TaffinderN(1996)Serioustrocaraccidentsinlaparoscopicsurgery:aFrenchsurveyof103,852operations.SurgLaproscEndosc6:367–370CoxMR,McCallJL,PadburyRTA,WilsonTG,WattchowDA,ToouliJ(1995)Laparoscopicsurgeryinwomenwithaclinicaldiagnosisofacuteappendicitis.MedJAust162:130–132DeutschAA,ZelikovskyA,ReissR(1982)Laparoscopyinthepreventionofunnecessaryappendicec-tomies:aprospectivestudy.BrJSurg69:336–337DeWildeRL(1991)Goodbyebowelobstructionafterappendicectomy.Lancet338:1012FrazeeRC,RobertsJW,SymmondsRE,SnyderSK,HendricksJC,SmithRW,CusterMD,HarrisonJB(1994)Aprospectiverandomizedstudycomparingopenvs.laparoscopyappendectomy.AnnSurg219:725–731FrittsLL,OrlandoR(1993)Laparoscopicappendectomy:asafetyandcostanalysis.ArchSurg128:521–525GrahamA,HenleyC,MobleyJ(1991)Laparoscopicevaluationofacuteabdominalpain.JLaparoscSurg1:165–168HansenJB,SmithersBM,SchacheD,WallDR,MillerBJ,MenziesBL(1996)WorldJSurg20:17–21HeinzelmannM,SimmenHP,CumminsAS,LargiaderF(1995)Islaparoscopicappendectomythenew»goldstandard«?ArchSurg130:782–784HellbergA(1999)Prospectiverandomizedmulticenterstudyoflaparoscopyvs.openappendicec-tomy.BrJSurg86:48–53HenleK,BellerS,RechnerJ,ZerzA(1996)Laparoskopischevs.konventionelleappendektomie:eineprospektive,randomisiertestudie.Chirurg67:526JansenFW,KapiteynK,Trimbos-KemperT,HermansJ,TrimborJB(1997)BrJObstetGynecol104:595–600KokHJM(1992)Laparoscopicappendectomy:anewopportunityforcuringappendiocopathy.SurgLapend2:297–302KrähenbühlL,FreiE,KlaiberCh,BüchlerMW(1998)Acuteappendicitisstandardtreatmentorlaparoscopicsurgery.In:BüchlerMW,FarthmannEH(eds)Porgressinsurgery.Karger,Basel,pp1–191 Literature117KumCK,NgoiSS,GohPMY,TekantY,IsaacJR(1993)Randomizedcontrolledtrialcomparinglapar-oscopicandopenappendicectomy.BrJSurg80:1599–1600LaineS,RantalaA,GullichsenR,OvaskaJ(1997)Laparoscopicappendectomy:isitworthwhile?SurgEndosc11:95–720LauWY,FanST,YluTF,ChuKW,WongSH(1984)Negativefindingsatappendectomy.AmJSurg148:375–378LeapeLL,RamenofskyML(1980)Laparoscopyforquestionableappendicitis:canitreducethenega-tiveappendectomyrate?AnnSurg191:410–413Lehmann-WillenbrockE,MeckeH,ReidelHH(1990)Sequellaeofappendectomy,withspecialrefer-encetointra-abdominaladhesions,chronicabdominalpain,andinfertility.GynObst29:241–245MacarullaE,ValletJ,AbadJM,HusseinH,FernandezE,NietoB(1997)Laparoscopicvs.openappendectomy:aprospectiverandomizedtrial.SurgLapEndosc7:335–339MartinLC,PuenteI,SosaJL,BassinA,BreslawR,McKenneyMG,GinzburgE,SleemanD(1995)Openvs.laparoscopicappendectomy.AnnSurg22:256–262McAnenaOJ,AustinO,O’ConnellPR,HedermanWP,GoreyTF,FitzpatrickJ(1992)Laparoscopicvs.openappendicectomy:aprospectiveevaluation.BrJSurg79:818–820MobergAC,MontgomeryA(1997)Appendicitis:laparoscopicvs.conventionaloperation:astudyandreviewoftheliterature.SurgLaparoscEndosc7:459–463MobergA,AhlbergG,LeijonmarckCE,MontgomeryA,ReiertsenO,RosselandAR(1988)Diagnosticlaparoscopyin1,043patientswithsuspectedacuteappendicitis.EurJSurg164:833–840MutterD(1996)Laparoscopynotrecommendedforroutineappendectomyinmen:resultsofapro-spectiverandomizedstudy.Surgery10:71–74NagyAG,JamesD(1989)Diagnosticlaparoscopy.AmJSurg157:3OlsenJB,MyrenCJ,HaahrPE(1993)Randomizedstudyofthevalueoflaparoscopybeforeappendi-cectomy.BrJSurg80:922–923OrtegaAE,HunterJG,PetersJH,SwanstromLL,SchirmerB(1995)Aprospective,randomizedcom-parisonoflaparoscopicappendectomywithopenappendectomy.169:208–212PedersenAG,PetersenOBB,WaraP,QvistN,LaurbergS(1996)laparoskopivedformodetappen-dicitisacuta.UgeskrLaeger158:2377–2380PieperR,KagerL,NäsmanP(1982)Acuteappendicitis:aclinicalstudy1,018casesofemergencyappendectomy.ActaChitScand148:51–62PierA,GötzF,BacherC,IbaldR(1993)Laparoscopicappendectomy.WorldJSurg17:29–33ReiertsenO,LarsenS,EdwinB,FaerdenAE,RosselandAR(1997)Arandomizedcontrolledtri-alwithsequentialdesignoflaparoscopicvs.conventionalappendicectomy.BrJSurg84:482–486RiberC,SoeK,JorgensenT,TonnesenH(1997)Intestinalafterappendectomy.ScandJGast32:1125–1128RichardsW,WatsonD,LynchG,ReedGW,OlsenD,SpawA,HolcombW,Frexes-SteedM,GoldsteinR,SharpK(1993)Areviewoftheresultsoflaparoscopicvs.openappendectomy.GynecolObstet177:473–480Scott-ConnerCEH,HallTJ,AnglinBL,MuakkassaFF(1992)Laparoscopicappendectomy.AnnSurg215:660–668SemmK,MettlerL(1980)Progressinpelvicsurgeryviaoperativelaparoscopy.AmJObstetGynecol138:121–127SilbermanVA(1981)Appendectomyinalargemetropolitanhospital.AmJSurg142:615–618SlimK,PezetD,ChipponiJ(1998)Laparoscopicoropenappendectomy?DisColonRectum41:398–405SpirtosNM,EisenkopSM,SpirtosTW,PoliakinRI,HibbardLT(1987)Laparoscopy,adiagnosticaidincasesofsuspectedappendicitis:itsuseinwomenofreproductiveage.AmJObstetGynecol156:90 1187LaparoscopicAppendectomyTanphiphatC,ChittmittrapapS,PrasopsuntiK(1987)Adhesivesmallbowelobstruction:areviewof321casesinaThaiHospital.AmJSurg154:283–287TateJJT,DawsonJW,ChungSCS,LauWY,LiAKC(1993)Laparoscopicvs.openappendicectomy:aprospectiverandomizedtrial.Lancet342:633–637TaylorEW,KennedyCA,DunhamRH,BlochJH(1995)Diagnosticlaparoscopyinwomenwithacuteabdominalpain.SurgLaparoscEndosc5:125–128TroninRJ,BurovaVA,GrinbergAA(1996)Laparoscopicdiagnosisofacuteappendicitisinwomen.JAmAssocGynecolLaparosc3:257–261WalkerSJ,WestCR,ColmerMR(1995)Acuteappendicitis:doesremovalofanormalappendixmatter,whatisthevalueofdiagnosticaccuracy,andissurgicaldelayimportant?AnnRCollSurgEngl77:358–363ZbarRIS,CredeWB,MckhannCF,JekelJF(1993)Thepostoperativeincidenceofsmallbowelob-structionfollowingstandard,openappendectomyandcholecystectomy.ConnMed57:123–127 8LaparoscopicLeftColectomy8.1OperatingRoomSetup:PositionofthePatientThepatientisplacedsupine,witha20°Trendelenburgposition.Thesurgeonandthefirstassistantstandtotherightofthepatient.Thesecondassistantisposi-tionedbetweenthelegsofthepatient.Thevideomonitorisonthepatient’sleftside(>Figs.8.1,8.2).Fig.8.1.ORsetup–trocarposition 1208LaparoscopicLeftColectomyFig.8.2.Surgeonandteam8.2RecommendedInstrumentsTwo10-mmtrocarsThree5-mmtrocarsA12-mmtrocarwithreducersThree5-mmfenestratedgraspingforcepsFive-millimetrecoagulatingshearsA5-mmstraightgraspingforcepsHarmonicscalpel,5or10mmA10-mmfenestratedforcepsA10-mmdissectorA5-mmneedleholderTwelve-millimetrelinearstaplersAcircularstaplerfortheanastomosisA0°endoscopeAparietalprotectivedrapewithanopeningof7cm 8.3TrocarPlacementandExposure121Fig.8.3.Trocarsites8.3TrocarPlacementandExposureThepneumoperitoneumiscreatedwithaVeressneedle.Thefirsttrocarfortheendoscopeisinsertedlaterally,about5cmtotherightoftheumbilicus.Theothertrocarsarethenintroducedunderdirectvision.A5-mmtrocarisplacedsuprapu-bic,a12-mmtrocarintherightiliacfossa,anda10-mmtrocarwithreduceratthelowermarginoftheumbilicus(>Fig.8.3).Twoextratrocarswillbeneededatthetimeofsplenicflexuremobilization.Theabdominalcavityisvisuallyexploredasa20°Trendelenburgpositionisinstalled.Thegraspingforcepsinsertedthroughthesuprapubicportmobilizestheomentum,thetransversecolonandthesmallbowel.Therectosigmoidjunctionisthenexposedusingthesuprapubicinstrument. 1228LaparoscopicLeftColectomy8.4RectosigmoidMobilizationandControlofInferiorMesentericVesselsThesecondaryattachmentsofthesigmoidmesocolonaretransectedusingthecoag-ulatingshearsortheharmonicscalpel.Theleftureterisidentified(>Figs.8.4,8.5).Thesuprapubicforcepsmobilizestherectosigmoidjunctiontotheleftsideofthepatient.Thepromontoriumiseasilyidentified(>Fig.8.6).Therightureterisoutlinedandtheposteriorparietalperitoneumisopenedwiththeharmonicscalpelorthecoagulatingshears.Dissectioniscontinuedinthepre-sacralregionincontactwiththemesorectalfat.Thesuprapubicfenestratedinstrumentappliesverticaltractionontheinferiormesentericvessels.Thedissectioniscontinuedalongtheinferioredgeoftheinferiormesentericpedicletoitsorigin.Aretrome-sentericwindowismade(>Fig.8.7).Theleftureterisrecognizedonceagaininthisfreedspace(>Fig.8.8).Theinferiormesentericvesselscanbecontrolledwithalinearstaplerorwithintracorporealligatureorclipping(>Figs.8.9,8.10).Fig.8.4.Freeingthesigmoidcolon 8.4RectosigmoidMobilizationandControlofInferiorMesentericVessels123Fig.8.5.OpeningleftlateralperitoneumFig.8.6.Openingperitoneumontherightabovethepromontorium 1248LaparoscopicLeftColectomyFig.8.7.CreatingaretromesentericwindowFig.8.8.Mesocolicdissectionandidentifyingtheleftureter 8.4RectosigmoidMobilizationandControlofInferiorMesentericVessels125Fig.8.9.DissectionofinferiormesentericvesselsFig.8.10.Staplingofinferiormesentericvessels 1268LaparoscopicLeftColectomy8.5TakingDowntheSplenicFlexureThepositionofthetrocarsischanged.Theendoscopeispositionedintheumbilicalregioninthe10-mmtrocar.Anew5-or10-mmtrocarispositionedintheleftiliacfossa,andafinal5-mmtrocarispositionedonthemediansupraumbilicalline.ThepatientisplacedinareverseTrendelenburgposition.Thesmallbowelisre-posi-tionedinthepelviccavity.Thecoloparietalattachmentsarekeptatthisstage.Aleftretromesocolicdissectioniscarriedout.Theleftmesocolonisliftedbythesuprapu-bicinstrument.Theharmonicscalpelorthecoagulatingscissorsinsertedthroughtheleftiliacfossaportenableopeningoftheleftretrocolicsub-peritonealspaceuptothesplenicflexure,andreachingtheloweredgeofthepancreas(>Figs.8.11,8.12).Thelessersacisopenedanteriorlytothepancreas.Thus,theresectionoftheretroperitonealattachmentsofthesplenicflexureofthecoloniseasilycarriedout.Theinferiormesentericveinistransectedatitsterminationinanenlargedleftcolec-tomy,orsomewhatlowerdependingontheleveloftheleftcolicresection.Thefree-ingoftheleftparietocolicperitonealattachmentsiscontinuedusingtheharmonicscalpel(>Fig.8.13).Thewholesplenicflexureisthuslowered.Thegastrocolicliga-mentcannowbereleased.Theomentumandthetransversecolonareexposedus-ingthesuprapubicforcepsandthesupraumbilicalinstrument.Thecolo-omentalattachmentsarereleasedwiththeharmonicscalpelorthecoagulatingshears.Theleftcolonisthentotallyreleasedfromitsparietalattachments(>Fig.8.14).Fig.8.11.Openingthelessersacinfrontofthepancreas 8.5TakingDowntheSplenicFlexure127Fig.8.12.Retroperitonealdissection,identifyingthepancreasFig.8.13.Dissectionoflateralperitonealattachments 1288LaparoscopicLeftColectomyFig.8.14.Takingdownthesplenicflexure8.6RectalDissectionThepatientisplacedbackasinthebeginningoftheprocedure,andtheendo-scopegoesbackintotherightlateraltrocar.Openingoftheleftandrightposteriorparietalperitoneumiscontinuedwiththeharmonicscalpelandthecoagulatingshears(>Fig.8.15).Resectionoftheperirectalperitoneumiscontinued.Theup-perrectalwallisoutlined(>Figs.8.16–8.21).Wideopeningofthepresacralspaceiscontinuedposteriorly,respectingtheposteriorpresacrallayer.Asnocompletemesorectalexcisionisneededinaleftcolectomy,thelevelofresectionislocatedintheupperrectum.Butthedissectionmayincludetotalmesorectalexcisionincaseofcoloproctectomy.Theposteriormesorectumisfreedfromtherectaltubewitha10-mmfenestratedforcepsatthelevelchosenforrectaltransection.Theposteriormesorectumistransectedeitherwiththeharmonicscalpelorthelinearstapler(>Fig.8.22).Therectumitselfisthentransectedwithalinearstaplerintroducedinthe12-mmrightiliacfossaport(>Fig.8.23).Severalfiringsarerequired.Anangulatingstaplerispreferred,especiallyinlowerresections. 8.6RectalDissection129Fig.8.15.AnteriorperirectalperitoneumFig.8.16.Rectaldissection 1308LaparoscopicLeftColectomyFig.8.17.PosteriorrectaldissectionFig.8.18.Leftlateralrectaldissectionandtransectionoflateralligaments 8.6RectalDissection131Fig.8.19.RightlateralrectaldissectionandtransectionoflateralligamentsFig.8.20.Lowrectaldissection 1328LaparoscopicLeftColectomyFig.8.21.TotalmesorectalexcisioncompletedFig.8.22.Transectionofmesorectum 8.7SpecimenRetrievalandColonicResection133Fig.8.23.Staplingtherectum8.7SpecimenRetrievalandColonicResectionTheproximaltransectedcolonisgraspedwiththesuprapubicforceps.AMcBur-neytypeleftretrievalincisionismade.Aprotectivedrapeisinstalled.Theproxi-malcolonextractionishelpedbythesuprapubicinstrument.Thecolonischeckedforthelevelofdisease.Mesocolicresectionisdoneatthelevelofproximalcolonresection.Vesselsareligated.Thesiteofcolonicresectionisprepared.Atension-freeanastomosisrequires15cmofcolonlengthoutsidetheabdomen.Thecolonistransectedandthespecimenretrieved.Anautomaticorhand-sewnpursestringisperformedwith3/0nylonsuture.Thecoloniscleanedwithiodine.Theanvilofacircularstaplerisintroducedandthepursestringtightened.Thecolonisreplacedintheperitonealcavity,andtheretrievalwoundisclosed. 1348LaparoscopicLeftColectomyFig.8.24.Colorectalanastomosis8.8ColorectalAnastomosisThepneumoperitoneumisresumedandthesmallbowelisre-positioned.Theperi-tonealcavityisrinsedwithsaline.Afteranaldilatation,thecircularstapleriscarefullyinsertedtransanally.Therectalstumpisperforated,andtheanvilisconnected.Thecircularstaplerisclosedandfired(>Fig.8.24).Thestaplerisremoved,andthetissuedoughnutsarein-spected.Thereshouldbenotensionontheanastomosis.Asuctiondrainisin-sertedthroughthesuprapubicport.8.9TipsandCommentsTrendelenburgpositionmustbesufficientforadequateexposure.Theactualdegreehastobemeasured,notguessed,bytheanaesthesiologist.Theleftureterismoreeasilyfoundintheleftparietalcolicpositioninthelearn-ingstageandoccasionallyindifficultanatomicalconditions.Withexperience,however,itiseasytoperformaprimarycontroloftheinferiormesentericvesselswithvisualizationoftheleftureterfromtherightside.Complexinflammatoryconditions(abscess,fistula)occasionallymakethelat-tersolutionmandatory. Literature135Thefirstlandmarkforthedissectionoftheinferiormesentericvesselsisthepromontorium.Openingoftheperitoneumatthislevelmakesitpossibletoseethevascularelementscorrectly.Dissectionofthemesorectummustbeperformedinclosecontacttoleavethepelvicinnervationsandtheposteriorpresacralfasciauntouched.Tofreethesplenicflexure,onecanchoosetostartatthelevelofthegastrocolicligament.Theretroperitonealdetachmentofthemesocolicspacemaybemadedifficultbyexcesstissue.Onemustknowhowtocontinuelaterallyattheparietalcolicattachmentsorattheupperpartofthesplenicflexuretocompletethedissectionandloweringoftheleftangle.Apartfromanyprioroperativestrategy,resectionoftheinferiormesentericarteryatitsoriginmaysacrificealeftcolicartery.Thelevelofthecolonicre-sectionmustbeadaptedtothisanatomicalcircumstanceandthequalityofvascularizationofthecolon.Theresectionoftheinferiormesentericveincanbemadeatitsterminationnearthepancreasinatrueleftcolectomy(transversecolon–rectalanastomo-sis)orpreferablyloweroftheleftcolicvenousbranchesinthecaseofaresec-tionofthedescendingcolon.LiteratureBemelmanWA,RingersJetal(1996)Laparoscopicassistedcolectomywiththedexteritypnemosleeve.DisColonRectum39[Suppl]:S59–S61BergamaschiR(1997)Uncomplicateddiverticulitisofthesigmoid:oldchallenges.ScandJGastro-enterol32:1187–1189BerthouJC,CharbonneauP(1997)Resultsoflaparoscopictreatmentofdiverticularsigmoiditis:aproposof85cases.Chirurgie122:424–429BruceCJ,CollerJAetal(1992)Laparoscopicresectionofdiverticulardisease.DisColonRectum35:64–68BruceCJ,CollerJAetal(1996)Laparoscopicresectionofdiverticulardisease.DisColonRectum39[Suppl]:S1–S6CadyJ,GodfroyJ,SibaudO(1995)Laparoscopicresectionanastomosisindiverticularsigmoiditisanditscomplications:aproposof65cases.Chirurgie10:605–610CuestaMA,BorgsteinPJ,PaulMA,deJongD(1992)Surgeryofthedistalcolonassistedbylaparos-copy.VideoRevSurg9:10–21EijsboutsQAJ,CuestaMA,deBrauwLM,SietsesC(1997)Electivelaparoscopic-assistedsigmoidresectionfordiverticulardisease?SurgEndosc1:750–753.DOI10.1007/s004649900442FranklinMEJr,DormanJPetal(1997)Islaparoscopicsurgeryapplicabletocomplicatedcolonicdiverticulardisease?SurgEndosc11:1021–1025.DOI10.1007/s004649900516HewettPJ,StitzR(1995)Thetreatmentofinternalfistulaethatcomplicatediverticulairediseaseofthesigmoidcolonbylaparoscopicallyassistedcolectomy.SurgEndosc9:411–413HincheyEJ,SchaalPG,RichardsGK(1978)Treatmentofperforateddiverticulardiseaseofthecolon.AdvSurg12:85–109JacobsM,VerdejaJC,GoldsteinHS(1991)Minimallyinvasivecolonresection(laparoscopiccolec-tomy).SurgLaparoscEndosc1:144–150 1368LaparoscopicLeftColectomyJunghansTB,Bohm(1997)Progressinlaparoscopicsigmoidresectioninelectivesurgicaltherapyofsigmoiddiverticulitis.Langenbecksinelectivesurgicaltherapyofsigmoiddiverticulitis.Langen-becksArchChir382:266–270.DOI10.1007/s004230050064KohlerL,RixenDetal(1998)Laparoscopiccolorectalresectionfordiverticulitis.IntJColorectalDis13:43–47.DOI10.1007/s003840050130LibermanMA,PhillipsEHetal(1996)Laparoscopiccolectomyvs.traditionalcolectomyfordiver-ticulitis:outcomeandcosts.SurgEndosc10:15–18.DOI10.1007/s004649910002MooneyMJ,ElliotLetal(1998)Handassistedlaparoscopicsigmoidectomyfordiverticulitis.DisColonRectum41:630–635PhillipsEH,RosenthalRJ(19xx)Nomenclatureinlaparoscopiccolonsurgery.In:PhillipsEH,RosenthalRJ(eds)Operativestrategiesinlaparoscopicsurgery.Springer,BerlinHeidelbergNewYork,pp215–218PuenteI,SosaJL,UtpalDesaiBS,SleemanD,HartmannR(1994)Laparoscopictreatmentofcolovesi-calfistulas:techniqueandreportsoftwocases.SurgLaparoscEndosc4:157–160SchiedeckTH,SchwandnerOetal(1998)Laparoscopicsigmoidresectionindiverticulitis.Chirurg69:846–853.DOI10.1007/s001040050499SenagoreAJ,LuchtfeldM(1994)Initialexperiencewithlighteduretralcathetersduringlaparoscopiccolectomy.SurgLaparoscEndosc4:399–403SherME,AgachanFetal(1997)Laparoscopicsurgeryfordiverticulitis.SurgEndosc11:264–267.DOI10.1007/s004649900340StabieleBE,PuccioE,vanSonnenebergE,NeffCC(1990)Percutaneousdrainageofdiverticularabscesses.AmJSurg159:99–105StandardTaskForceoftheAmericanSocietyofColonandRectalSurgeons(1995)Practiceparam-etersforsigmoiddiverticulitis–supportingdocumentation.DisColonRectum38:126–132StevensonAR,StitzRW(1998)Laparoscopicassistedanteriorresectionfordiverticulardisease:follow-upof100consecutivepatients.AnnSurg27:335–342 9LaparoscopicRightColectomy9.1OperatingRoomSetup:PositionofthePatientThepatientisplacedsupine.ATrendelenburgpositionisrequiredattheinitialstageoftheoperationwithsomeleftrotation.Thesurgeonstandstotheleftofthepatient,andthefirstassistanttothesurgeon’sleft.Thesecondassistantisposi-tionedbetweenthepatient’slegs(>Fig.9.1).Fig.9.1.ORsetup–trocarposition 1389LaparoscopicRightColectomy9.2RecommendedInstrumentsTwo10-mmtrocarsThree5-mmtrocarsA12-mmtrocarwithreducerThree5-mmfenestratedgraspingforcepsFive-millimetrecoagulatingshearsA5-mmstraightgraspingforcepsA5-or10-mmharmonicscalpelA10-mmfenestratedforcepsA10-mmcurveddissectorA5-mmneedleholderA12-mmlinearstaplerA0°endoscope9.3Trocars:PeritonealExploration–CecalandMesentericMobilizationApneumoperitoneumisperformedusingtheVeressneedle.A10-mmpara-um-bilicaltrocarforthe0°scopeisinserted.Twotrocars,one5-mmsuprapubicandtheother12-mmsupra-umbilical,willenablethepositioningofworkinginstru-mentsforbothhands.Two5-mmrightiliacfossaandrightsubcostaltrocarswillbeusedfortheex-posureinstruments.ThecaecumisgraspedwithaJohannfenestratedforceps.Thepatientisplacedina20°Trendelenburgpositionwithleftlateralrotation.Thesmallbowelisplacedintheupperpartoftheperitonealcavity.Dissec-tionstartswiththecoagulatingscissorsorharmonicscalpel.Theposteriorparietalperitoneumisopened,aftercheckingfortherightureter(>Fig.9.2).Therightmesocolonisdetachedfromtherightrenalfasciatotheduodenalgenusinferius(>Figs.9.3,9.4).Rightparietalcolonicdetachmentiscontinuedwithcompletereleaseoftheparietalattachments.9.4MobilizationoftheHepaticFlexureThepatientisnowplacedinaslightlyproneposition.Thetransversecolonandthegreateromentumareexposed.Theomentalattachmentsofthetransversecolonarereleasedusingthecoagulatingshearsorharmonicscalpel(>Fig.9.5).Properdissectionfreesthegenussuperius.Theligamentsofthehepaticflexurearedis-sected.Thetwolowerandupperdissectionplanesthencommunicate.Therightcolonandmesocolonarecompletelyfreed(>Figs.9.6,9.7). 9.4MobilizationoftheHepaticFlexure139Fig.9.2.RightparietalcolonicdetachmentFig.9.3.Caecaldissection 1409LaparoscopicRightColectomyFig.9.4.DuodenalandpancreaticdissectionFig.9.5.Dissectionofomentalattachmentsofthetransversecolon 9.4MobilizationoftheHepaticFlexure141Fig.9.6.MobilizationofthehepaticflexureFig.9.7.Duodenaldissection(genusinferius) 1429LaparoscopicRightColectomy9.5VesselControlThepatientisleftinthesameposition.Exposureoftheileocecaljunctionisini-tiallyperformedthroughthesuprapubicandsubcostaltrocars.Thecolonisnowundertractionbythetwoexposureinstruments.Mesentericfenestrationonbothsidesoftheileocaecalvesselsisperformed.Thevesselsarecontrolledeitherbyanintracorporealligatureorbyvascularlinearstapling(>Figs.9.8–9.10).Second,therightcolicvesselsareexposedattheanteriorpartoftheheadofthepancreas,respectingHenlé’sgastrocolicvenoustrunk(>Figs.9.11,9.12).Transversemeso-colicfenestrationmakesitpossibletoisolatepreciselythevascularpediclebeforeligatureorstapling.Anadditionalomentalresectionisdone.9.6SpecimenRetrievalandColonicResectionThesurgeonmovestothepatient’srightsideatthisstep.Asmall,up-to-5-cmlateralincisionismadeintherightlowerquadrant.Thewoundisprotectedwithaplasticsheet.Thepreparedcolonisextracted.Theparacolicvesselsarecontrolledwithconventionalligature.Ilealandcolicresectioniscarriedout.Fig.9.8.Dissectionoftheileocaecalvessels 9.6SpecimenRetrievalandColonicResection143Fig.9.9.DissectionofileocolicvesselsFig.9.10.Staplingoftheileocaecalvessels 1449LaparoscopicRightColectomyFig.9.11.ExposureofrightcolicvesselsFig.9.12.Controloftherightcolonicvessels 9.8CheckingforBleeding,Lavage,SuturingoftheMesentericDefect1459.7IleotransverseAnastomosisAhand-sewn,orstapledlatero-lateralanastomosiswithtwofiringsisdone(>Fig.9.13).Thebowelisputbackintotheperitonealcavity.Theincisionisclosedwithcare.9.8CheckingforBleeding,Lavage,SuturingoftheMesentericDefectTheabdominalcavityisre-inflated.Theileocolicanastomosisisinspectedandtheproperpositioningofthesmallbowelischecked(>Fig.9.14).Theperitonealcav-ityiscleanedwithsalineandcheckedforbleeding.Themesentericopeningcanbesuturedatthisstage(>Fig.9.15),butcanalsobemissed.Asuctiondrainisleftintherightparietalfossa.Fig.9.13.Ileotransverseanastomosis(externalview) 1469LaparoscopicRightColectomyFig.9.14.Ileotransverseanastomosis(internalview)Fig.9.15.Suturingofthemesentericdefect Literature1479.9TipsandCommentsInobesepatients,thefirsttrocarcanbeinsertedlefttotheumbilicusforabetterviewoftherightcolon.Theomentaldetachmentmustbestartedinthemedialpartofthetransversecolontofacilitatethedissection.Thevesselsshouldonlybeligatedaftermobilizationoftheentirerightco-lon.Aprimarycontrolofthevesselsmaybeextremelydifficultduetoexcesstissue.Thecoloncannotbeproperlyextractedwithoutpriorvesselcontrol.Therefore,thevesselsshouldalwaysbecontrolledatthetimeoflaparoscopicdissection.Completemobilizationcanbedonefromdownwardswithoutchangingposi-tion.Omentalresectionshouldbedoneinallcancercases,butisevenadvisableatalltimesforeasierdissection.LiteratureBemelmanWA,RingersJetal(1996)Laparoscopicassistedcolectomywiththedexteritypnemosleeve.DisColonRectum39[Suppl]:S59–S61BergamaschiR(1997)Uncomplicateddiverticulitisofthesigmoid:oldchallenges.ScandJGastro-enterol32:1187–1189BerthouJC,CharbonneauP(1997)Resultsoflaparoscopictreatmentofdiverticularsigmoiditis:aproposof85cases.Chirurgie122:424–429BruceCJ,CollerJAetal(1992)Laparoscopicresectionofdiverticulardisease.DisColonRectum35:64–68BruceCJ,CollerJAetal(1996)Laparoscopicresectionofdiverticulardisease.DisColonRectum39(Suppl):s1-S6CadyJ,GodfroyJ,SibaudO(1995)Laparoscopicresectionanastomosisindiverticularsigmoiditisanditscomplications:aproposof65cases.Chirurgie10:605–610CuestaMA,BorgsteinPJ,PaulMA,deJongD(1992)Surgeryofthedistalcolonassistedbylaparos-copy.VideoRevSurg9:10–21EijsboutsQAJ,CuestaMA,deBrauwLM,SietsesC(1997)Electivelaparoscopic-assistedsigmoidresectionfordiverticulardisease?SurgEndosc1:750–753.DOI10.1007/s004649900442FranklinMEJr,DormanJPetal(1997)Islaparoscopicsurgeryapplicabletocomplicatedcolonicdiverticulardisease?SurgEndosc11:1021–1025.DOI10.1007/s004649900516HewettPJ,StitzR(1995)Thetreatmentofinternalfistulaethatcomplicatediverticulardiseaseofthesigmoidcolonbylaparoscopicallyassistedcolectomy.SurgEndosc9:411–413HincheyEJ,SchaalPG,RichardsGK(1978)Treatmentofperforateddiverticulardiseaseofthecolon.AdvSurg12:85–109JacobsM,VerdejaJC,GoldsteinHS(1991)Minimallyinvasivecolonresection(laparoscopiccolec-tomy).SurgLaparoscEndosc1:144–150JunghansTB,Bohm(1997)Progressinlaparoscopicsigmoidresectioninelectivesurgicaltherapyofsigmoiddiverticulitis.Langenbecksinelectivesurgicaltherapyofsigmoiddiverticulitis.Langen-becksArchChir382:266–2.DOI10.1007/s004230050064KohlerL,RixenDetal(1998)Laparoscopiccolorectalresectionfordiverticulitis.IntJColorectalDis13:43–47.DOI10.1007/s003840050130 1489LaparoscopicRightColectomyLibermanMA,PhillipsEHetal(1996)Laparoscopiccolectomyvs.traditionalcolectomyfordiver-ticulitis:outcomeandcosts.SurgEndosc10:15–18DOI:10.1007/s004649910002MooneyMJ,ElliotLetal(1998)Handassistedlaparoscopicsigmoidectomyfordiverticulitis.DisColonRectum41:630–635PhillipsEH,RosenthalRJ(19xx)Nomenclatureinlaparoscopiccolonsurgery.In:PhillipsEH,RosenthalRJ(eds)Operativestrategiesinlaparoscopicsurgery.Springer,BerlinHeidelbergNewYork,pp215–218PuenteI,SosaJL,UtpalDesaiBS,SleemanD,HartmannR(1994)Laparoscopictreatmentofcolovesi-calfistulas:techniqueandreportsoftwocases.SurgLaparoscEndosc4:157–160SchiedeckTH,SchwandnerOetal(1998)Laparoscopicsigmoidresectionindiverticulitis.Chirurg69:846–853.DOI10.1007/s001040050499SenagoreAJ,LuchtfeldM(1994)Initialexperiencewithlighteduretralcathetersduringlaparoscopiccolectomy.SurgLaparoscEndosc4:399–403SherME,AgachanFetal(1997)Laparoscopicsurgeryfordiverticulitis.SurgEndosc11:264–267.DOI10.1007/s004649900340StabieleBE,PuccioE,vanSonnenebergE,NeffCC(1990)Percutaneousdrainageofdiverticularabscesses.AmJSurg159:99–105StandardTaskForceoftheAmericanSocietyofColonandRectalSurgeons(1995)Practiceparam-etersforsigmoiddiverticulitis–supportingdocumentation.DisColonRectum38:126–132StevensonAR,StitzRW(1998)Laparoscopicassistedanteriorresectionfordiverticulardisease:follow-upof100consecutivepatients.AnnSurg27:335–342 10LaparoscopicTotalColectomy10.1OperatingRoomSetup:PositionofthePatientThepatientisplacedsupineina20°Trendelenburgposition.Thesurgeonandfirstassistantareontherightsideofthepatient.Thesecondassistantstandsbetweenthelegsofthepatient.Thevideomonitorisplacedtotheleftofthepatient.10.2RecommendedInstrumentsA0°endoscopeTwo10-mmtrocarsThree5-mmtrocarsA12-mmtrocarwithreducerThree5-mmfenestratedgraspingforcepsFive-millimetercoagulatingshearsThree5-mmstraightgraspingforcepsA5-or10-mmharmonicscalpelA10-mmfenestratedforcepsA10-mmcurveddissectorA5-mmneedleholderOne12-mmlinearstaplerOnecircularstaplerAplasticprotectivesurgicaldrapewitha7-cmopening10.3TotalColectomywithRectalResectionIstheAdditionofaLeftColectomyFollowedbyaRightColectomyTwovideomonitorsonbothsidesofthepatientsimplifythesubsequentposi-tionsofthesurgeon,whostartswiththeleftcolonresectionandendswiththerightcolonresection.ThespecimenisdeliveredthrougharightMacBurney-typeincision.Thesta-pledilealJ-pouchiscreatedatthattimeinopensurgery.Aprotectiveileostomycanalsobedone. 15010LaparoscopicTotalColectomyThebowelisplacedbackintheperitonealcavity,takingextremecaretoavoidrotatingthedistalmesentery.Thelateralligamentsarecontrolledusingtheharmonicscalpel,linearstaplingorcoagulatingsystems.Totalexcisionofthemesorectumisperformedincaseoftotalcoloproctectomy.Thelowtransectionoftherectumispreferablyperformedusinganarticulatedlinearstapler.Inallcases,1cmto5mmofrectaltissueremainsafterstapling,allowingcircu-larstapling.Omentoplastyisalwayspossiblebyfreeingthegreateromentumandkeepingitsleftvessels.Omentalvesselsarecontrolledbytheharmonicscalpelorwithclips.LiteratureBemelmanWA,RingersJetal(1996)Laparoscopicassistedcolectomywiththedexteritypneumosleeve.DisColonRectum39[Suppl]:S59–S61BergamaschiR(1997)Uncomplicateddiverticulitisofthesigmoid:oldchallenges.ScandJGastro-enterol32:1187–1189BerthouJC,CharbonneauP(1997)Resultsoflaparoscopictreatmentofdiverticularsigmoiditis:ap-roposof85cases.Chirurgie122:424–429BruceCJ,CollerJAetal(1992)Laparoscopicresectionofdiverticulardisease.DisColonRectum35:64–68BruceCJ,CollerJAetal(1996)Laparoscopicresectionofdiverticulardisease.DisColonRectum39(Suppl):s1-S6CadyJ,GodfroyJ,SibaudO(1995)Laparoscopicresectionanastomosisindiverticularsigmoiditisanditscomplications:aproposof65cases.Chirurgie10:605–610CuestaMA,BorgsteinPJ,PaulMA,deJongD(1992)Surgeryofthedistalcolonassistedbylaparos-copy.VideoRevSurg9:10–21EijsboutsQAJ,CuestaMA,deBrauwLM,SietsesC(1997)Electivelaparoscopic-assistedsigmoidresectionfordiverticulardisease?SurgEndosc1:750–753.DOI10.1007/s004649900442FranklinMEJr,DormanJPetal(1997)Islaparoscopicsurgeryapplicabletocomplicatedcolonicdiverticulardisease?SurgEndosc11:1021–1025.DOI10.1007/s004649900516HewettPJ,StitzR(1995)Thetreatmentofinternalfistulaethatcomplicatediverticulardiseaseofthesigmoidcolonbylaparoscopicallyassistedcolectomy.SurgEndosc9:411–413HincheyEJ,SchaalPG,RichardsGK(1978)Treatmentofperforateddiverticulardiseaseofthecolon.AdvSurg12:85–109JacobsM,VerdejaJC,GoldsteinHS(1991)Minimallyinvasivecolonresection(laparoscopiccolec-tomy).SurgLaparoscEndosc1:144–150JunghansTB,Bohm(1997)Progressinlaparoscopicsigmoidresectioninelectivesurgicaltherapyofsigmoiddiverticulitis.Langenbecksinelectivesurgicaltherapyofsigmoiddiverticulitis.Langen-becksArchChir382:266–270.DOI10.1007/s004230050064KohlerL,RixenDetal(1998)Laparoscopiccolorectalresectionfordiverticulitis.IntJColorectalDis13:43–47.DOI10.1007/s003840050130LibermanMA,PhillipsEHetal(1996)Laparoscopiccolectomyvs.traditionalcolectomyfordiver-ticulitis:outcomeandcosts.SurgEndosc10:15–18.DOI10.1007/s004649910002MooneyMJ,ElliotLetal(1998)Handassistedlaparoscopicsigmoidectomyfordiverticulitis.DisColonRectum41:630–635 Literature151PhillipsEH,RosenthalRJ(19xx)Nomenclatureinlaparoscopiccolonsurgery.In:PhillipsEH,RosenthalRJ(eds)Operativestrategiesinlaparoscopicsurgery.Springer,BerlinHeidelbergNewYork,pp215–218PuenteI,SosaJL,UtpalDesaiBS,SleemanD,HartmannR(1994)Laparoscopictreatmentofcolovesi-calfistulas:techniqueandreportsoftwocases.SurgLaparoscEndosc4:157–160SchiedeckTH,SchwandnerOetal(1998)Laparoscopicsigmoidresectionindiverticulitis.Chirurg69:846–853.DOI10.1007/s001040050499SenagoreAJ,LuchtfeldM(1994)Initialexperiencewithlightedurethralcathetersduringlaparo-scopiccolectomy.SurgLaparoscEndosc4:399–403SherME,AgachanFetal(1997)Laparoscopicsurgeryfordiverticulitis.SurgEndosc11:264–267.DOI10.1007/s004649900340StabieleBE,PuccioE,vanSonnenebergE,NeffCC(1990)Percutaneousdrainageofdiverticularabscesses.AmJSurg159:99–105StandardTaskForceoftheAmericanSocietyofColonandRectalSurgeons(1995)Practiceparam-etersforsigmoiddiverticulitis–supportingdocumentation.DisColonRectum38:126–132StevensonAR,StitzRW(1998)Laparoscopicassistedanteriorresectionfordiverticulardisease:fol-low-upof100consecutivepatients.AnnSurg27:335–342 11LaparoscopicRectopexyforRectalProlapseTwolaparoscopicmeshtechniquesaddressrectalprolapse:theOrrLoygueproce-dureandtheWellstechnique.Bothtechniquesonlydifferintheshapeofthemeshandthewayitissuturedtotherectum.11.1OperatingRoomSetup:PositionofthePatientThepatientisplacedsupine,withlegsapart.Thepatienthasbeenmadetoemptyhisbowelbeforesurgery.Abladdercatheterisinserted.A25°Trendelenburgpo-sitionisuseful.Thesurgeonstandsonthepatient’sleftside.Thefirstassistantisonthesurgeon’sleft.Asecondassistantstandsbetweenthepatient’slegs.Thevideomonitorisplacedonthepatient’srightside,atthelevelofhisrightfoot(>Fig.11.1).Fig.11.1.ORsetup–trocarposition 15411LaparoscopicRectopexyforRectalProlapse11.2RecommendedInstrumentsOne10-mmtrocarA0°or30°endoscopeTwo5-mmtrocarsA10-mmtrocarA5-mmfenestratedgraspingforcepsA5-mmgraspingforcepsApairofdissectingandcoagulatingscissorsA5-mmstapler(ProTak,TycoHealthCareorEndoAnchor,Ethicon)A5-mmneedleholderAcurved10-mmdissectorAvaginalretractorHeggarbougiesPolyesterorpolypropylenemeshcutintotwo3×20-cmstripsHarmonicscalpel(usefulbutnotmandatory)11.3PositionofTrocarsThepneumoperitoneumiscreatedwithaVeressneedle.Apressureof14mmHgisachievedataflowrateof6l/min.Thefirsttrocarisinsertedintheleftpara-um-bilicalregion,5cmleftoftheumbilicus.Theendoscopeisinsertedthroughthistrocar.A5-mmtrocarisplacedmedialtotheleftantero-superioriliacspinefortheleft-handgraspingforceps.Another5-mmtrocarisplacedattheinferiormarginoftheumbilicusinordertoreceivetheright-handoperatinginstruments.Afinal5-mmtrocarisinsertedsuprapubic.Ifneeded,afifthtrocarcanbeplacedintherightiliacfossaforbetterexposure(>Fig.11.1).Thelateralpositionoftheendoscopeprovidesimprovedoperatingcomfortbutalsorequirespermanentcontrolofanymedianaxialdeviation. 11.4ExposureoftheRectosigmoidJunction15511.4ExposureoftheRectosigmoidJunctionTheperitonealcavityisexploredaftertheORtablehasbeenplacedinthe25°Trendelenburgposition.Thesmallbowelispushedbackintothesuperiorpartoftheabdominalcavity.Inwomen,ithelpstosuspendtheuterusanteriorlywithatransfixingsuturethroughtheabdominalwall.ThedepthoftheDouglaspouchisthenassessed.Thereisalwayssomedegreeofperitonealthicknessaroundtherectum.Thesuprapubicgraspingforceps,handledbythesecondassistant,mobilizesthesigmoidloop,thenthesuperiorpartoftherectum.Rectaldissectionisbegunbyopeningtherightpararectalposteriorparietalperitoneumincontactwiththemesorectumandtherectum.Thispararectalperitonealopeningiscontinuedfromrighttoleft(>Figs.11.2,11.3).Inwomen,avaginalretractorintheposteriorvagi-nalcul-de-sacshowstherectovaginaljunctionmoreeasilyandfacilitatescompleteexcisionofexcessperitoneum(Douglassectomy)withthecoagulatingscissorsorharmonicscalpel.Fig.11.2.Peritonealexcision 15611LaparoscopicRectopexyforRectalProlapseFig.11.3.Exposureofsacralligament11.5RectalDissectionPosteriordissectioncontinueswithcoagulatingshearsontherightinfrontofthesacralpromontorium(>Fig.11.4)andgoesdowntotheDouglaspouchafteriden-tifyingbothureters,fromrighttoleft.Thesuprapubicgraspingforcepspushesandpullstherectosigmoidtothepatient’sleft.Inthisway,itispossiblewithasoftforcepsorasoft-tippedfenestratedforcepstoperformpre-sacraldissectionbyquicklymobilizingtheposteriormesorectumasfarasthelevators.Theintraperi-tonealpressurehelpsatthisstage.Anteriorly,dissectionoftherectovaginalorrectoprostatespacesisperformedcautiouslywiththecoagulatingscissorsincontactwiththeanteriorwalloftherectum(>Fig.11.5).AHeggarbougiemaybeusedtobetterdemonstratethean-teriorwalloftherectum.Thelateralligamentsarerespectedbutnottheirsuperiorfibrouselements,whicharecoagulated.LikeSpeakmanetal.(1991)atSt.Mark’sHospital,wefinditusefultoleavethelateralligamentsoftherectuminordertopreventconstipationafterrectopexy.Inmales,itisessentialtorespectthehypogastricnerveplexus.TheCO2pres-surehelpsinlocatingthecorrectplaneofthedissectionofthepresacralspace.Digitalcontrolofthedistaldissectionoftherectumisthenperformed(5–6cmfromtheanalverge). 11.5RectalDissection157Fig.11.4.SacraldissectionFig.11.5.Rectaldissection 15811LaparoscopicRectopexyforRectalProlapse11.6OrrLoygueProcedure:RectalFixationoftheMeshesTwopolyester,polypropyleneorpTFE3×20-cmmeshesareinsertedthroughtheumbilicaltrocar.Theyaresuturedtotherightandleftantero-lateralfacesoftherectum(>Fig.11.6)withnonabsorbable2/0stitches.Fourtosixstitchesareplacedontherectumforeachmesh.Stitchesneedtoenterdeepinthemuscularlayersoftherectumandknottingisdoneintracorporeally(>Figs.11.7,11.8).11.7OrrLoygueProcedure:MeshPlacementIntheclassicalFrenchopentechniquedescribedbyLoygueandCerbonnetin1957,bothmesheswereplacedoneithersideoftherectosigmoidcolonandwerethensuturedtothepromontorium.Thiscanalsobeperformedlaparoscopically.Theleftmeshmustbepassedunderthemesorectumwiththeumbilicalgraspingfor-ceps,andtherectosigmoidcolonisthenplacedontheleftwiththesuprapubicgraspingforceps.Wenoted,however,thattherectosigmoidcolonmayundergostricturefromthetwomeshesandthismayleadtopostoperativeconstipationinsomepatients.Since1983,wedevelopedanoriginaltechniqueofplacingthetwomeshesfirstinopen,theninlaparoscopic,surgery.Therightmeshsuturedtotherightantero-Fig.11.6.Orr-Loygue:suturingrightmesh 11.7OrrLoygueProcedure:MeshPlacement159Fig.11.7.Orr-Loygue:rightmeshsuturingcompletedFig.11.8.Orr-Loygue:finalmeshplacement 16011LaparoscopicRectopexyforRectalProlapselateralfaceoftherectumisplacedbehindtherightlateralligamentoftherectumandpassesthroughthelowermesorectum,andisthenstapledtothepromonto-rium(>Figs.11.9,11.10).Thismanoeuvreisperformedwiththeangulated10-mmdissectorinsertedthroughtheumbilicaltrocar.Anopeningismadethroughthelowermesorectumwiththedissectorintroducedbehindthelateralligamentbeforegraspingtherightmesh.Theleftmeshsuturedtotheleftantero-lateralfaceoftherectumpassesanteriortotherectosigmoidcolonandisstapledtotheleftpartofthepromontorium.Therectumusuallyundergoesaslight20°rightrotation.Thereisnostrictureandtheposteriororleftlateralmovementofthesuperiorpartoftherectumiscontrolled.11.8OrrLoygueProcedure:FixingtheMeshtothePromontoriumThevertebralligamentonthepromontoriumislocated.Onlylimitedopeningoftheperitoneumisneeded.Therightureterisidentifiedandtheperitoneumisopenedwithcoagulatingshears.Thesmallvesselsonthepromontoriumareidentified.Thetwomeshesarestapledtothepromontoriumandtheirtensionisadjusted.Thefixationtothepromontoriumcanbesecuredwithoneortwoextrasutureswithintracorporealknotting.Thetensionmustbejustenoughtoensuregoodsupport.Anyexcessmeshisresected(>Figs.11.11,11.12).Fig.11.9.Orr-Loygue:tunnellingofrightmesh 11.8OrrLoygueProcedure:FixingtheMeshtothePromontorium161Fig.11.10.Orr-Loygue:therightmeshistunnelledbehindthelateralligamentFig.11.11.Orr-Loygue:staplingthemeshtothevertebralligament 16211LaparoscopicRectopexyforRectalProlapseFig.11.12.Orr-Loygue:finalresult11.9LaparoscopicWellsProcedureRectaldissectionisidenticaltothatintheprevioustechnique,butthesuperiorpartsofthelateralligamentsoftherectumaretransected.Thedifferenceisintheshapeofthemeshandthewayitissuturedtotherectumandstapledtothesacrum.Aftertherectumisfullydissected,a7×7-cmmesh(polyvinyl,polypropylene,polyesterorPTFE)isstapledtothesacralconcavityandthepromontoriumbyanextraportion4cmlongand2cmwide.FixationisperformedwithhelicalstapleslikeTaksorwithnonabsorbablerunningsutures.(>Fig.11.13).Fourtosixme-diansuturesareneededforgoodfixationoftheextrapartofthemeshontothepromontorium.Thestaplinginstrumentisbeingintroducedthroughthesuprapu-bicport.Themeshiswrappedlaterallyaroundtheextraperitonealrectumwithoutten-sion(>Figs.11.14–11.16).Theedgesofthemesharesuturedtotheantero-lateralfacesoftherectumbyinterruptedorrunning2/0nonabsorbablesutures. 11.9LaparoscopicWellsProcedure163Fig.11.13.Wells:sacralstaplingFig.11.14.Wells:meshwrappedandsuturedtotherectum 16411LaparoscopicRectopexyforRectalProlapseFig.11.15.Wells:suturingmeshtotherightsideoftherectumFig.11.16.Wells:finalresult 11.11TipsandComments16511.10DouglassectomyandPeritonizationClosureoftheperitoneumisperformedwithcontinuous2/0absorbablesutures.ExcessperitonealtissueoftheDouglaspouchisresectedorplicatedafterlocatinguretersandnerveplexus(>Figs.11.17–11.19).11.11TipsandCommentsDouglassectomycanbeperformedatthestartwiththecoagulatingshearsorharmonicscalpel.ForthemodifiedWellsprocedure,theupperpartofthelateralligamentsmustbetransectedinordertoproperlyplacethemeshandtohavesatisfactoryperi-tonizationintheend.Runningsuturescanbeusedtofixthemeshtotherectum.Anarticulatedinstrumentisrequiredforthetrans-ligamentpassageofthemesh.StaplingofthemeshtothepromontoriumismostlyperformedwithhelicalTaks.Fig.11.17.Orr-Loygue:peritonealclosure 16611LaparoscopicRectopexyforRectalProlapseFig.11.18.Wells:peritonealclosureFig.11.19.Finalresultafterperitonealclosure Literature167Wepreferpolyestermesheswhichareeasilyhandledlaparoscopicallyandarenon-traumaticfortherectalwall.Lateralmeshfixationtotherectumislimitedbythelateralligaments.Fixationisusuallyantero-lateral.Exceptionallyinwomen,agenitalprolapsemaybeconcurrentwithcompleterectalprolapse.Dualfixationwillcontrolhysteroceleassociatedwitheithercys-toceleorrectocele.LiteratureCuschieriA,ShimiSM,VandervelpenG,BantingS,WoodAB(1994)Laparoscopicprosthesisfixa-tionrectopexyforcompleterectalprolapse.BritJSurg81:138–139DelormeR(1900)Surletraitementdesprolapsusdurectumtotauxparl’excisiondelamuqueuserectaleetrectocolique.BulletinMémoiresSocChirurgie,Paris26:498–499DulucqJL(1993)Prolapsusrectal,rectopexieparlaparoscopie,TechniquedeOrrLoyguemodifiée.Journaldecoeliochirurgie,6DulucqJL,WintringerP(1997)XIXjournéesniçoisespathologieetchirurgiedigestives,ActualitésMédicoChirurgicales,Ed.MassonLechauxJP,LechauxD,PerezM(1995)ResultsofDelorme’sprocedureforrectalprolapse.Advan-tagesofamodifiedtechnique.DisColonRectum38:301–307LoygueJ,CerbonnetG(1957)Traitementchirurgicalduprolapsustotaldurectumparlarectopexieselonleprocédéd’Orr.MemAcChir83:325–329LoygueJ,NordlingerB,CunciO,MalafosseM,HuguetC,ParcR(1984)Rectopexytothepromontoryforthetreatmentofrectalprolapse.Reportof257cases.DisColonRectum27:356–359OliverGC,VachonD,EisensatTE,RubinRJ,SalvatiEP(1994)Delorme’sprocedureforcompleterectalprolapseinseverelydebilitatedpatients.DisColonRectum37:461–467RatelleR,VollantS,PeloquinAB,Gravel,D(1994)Larectopexieaupromontoire(OrrLoygue)dansleprolapsusrectal:approchecoelioscopiqueouchirurgieconventionnelle.AnnChir48:679–684RipsteinCB(1952)Treatmentofmassiverectalprolapse.AmJSurg83:68–71SenapatiA,NichollsRJ,ThomsonJPS,PhilippsRKS(1994)ResultsofDelorme’sprocedureforrectalprolapse.DisColonRectum37:456–460SpeakmanCTM,MaddenMS,NichollsRJ,KammMA(1991)Lateralligamentdivisionduringrec-topexycausesconstipationbutpreventsrecurrence:resultsofaprospectiverandomisedstudy.BritJSurg78:1431–1433WedellJ,ZuEissenPM,FiedlerR(1980)Anewconceptforthemanagementofrectalprolapse.AmJSurg139:723–725WellsC(1959)Newoperationforprolapseofrectum.ProcRSocMed52:602–603WilliamsJG,WongWD,JensenL,RothenbergerDA,GoldbergS(1991)Incontinenceandrectalprolapse.Aprospectivemanometrystudy.DisColonRectum34:209–216 PART3InguinalHerniaandRetroperitonealProcedures12TotallyExtraperitonealApproach(TEPA)forLaparoscopicHerniaRepair17113LaparoscopicRightAdrenalectomy18914LaparoscopicLeftAdrenalectomy203 12TotallyExtraperitonealApproach(TEPA)forLaparoscopicHerniaRepair12.1OperatingRoomSetup:PositionofthePatientThepatientisplacedsupineina10°Trendelenburgposition.Abladdercatheterisneededunlessthepatienthasemptiedhisbladderbeforetheoperation.Thesur-geonstandsoppositetheherniatobecured.Theassistantisonthesurgeon’sleftorrightaccordingtotheside(>Fig.12.1).Fig.12.1.ORsetup–positionoftrocars 17212TotallyExtraperitonealApproach(TEPA)forLaparoscopicHerniaRepair12.2RecommendedInstrumentsA10-mmtrocarfortheendoscopeA0°or30°endoscopeTwo5-mmtrocars(3-mmtrocarsandinstrumentspossible)Two5-mmfenestratedgraspingforcepsA5-mmstronggraspingforcepsApairofdissectingandcoagulatingshearsOptionally,astaplerorTakkerA5-mmendoscopicneedleholderApowerfulXenonlightfountainAnelectronicinflatorAnendoscopiccamerasystemAnanatomicallypre-shaped14×10-cmor16×12-cmpolypropylenemeshAsuctioncannula12.3PositionofTrocarsandExposureCreatingthepneumoperitoneumisdonebeforeinsertingthefirsttrocar.TheVeressneedleisinsertedonthemidline,straightthroughtheaponeurosisintoRetzius’space,1cmabovethepubicbone.OnelitreofCO2isinflatedatapressureof15mmHg.Thispriorcreationofapreperitonealspaceallowssubsequenteasyinsertionofthefirsttrocarwithoutanyriskofperitonealorbladderperforation.Thefirsttrocarisintroducedattheinferiormarginoftheumbilicus(>Fig.12.2).A4-cmsubcutaneousrouteisfollowedbeforeenteringobliquelythroughtheaponeurosisintothepreperitonealspacepreviouslycreatedbytheVeressneedle.Atthisstage,CO2pressureisloweredtoamaximumof12mmHg.Ineasycasesasinglesecond5-or3-mmtrocarisintroducedonthemidlineapproximatelythreefingerwidthsabovethepubicbone.Whenneeded,athird5-mmtrocarisplacedmedialtotheantero-superioriliacspineonthesideoftheherniafordissection.Theendoscopegoesintothe10-mmtrocarattheumbilicus,andthegraspingforcepsforbluntdissectionintothe5-mmports.TheendoscopeinthepreperitonealspacecaneasilyidentifythepubicboneandCooper’sligamentonbothsides(>Fig.12.3),whicharethefirstlandmarksintheextraperitonealdissectionofRetzius’space.Thesecondlandmarksaretheepigastricvesselsinthesuperiorpartofthefieldofdissection.Theanatomicaltypeofhernia,direct,indirectorfemoralisdefinedbythepositionoftheherniasactotheepigastricvessels(>Fig.12.4). 12.3PositionofTrocarsandExposure173Fig.12.2.InsertionoffirsttrocarFig.12.3.ExposureofCooper’sligament 17412TotallyExtraperitonealApproach(TEPA)forLaparoscopicHerniaRepairFig.12.4.Exposureofepigastricvessels12.4DissectionofthePeritoneumLeavingtheepigastricvesselsontheabdominalwallrevealsthesuperioredgeoftheherniasac.Thedissectorplacedinthesuprapubictrocargraduallydissectsfreethesuperiorpartoftheperitonealsacfromtheextraperitonealspace(>Fig.12.5).Laterally,peritonealattachmentsareloose,anddissectionisperformedeasilyandquickly.Theherniasacbecomespediculated.Ifnecessary,athird5-mmtrocarforaseconddissectinginstrumentisinsertedattheleveloftheiliacfossa(>Fig.12.6).Lateraldissectioniscontinuedbysuperiordissectionbehindthemusclewallandinferiordissectiononthepsoasmuscle.Thesetwolateralextraperitonealspacesareseparatedbyafasciawhichhastobetransectedwiththecoagulatingscissors(>Fig.12.7).Theherniasacisthusfullypediculated. 12.4DissectionofthePeritoneum175Fig.12.5.DissectionoftheupperedgeoftheperitonealsacFig.12.6.Introductionofthirdtrocar 17612TotallyExtraperitonealApproach(TEPA)forLaparoscopicHerniaRepairFig.12.7.Dissectionoftheleftlateralfascia12.5DissectionoftheHerniaSacAdirectherniaiseasilyreducedbysimpletraction.Anindirectobliqueherniarequirestheuseofcoagulatingshearsandafenestrateddissectingforceps.Theherniasacisgraduallydissectedandfreedfromtheinternalinguinalring.Dissec-tioncontinuesbygentletraction(>Figs.12.8–12.10)onthecordelementsinordertoidentifythespermaticvesselsandthevasdeferens.Theremainingperitonealattachmentsarethentransectedwiththecoagulatingshears.Thesacinfemoralherniasisreducedbygentletractionwithafenestratedforceps.12.6SkeletonizationofSpermaticCordTheperitonealsacisgraduallyfreedfromthespermaticcord,vasdeferensandspermaticvessels(>Fig.12.11).Lipomasaretoberemoved.Theperitoneumispushedbackasfaraspossibleintotheabdominalcavity.Theanteriorpartofthepsoasmuscle,aswellasthecrossingoftheiliacveinbythevasdeferensmustbefullyexposed(>Fig.12.12). 12.6SkeletonizationofSpermaticCord177Fig.12.8.DissectionoftheupperpartoftheherniasacFig.12.9.Dissectionoftheherniasac 17812TotallyExtraperitonealApproach(TEPA)forLaparoscopicHerniaRepairFig.12.10.DissectionofherniasacFig.12.11.Pullingbacktheperitoneum 12.8MeshInsertion179Fig.12.12.Finishedlateraldissectionwithpsoasmuscleandnerves12.7FullExposureoftheInguinalRegionThefinalanatomicaldetailsoftheregionaredissected.Cooper’sligamentisfullyexposedandtheiliacvesselsareidentified.Theobturatorringisfreedofitsusuallipomacontent.DissectioncontinuessuperiorlybysectioningtheDouglasarch.Theanatomicaltypeofherniacanbeassessed,eitherindirect(>Fig.12.13)ordirect(>Fig.12.14).12.8MeshInsertionThe3-Dmeshisrolledandintroducedthroughthe10-mmtrocar.Itisplacedacrosstheinguinalringandfitstheanatomyoftheinguinalregion(>Figs.12.15–12.18).Itsinferiorandlateraledgeisplacedontheanterioraspectofthepsoasmuscle(>Fig.12.19)andtheinferiorandinternaledgeisplacedunderCooper’sligament(>Fig.12.20).Theinferioredgeofthemeshcoverstheiliacvesselsandthesper-maticcordwhichwereskeletonizedpreviously.Themeshisthenappliedagainsttheinternalinguinalringand(>Fig.12.21)itssuperioredgefollowsthecontoursoftheabdominalwallduringreleaseofthepneumoperitoneum(>Fig.12.22).Desufflationmustbeperformedwithcare,underpermanentvisualcontrolofthecorrectpositionofthemesh(>Fig.12.23).Portwoundsareclosedbyintradermalevertingsutures. 18012TotallyExtraperitonealApproach(TEPA)forLaparoscopicHerniaRepairFig.12.13.EnlargedinternalinguinalringFig.12.14.Directweakness 12.8MeshInsertion181Fig.12.15.DissectioncompletedFig.12.16.3-Dmesh 18212TotallyExtraperitonealApproach(TEPA)forLaparoscopicHerniaRepairFig.12.17.3-DmeshrolledupFig.12.18.Insertionofthe3-Dmeshthroughumbilicalport 12.8MeshInsertion183Fig.12.19.Positioningthe3-DmeshonthepsoasmuscleFig.12.20.Inferiorpartof3-DmeshbelowCooper’sligament 18412TotallyExtraperitonealApproach(TEPA)forLaparoscopicHerniaRepairFig.12.21.Medialpositioningofthe3-DmeshFig.12.22.Upperpartofthe3-Dmesh 12.9TipsandComments185Fig.12.23.Releaseofgaspressureundervision12.9TipsandCommentsWhilecreatingthepneumoperitoneumwiththeVeressneedle,pressureshouldbemaintainedat15mmHg,thenloweredduringtheoperationto12mmHg.Incasethepressuredropsduetoinadvertentopeningoftheperitoneum,theoperationusuallycangoon.However,theremustbeabalancebetweentheintra-andextraperitonealpressures.Iftheperitonealtearissmall,anintraperi-tonealtrocarfittedwithavalveisrequiredtobalancethepressure.Ifabalancecannotbeobtained,theperitonealopeningmustbeclosedwithasuture.Theperitonealrepairmustbeperformedeitherduringorattheendofsur-gery.Thelateraloranteriorparietalperforatingvesselsmaybecontrolledbycoagu-lation.Thepresenceofaverylargeexternalobliqueherniasacmayrequiretheinser-tionofanadditional5-mmtrocartoallowaseconddissectortobeinserted.Dissectionwithonlyoneinstrumentisoftenpossibleincasesofdirectorfemo-ralhernias,wherereductioncanbeperformedbysimpletraction.Suchdissectionwithonlyoneinstrumentforexternalobliqueherniasmaybeachievedwithpartialreductionbytraction,theuseoffinecoagulatingscissorsandbyproceedingverycautiously.Lipomasmustalwaysberemoved. 18612TotallyExtraperitonealApproach(TEPA)forLaparoscopicHerniaRepairInverylargescrotalhernias,apreliminaryscrotalincisionenableseasierresec-tionoftheherniasac.Inthisway,thesubsequentextraperitoneallaparoscopicrepairissimplified.Correctpositioningofthe3-Dmeshiseasilyobtainedbyapplyingittothein-fero-externaledgeoppositetheanterioraspectofthepsoasmuscle.Itmaythenbeunfoldedontotheinfero-internaledgebelowCooper’sligament.Spiegelherniascanbetreatedinthesamewaybyreducingtheherniasacbysimpletraction.Thesuperiorpartoftheinguinalmeshismadetocovertheherniadefectoncewideranteriorparietaldissectionhasbeenperformed.Thepresenceofalargeherniadefectmayleadtothefollowing:(a)evertingthefasciatransversalisandfixingittoCooper’sligamenttopreventpostopera-tiveseromas;(b)fixingthesuperioredgeofthemeshtotheanteriorparietalmuscles;and(c)installingasuctiondrainage.Incisionoftheherniaringissometimesrequiredtoreducealargefemoralhernia.Abilateralapproachmeansonemeshoneachside,amoreharmonioussolu-tionthanusingonlyalargeone.Alargeherniasacmaybeleftrevertedinsidetheperitonealcavitywithoutre-section.Afinalintra-abdominalinspectionattheendoftheproceduremakesitpos-sibletostuckthemeshintoplace,tocheckitsposition,toensureperitonealclosureinasatisfactorymanner,tolookforaherniaontheothersideandtorevertalargeherniasac.LiteratureArreguiME,DavisCJ,YucelO,NaganRF(1992)Laparoscopicmeshrepairofinguinalherniausingapreperitonealapproach:apreliminaryreport.SurgLaparoscEndosc2:53–58BeginG(1992)Traitementlaparoscopiquedesherniesdel’ainedel’adulte:àproposde200cas.Lalettrechirurgicaleeuropéenne113BeginG(1993)Créationdupneumopéritoinesouscontrôlevisuel.JCoeliochir18–19BeginG(1993)Curecoelioscopiquedesherniesdel’aineparvoieprépéritonéale.JCoeliochir7:23–29BeginG(1994)Traitementlaparoscopiquedesherniesdel’aineparvoieextra-péritonéale–résultatàproposde520hernies.JCoeliochir9:33–35CorbittJD(1991)Laparoscopicherniorhapy.SurgLaparoscEndos23–25DulucqJL(1991)Traitementdesherniesdel’aineparlamiseenplaced’unpatchprothétiqueparlaparoscopie.Voietotalementextrapéritonéale.CahChir79:15–16DulucqJL(1992)Traitementdesherniesdel’aineparmiseenplaced’unpatchprothétiquesouspéritonéalenrétropéritonéoscopie.ChirEndoscop1:6–8DulucqJL(1992)Treatmentofinguinalherniasbyinsertionofmeshthroughretroperitoneoscopy.PostGraduateGeneralSurgery4:173–174FerzliG,RaboyA,KleinermanD,AlbertP(1992)Extraperitonealendoscopicpelviclymphnodedis-sectionvs.laparoscopiclymphnodedissectioninthestagingofprostaticandbladdercarcinoma.JLaparoendosSurg2:219–222 Literature187FitzgibbonsRJ(1991)Laparoscopicherniarepair.In:Proceedingsofsymposiumonnewfrontiersinendosurgery.Ethicon,NewBrunswick,NJFitzgibbonsRJ,AnnibaliR,LitkeBS(1993)Gall-bladderandgallstoneremoval,openversusclosedlaparoscopy,andpneumoperitoneum.AmJSurg165:497–504HimpensJM(1992)Laparoscopichernioplastyusingaselfexpendable(umbrellalike)prostheticpatch.SurgLaparoscEndosc2:312–316HimpensJM(1993)Laparoscopicinguinalhernioplasty:repairwithaconventionalvs.anewselfexpandablemesh.SurgEndos7:315–319LiechtensteinIL,ShulmanAJ,AmidPKetal(1989)Thetension-freehernioplasty.AmJSurg157:188–193McKernanJB,LawsHL(1993)Laparoscopicrepairofinguinalherniasusingatotallyprostheticap-proach.SurgEndos7:26–28PhillipsEH,FranklinM,CarrollBJetal(1992)Laparoscopiccolectomy.AnnSurg216:703–770PhillipsEH,CarollBJ,PearlsteinAR,DaykhovskyL,FallasMJ(1993)Laparoscopiccholedochoscopyandextractionofcommonbileductstones.WorldJSurg17:22–28StoppaRE,WharlaumontCR(1989)Thepreperitonealapproachandprostheticrepairofgroinher-nia.In:NyphusLM,CondomRE(eds)Hernia.JPLippincott,Philadelphia,pp199–255StoppaRE,RivesJL,WarlaumontCRetal(1984)TheuseofDacronintherepairofherniasofthegroin.SurgClinNorthAm64:269–285ToyFK,SmootRT(1991)ToySmoothernioplasty.SurgLaparoscEndos1:151–155VernayA(1980)Larétropéritonéoscopie:justificationanatomique.Expérimentationtechnique.Ex-périenceclinique[thèse].GrenobleWebbDR,RedgraveN,ChanY,HarewoodLM(1993)Extraperitoneallaparoscopy:earlyexperienceandevaluation.AustNZJSurg63:557–557WurtzA(1989)L‘endoscopiedel‘espacerétropéritonéal:techniques,résultatsetindicationsac-tuelles.AnnChir43:475–480 13LaparoscopicRightAdrenalectomy13.1OperatingRoomSetup:PositionofthePatientThepatientisplacedsupine,withlegsapart.SlightreverseTrendelenburgposi-tionand20°leftrotationisuseful.Thesurgeonstandsbetweenthepatient’slegs.Thefirstassistantisonthepatient’srightside,asecondassistantisontheleft(>Fig.13.1).Self-adhesivenon-wovendrapesarearrangedwithsterilepocketstoholdtheinstruments.Thevideomonitorisplacedatthepatient’shead,slightlytotheleft.Fig.13.1.ORsetup–positionoftrocars 19013LaparoscopicRightAdrenalectomy13.2RecommendedInstrumentsTwo10-mmtrocarsThree5-mmtrocarsA0°endoscopeTwoJohanfenestratedgraspingforcepsFive-millimetrestraightorcurvedcoagulatingshearsAbluntpaddleAstraight5-mmgraspingforcepsA5-mmdissectorA5-mmneedleholderA5-mmclipapplicatorA5-mmsuctioncannulaAvascularlinearstaplerHarmonicscalpel,ifavailableSpecimenretrievalbag13.3PositionoftheTrocarsandExposureThepneumoperitoneumiscreatedwithaVeressneedle.Thefirst10-mmtrocarisinsertedtotherightoftheumbilicus.Theskinincisionmustmatchthesizeofthetrocar.Insertionisoblique,inthedirectionofthesupposedpositionoftheadre-nal.Thisenablesatransmuscularrouteavoidingfutureincisionalhernias.Theotherthree5-mmoperatingtrocarsarepositionedasfollows:oneisap-proximately12cmlateraltotheumbilicus,ontherightside;asecondoperatingtrocarintherightsubcostalpositionenablesmobilizationoftheliver;andtheleft5-mmoperatingtrocarispositionedonthemedianline,4cmabovetheumbilicus(>Fig.13.1).Therightlobeoftheliverisliftedbyaliverretractor,insubcostalposition.Theperitonealcavityisexplored.13.4ApproachoftheRightAdrenalThehepaticflexureofthecolonisdetachedwithcoagulatingscissorsorhar-monicscalpel.Theduodenumisprogressivelyexposed,andthenthevenacava(>Fig.13.2).Therightrenalveinmustnextbeidentified(>Fig.13.3).Thisevidencestheadrenalparenchymaattheupperpoleoftherightkidney.Itsorangecolourdistin-guishesitfromtheperiadrenalfattytissue(>Fig.13.4). 13.4ApproachoftheRightAdrenal191Fig.13.2.InferiorvenacavaFig.13.3.Dissectionoftherenalvein 19213LaparoscopicRightAdrenalectomyFig.13.4.Dissectionofrenalvein13.5ControloftheMainAdrenalVeinDissectionofthelowervenacavaiscontinuedcaudallytotherightrenalvein(>Fig.13.5).Thevenacavaisprogressivelydissectedfromtheadrenalparen-chyma,usingeithercoagulatingshearsorametallicsuctioncannula(>Figs.13.6,13.7).Theadrenalveinisthusidentifiedandmustbeskeletonizedwitha5-mmdissector,enoughtosafelyplacetwoclips(>Fig.13.8).13.6DissectionoftheAdrenalOncecontroloftheveinhasbeencompleted,dissectionoftheposterioraspectoftheadrenalglandiscontinued.Upwardtractionontheparenchymawiththegraspingforcepsenablesexposureofthearterialbranchesandaccessoryveins,whicharecontrolledwith5-mmclipsorwiththecoagulatingshears(>Figs.13.9,13.10).Thelowerportionoftheadrenalisthendissociatedfromitsattachments.Anyresidualvesselsarecontrolledinthesameway(>Figs.13.11,13.12). 13.6DissectionoftheAdrenal193Fig.13.5.DissectionoftheinnerpartoftheadrenalFig.13.6.Anterioraspectofadrenal 19413LaparoscopicRightAdrenalectomyFig.13.7.DissectionbetweenvenacavaandrenalveinFig.13.8.Ligatureofadrenalvein 13.6DissectionoftheAdrenal195Fig.13.9.ArterialligatureFig.13.10.Arterialcontrolwithclips 19613LaparoscopicRightAdrenalectomyFig.13.11.DissectioncontinuedalongvenacavaFig.13.12.Arterialcontrol 13.8SpecimenRetrieval:Haemostasis–Drainage19713.7ControloftheUpperAdrenalPediclesDissectionoftheinnerpartoftheadrenalglandiscontinuedincontactwiththevenacava.Mobilizationoftheparenchymaissimplifiedbythepriordissectionofitsposteriorpart.Anupperadrenalveiniscontrolledbyclipsafterdissectionwiththe5-mmdissector(>Fig.13.13).Theresidualarterialbranchesarecontrolledattheleveloftheupperpartoftheadrenalparenchyma.Thelastcapsularelementscanbecontrolledbycoagulation(>Figs.13.14–13.18).Theadrenalisresected.13.8SpecimenRetrieval:Haemostasis–DrainageAspecimenretrievalbagisintroducedandtheadrenalisextractedthroughthelateralport(>Fig.13.19).Theskinincisionisenlargedto2cmafterremovalofthetrocar.Thebagispulledout,andtheadrenalisgraspedinsidethebagwithanappropriateforceps.Theoperativefieldischeckedforbleedingandcleanedwithsaline.Noperito-nealclosureisneeded.Asuctiondrainageisleft.Fig.13.13.Superioradrenalvein 19813LaparoscopicRightAdrenalectomyFig.13.14.DissectionatupperedgeFig.13.15.Dissectionoftheupperpartoftheadrenal 13.8SpecimenRetrieval:Haemostasis–Drainage199Fig.13.16.UpperpolarattachmentsFig.13.17.Dissectionoftheposterioraspectoftheadrenal 20013LaparoscopicRightAdrenalectomyFig.13.18.FinaldissectionFig.13.19.Retrievalwithabag Literature20113.9TipsandCommentsTheharmonicscalpelminimizestheneedforclips.However,clipsremainnec-essaryforcontrolofthemainadrenalveinandartery.Theinferioradrenalveinisveryshortandmustbedissectedwithextremecare.Thisjustifiestheuseofthe5-mmdissector.Ligatureoftheveinisoftenneces-sary.Alaparoscopicvascularclampmustbereadyforemergencylateralclampingofthevenacava.Therightrenalveinisthemainanatomicallandmarktodiscovertheadrenal,combinedwiththedissectionofthevenacava.Thesizeofthesuperioradrenalveinisoftenidenticaltothatoftheinferioradrenalvein.Thechoiceofitsearlycontrolisoftenwarranted.Useofametallicsuctioncannulaasadissectorintheperiadrenalfatisstronglyrecommended.TheadrenalparenchymamustbemobilizedverycarefullyusingaJohanfor-cepswithoutactualgrasping.Installingthepatientintherightposteriorlumbarpositionresultsinplacingthesurgeonontherightside.Itisamatterofchoice.Wepreferpositioningthepatientasindicatedabove,supine,withamaximumof30°rightrotation.Thispatientpositiondoesnotchangetheanatomy.LiteratureAmbrosiB,PassiniE,ReT,BarbettaL(1997)Theclinicalevaluationofsilentadrenalmasses.JEn-docrinolInvest20:90–107BendinelliC,MaterazziG,PucciniM,LacconiP,BucciantiP,MiccoliP(1988)Laparoscopicadrenal-ectomy:aretrospectivecomparisonwithtraditionalmethods.MinervaChir53:871–875BonjerHJ,VanderHastE,SteyebergEW,deHerderWW,KazeimierG,MohammedaminRS,Bruin-ingHA(1998)Retroperitonealadrenalectomy:openorendoscopic?WorldJSurg22:1246–1249BuelJF,AlexanderHR,NortonJA,YuKC,FrakerDL(1997)BilateraladrenalectomyforCushing’ssyndrome:anteriorversusposteriorsurgicalapproach.AnnSurg225:63–68ClaymanRV,KavoussiLR,SoperNJ,DierksSM,MeretykS,DarcyMD,RoemerFD,PingletonED,ThomsonPG,LongSR(1991)Laparoscopicnephrectomy:initialcarereport.JUrol146:278–281DeCanniereL,MichelL,HamoirE,HubensG,MeurisseM,SquiffletJP,UrbainP,VereeckenL(1997)MulticentricexperienceoftheBelgianGroupforEndoscopicSurgery(BGES)withendoscopicadrenalectomy.SurgEndosc11:1065–1067DemeureMJ,JordanM,ZeihemM,WilsonSD(1997)Endoscopicretroperitonealrightadrenalec-tomywiththepatientinthelateraldecubitusposition.SurgLaparoscEndosc7:307–309Fernandez-CruzL,SaenzA,TauraP,BenarrochG,AstudilloE,SabaterL(1999)Retroperitonealapproachinlaparoscopicadrenalectomy:isitadvantageous?SurgEndosc13:86–90FilipponiS,GuerrieriM,ArnaldiG,GiovagnettiM,MasiniAM,LezocheE,ManteroF(1998)Laparo-scopicadrenalectomy:areportof50operations.EurJEndocrinol138:548–553GagnerM,LacroixA,PrinzRA(1993)Earlyexperiencewithlaparoscopicapproachforadrenalec-tomy.Surgery114:1120–1125 20213LaparoscopicRightAdrenalectomyImaiT,FunahashiH,TanakaY,TobinagaJ,WadaM,Morita-MatsuyamaT,OhisoY,TakagiH(1996)AdrenalectomyfortreatmentofCushingsyndrome:resultsin122patientsandlong-termfollow-upstudies.WorldJSurg20:781–786IshikawaT,SowaM,NagayamaM,NishiguchiY,YoshikawaK(1997)Laparoscopicadrenalectomy:comparisonwiththeconventionalapproach.SurgLaparoscEndosc7:275–280JanetschekG,FinkenstedtG,GasserR,WaibelUG,PeschelR,BartschG,NeumannHP(1998)Lapar-oscopicsurgeryforpheochromocytoma:adrenalectomy,partialresection,excisionofparagan-gliomas.JUrol160:330–334KormanJE,HoT,HiattJR,PhillipsEH(1997)Comparisonoflaparoscopicandopenadrenalectomy.AmSurg63:908–912MacGillivrayDC,ShichmanSJ,FerrerFA,MalchoffCD(1996)Acomparisonofopenvs.laparoscopicadrenalectomy.SurgEndosc10:987–990ManteroF,MasiniAM,OpocherG,GiovagnettiM,ArnaldiG(1997)Adrenalincidentaloma:anover-viewofhormonaldatafromtheNationalItalianStudyGroup.HormRes47:284–289MobiusE,NiesC,RothmundM(1999)Surgicaltreatmentofpheocromocytomas:laparoscopicorconventional?SurgEndosc13:35–39PrinzRA(1995)Acomparisonoflaparoscopicandopenadrenalectomies.ArchSurg130:489–492SugarbackerPH(1995)Patientselectionandtreatmentofperitonealcarcinomatosisfromcolorectalandappendicealcancer.WordJSurg19:235–290ThompsonW(1990)Conn’ssyndrome:primaryaldosteronism.In:FriesenSR,ThompsonNW(eds)Surgicalendocrinology:clinicalsyndromes.JBLippincott,Philiadelphia,pp433–449TingAC,LoCY,LoCM(1998)Posteriororlaparoscopicapproachforadrenalectomy.AmJSurg175:488–490 14LaparoscopicLeftAdrenalectomy14.1OperatingRoomSetup:PositionofthePatientThepatientisinstalledsupine,witha30°rightrotation,andwithlegsapart.Thesurgeonstandsbetweenthepatient’slegs.Thefirstassistantstandsontherightsideofthepatient.Asecondassistantstandstothepatient’sleft.Self-adhesivenon-wovendrapesareusedwithsterilepocketstoholdtheinstruments.Thevideomonitorisplacedbehindandtotheleftsideofthepatient’shead.14.2RecommendedInstrumentsOneortwo10-mmtrocarsThree5-mmtrocarsA0°endoscopeTwoJohanfenestratedgraspingforcepsApairof5-mmstraightorcurvedcoagulatingshearsAstraight5-mmgraspingforcepsA5-mmdissectorA5-mmneedleholderA5-mmclipdispenserA5-mmsuctioncannulaAvascularlinearstaplerAnultrasounddissector,ifavailableAplasticspecimenretrievalbag14.3PositionoftheTrocarsandExposure:ExplorationofthePeritonealCavityThepneumoperitoneumiscreatedwithaVeressneedle.Thefirst10-mmtrocarisinsertedslightlyleftoftheumbilicus.Theskinincisionmustmatchtheprecisesizeofthetrocar.Insertionisoblique,inthedirectionofthesupposedpositionoftheadrenal.Thisenablesatransmuscularrouteavoidingfutureincisionalhernias.Theotherthreeoperatingtrocarsarepositionedasfollows:thefirstrightoper-atingtrocarisonthemedian,supra-umbilicallineroughly5cmabovetheumbili- 20414LaparoscopicLeftAdrenalectomycus;asecondoperatingleftsubcostaltrocarontheaxillarylineenablesgastroepi-ploicandpancreaticmobilization;andtheleft5-mmoperatingtrocarisinsertedintheleftpara-medianpositionroughly10cmtotheleftoftheumbilicus.Theabdominalcavityisvisuallyexplored.14.4ApproachoftheAdrenalTheleftcolicomentumisdetachedwiththeharmonicscalpelorbycoagulation.Sometimesloweringofthesplenicflexureofthecolonisneeded.Theloweredgeofthepancreasandtheanteriorpartoftheleftkidneyarevis-ibleinthelessersac.Theloweredgeofthepancreasisdissectedwithopeningoftheposteriorparietallayer.Theleftrenalveinandthesplenicveincaneasilybelandmarked.Theleftrenalveinandtheupperpoleoftheleftkidneyenablesituatingtheadrenal.DissectionisperformedwiththeJohanfenestratedforcepsandtheco-agulatingshears.Theorange-colouredadrenalparenchymaappearsattheinneredgeoftheupperpoleoftheleftkidneyandtheupperedgeoftheoriginoftheleftrenalvein.14.5ControlandDissectionoftheMainAdrenalVeinTheleftadrenalveinisfoundcaudaltotheleftrenalvein.Clearlyidentifyingtherenalveinisabsolutelynecessary.Theadrenalveinisdissectedoveradistanceof1–2cm,enablingitscontrolwithtitaniumclips.14.6DissectionoftheAdrenalIncontactwiththeaorta,theadrenalisthendissectedwiththe5-mmsuctioncan-nula.Theperi-adrenalfatcaneasilybedissociatedfromtheadrenalparenchyma.Caudallytotheoperativefielditispossibletodistinguishtheadrenalarteriesthatareclippedseparatelywithtitaniumclips.Asuperioradrenalpedicleisoftenencountered,botharterialandvenous.Everyvesselisclippedinturn.Dissectionresumesattheposterioraspectoftheadrenal,eitherwiththeharmonicscalpelorcoagulatingshears. 14.9TipsandComments20514.7FinalDissectionDissectionoftheglandparenchymaiscompletedbythecontrolofafewuppertractsincontactwiththediaphragm.Numeroussmallcollateralvesselsarecoagu-latedorclipped.Theentireadrenalisfreed.Acoagulatingforcepscanbeusedtoperfectthehaemostasisoftheentireadrenalbed.14.8SpecimenRetrieval:DrainageThelefttrocarportiswidenedtoretrievethespecimenthroughaprotectivebag.Thefieldiscleanedwithsaline.Asuctiondrainageisleft.Thereclinedorgans,caudalpartofpancreas,splenicflexure,andomentumarerepositioned.14.9TipsandCommentsUseoftheharmonicscalpelmakesitpossibletominimizetheuseofclips,neededonlyforthecontrolofthemainadrenalveinandofthemainadrenalartery.Theadrenalveinisusuallyveryshort.Dissectionshouldbedoneespeciallycarefully,andtheuseofa5-mmdissectorisrecommended.Aligaturemaybenecessary.Alaparoscopicvascularclampmustbereadyincaseofinjurytothelargevessels.Therightrenalveinisthemainanatomicallandmarktofindingtheadrenalgland.Thesizeofthesuperioradrenalveinisoftenidenticaltothatoftheinferioradrenalvein.Thechoiceofitsearlycontrolisoftenwarranted.Useofametallicsuctioncannulaasadissectorintheperi-adrenalfatisstronglyrecommended.TheadrenalparenchymamustbemobilizedverycarefullyusingaJohanfor-cepswithoutactualgrasping.Installingthepatientintherightposteriorlumbarpositionresultsinplacingthesurgeonontheleftside.Itisamatterofchoice.Wepreferpositioningthepatientasindicatedabove,supine,withamaximumof30°leftrotation.Thispositiondoesnotchangetheanatomy.Theremaybeonlyoneleftadrenalvein.Alargebranchis,however,frequentlyfoundnearbythatmustbecontrolledinthesameway.Findingtheadrenalparenchymaisalwaysensuredbyaproperdissectionoftheanterioraspectoftheupperpoleoftheleftkidneyandbythedissectionoftheleftrenalvein. 20614LaparoscopicLeftAdrenalectomyLiteratureAmbrosiB,PassiniE,ReT,BarbettaL(1997)Theclinicalevaluationofsilentadrenalmasses.JEn-docrinolInvest20:90–107BendinelliC,MaterazziG,PucciniM,LacconiP,BucciantiP,MiccoliP(1988)Laparoscopicadrenal-ectomy:aretrospectivecomparisonwithtraditionalmethods.MinervaChir53:871–875BonjerHJ,VanderHastE,SteyebergEW,deHerderWW,KazeimierG,MohammedaminRS,Bruin-ingHA(1998)Retroperitonealadrenalectomy:openorendoscopic?WorldJSurg22:1246–1249BuelJF,AlexanderHR,NortonJA,YuKC,FrakerDL(1997)BilateraladrenalectomyforCushing’ssyndrome:anteriorversusposteriorsurgicalapproach.AnnSurg225:63–68ClaymanRV,KavoussiLR,SoperNJ,DierksSM,MeretykS,DarcyMD,RoemerFD,PingletonED,ThomsonPG,LongSR(1991)Laparoscopicnephrectomy:initialcarereport.JUrol146:278–281DeCanniereL,MichelL,HamoirE,HubensG,MeurisseM,SquiffletJP,UrbainP,VereeckenL(1997)MulticentricexperienceoftheBelgianGroupforEndoscopicSurgery(BGES)withendoscopicadrenalectomy.SurgEndosc11:1065–1067DemeureMJ,JordanM,ZeihemM,WilsonSD(1997)Endoscopicretroperitonealrightadrenalec-tomywiththepatientinthelateraldecubitusposition.SurgLaparoscEndosc7:307–309Fernandez-CruzL,SaenzA,TauraP,BenarrochG,AstudilloE,SabaterL(1999)Retroperitonealapproachinlaparoscopicadrenalectomy:isitadvantageous?SurgEndosc13:86–90FilipponiS,GuerrieriM,ArnaldiG,GiovagnettiM,MasiniAM,LezocheE,ManteroF(1998)Laparo-scopicadrenalectomy:areportof50operations.EurJEndocrinol138:548–553GagnerM,LacroixA,PrinzRA(1993)Earlyexperiencewithlaparoscopicapproachforadrenalec-tomy.Surgery114:1120–1125ImaiT,FunahashiH,TanakaY,TobinagaJ,WadaM,Morita-MatsuyamaT,OhisoY,TakagiH(1996)AdrenalectomyfortreatmentofCushingsyndrome:resultsin122patientsandlong-termfollow-upstudies.WorldJSurg20:781–786IshikawaT,SowaM,NagayamaM,NishiguchiY,YoshikawaK(1997)Laparoscopicadrenalectomy:comparisonwiththeconventionalapproach.SurgLaparoscEndosc7:275–280JanetschekG,FinkenstedtG,GasserR,WaibelUG,PeschelR,BartschG,NeumannHP(1998)Lapar-oscopicsurgeryforpheochromocytoma:adrenalectomy,partialresection,excisionofparagan-gliomas.JUrol160:330–334KormanJE,HoT,HiattJR,PhillipsEH(1997)Comparisonoflaparoscopicandopenadrenalectomy.AmSurg63:908–912MacGillivrayDC,ShichmanSJ,FerrerFA,MalchoffCD(1996)Acomparisonofopenvs.laparoscopicadrenalectomy.SurgEndosc10:987–990ManteroF,MasiniAM,OpocherG,GiovagnettiM,ArnaldiG(1997)Adrenalincidentaloma:anover-viewofhormonaldatafromtheNationalItalianStudyGroup.HormRes47:284–289MobiusE,NiesC,RothmundM(1999)Surgicaltreatmentofpheocromocytomas:laparoscopicorconventional?SurgEndosc13:35–39PrinzRA(1995)Acomparisonoflaparoscopicandopenadrenalectomies.ArchSurg130:489–492SugarbackerPH(1995)Patientselectionandtreatmentofperitonealcarcinomatosisfromcolorectalandappendicealcancer.WordJSurg19:235–290ThompsonW(1990)Conn’ssyndrome:primaryaldosteronism.In:FriesenSR,ThompsonNW(eds)Surgicalendocrinology:clinicalsyndromes.JBLippincott,Philiadelphia,pp433–449TingAC,LoCY,LoCM(1998)Posteriororlaparoscopicapproachforadrenalectomy.AmJSurg175:488–490 PART4ProceduresforPelvicFloorDisorders15LaparoscopicPosteriorColpopexy20916LaparoscopicAnteriorColpopexy22117LaparoscopicBurchColposuspension233 15LaparoscopicPosteriorColpopexy15.1OperatingRoomSetup:PositionofthePatientThepatientisplacedsupineina20°Trendelenburgposition.Thesurgeonandthescrubnursestandontheleftsideofthepatient.Thesecondassistantstandsbe-tweenthepatient’slegs.Thevideomonitorispositionedtotherightofthepatient,laterallytotherightleg.Thepatientisundergeneralanaesthesiawithanendotrachealtube.Self-adhe-sivenon-wovendrapesareused,withbagstoholdtheinstruments.15.2RecommendedInstrumentsTwo10-mmtrocarsTwo5-mmtrocarsThree5-mmJohannfenestratedgraspingforcepsA5-mmcoagulatingshearsAstraight5-mmgraspingforcepsA5-or10-mmharmonicscalpelA10-mmcurveddissectorA5-mmneedleholderA0°endoscope15.3PositionoftheTrocarsandExposureThepneumoperitoneumiscreatedwithaVeressneedleatthelowermarginoftheumbilicus.Alefttransrectaltrocarisinserted5cmoutsideoftheumbilicusfortheendoscope.Theotheroperatingtrocarsareinsertedafterinflationoftheabdomi-nalcavity,a5-mmmediansuprapubictrocar,a5-mmleftiliacfossatrocar,anda10-mmtrocaratthelowermarginoftheumbilicuswitha5-mmreducer.Theabdominalcavityisthenexplored(>Fig.15.1).A20°Trendelenburgposi-tionenablespositioningofthesmallbowelintheupperquadrantsoftheabdomen.Afenestratedgraspingforcepsinsertedthroughthesuprapubicportprogressivelyexposestherectosigmoidjunction. 21015LaparoscopicPosteriorColpopexyFig.15.1.Pelvicfloorexposure15.4DissectionofthePromontoriumTheposteriorparietalperitoneumisopenedwiththecoagulatingshearslongi-tudinallyinlinewiththepromontorium,whichiseasilyidentified(>Fig.15.2).Asecondpre-promontoriumlayerisopenedenablingtheexposureoftheverte-bralligamentofthepromontoriumandofitsvessels.Thedissectioniscontinuedlaterally.15.5PeritonealOpeningandExcisionAnincisionoppositethepromontoriumoftheparietalperitoneumiscontinuedtothebackoftheDouglaspouch,withthetwouterosacralligamentsattheupperlimitoftheperitonealincision,afterlocationoftherightandthentheleftureter(>Figs.15.3,15.4).Theuteruscanbesuspendedthroughtheabdominalwallbyatransfixingstitch.Theperitoneumthusdelineatedisthenresectedtoitsrectalinsertion.Theresectionisperformedincontactwiththeperitoneallayerusingthecoagulatingshearsortheharmonicscalpel.Aperirectalcollarislefttoenableproperperitonization. 15.5PeritonealOpeningandExcision211Fig.15.2.DissectionofvertebralligamentFig.15.3.Peritonealincision 21215LaparoscopicPosteriorColpopexyFig.15.4.Peritonealincisionleftwards15.6RectovaginalDissectionThepositioningofavaginalretractorintheposteriorvaginalpouchmakesitpos-sibletoexposeandthenopentherectovaginalseptum(>Fig.15.5).Tractionisappliedattheleveloftherectosigmoidjunctionbythesuprapubicgraspingfor-ceps.Therectovaginalseptumcanbeprogressivelydissectedusingthecoagulatingshears,theharmonicscalpelorabluntinstrument(>Fig.15.6).Haemostasismustbecarefullyperformed.Theposteriorvaginalwallnowappears,presentedbythevaginalretractor,andisdissectedaslowaspossible.15.7MeshPlacementAmersilenemeshandtwononabsorbable2/0sutureswitha26-mmneedleareinsertedthroughtheumbilicaltrocar.Themeshsizeis3×20cm.Themeshissu-turedtotheposteriorvaginalwallbysixstitches(>Figs.15.7,15.8).Afinalstitchisappliedtothecervixoristhmuspartoftheuterus,transfixingtheposteriorwallofthecervixortheuterineisthmus(>Fig.15.9).Themeshistunneledundertheperitoneumtowardsthepromontorium(>Fig.15.10). 15.7MeshPlacement213Fig.15.5.VaginalretractorpresentingDouglaspouchFig.15.6.Dissectingtherectumfreefromposteriorvaginalwall 21415LaparoscopicPosteriorColpopexyFig.15.7.LowsutureofmeshtoposteriorvaginalwallFig.15.8.Sutureofmeshtoupperpartofposteriorvaginalwall 15.7MeshPlacement215Fig.15.9.SutureofmeshtovaginalwallcompletedFig.15.10.Retroperitonealtunnelingofthemesh 21615LaparoscopicPosteriorColpopexy15.8StaplingtothePromontoriumandPeritonealClosureThemeshisappliedattherighttensiontothevertebralligament(>Fig.15.11),andfixedwithTaksorseparatestitchesofnonabsorbable0sutures(>Fig.15.12).Peritonealclosureisperformedusingabsorbablesutures.Asuctiondrainagemaybeleft(>Fig.15.13).15.9TipsandCommentsItissometimesnecessarytomobilizethesigmoidcolontoobtainproperexpo-sureofthepromontorium.Averylargeandfibromatousuterusmayrenderhysterectomynecessary.How-ever,inmostcasesitisbesttokeeptheuterus.Ananteriorcolpopexymaybecombinedwithaposteriorcolpopexy.Asecondmeshisthenneeded.TractionontheperitoneumtoperformtheexcisionoftheDouglaspouchmayrequireanadditional,rightiliacfossatrocar,foranadditionalfenestratedfor-ceps.Fig.15.11.Staplingmeshtopromontorium 15.9TipsandComments217Fig.15.12.PosteriorcolpopexycompletedFig.15.13.Peritonealclosurecompleted 21815LaparoscopicPosteriorColpopexyTheabsenceofrectalsymptomsrequiresaposteriorcolpopexywithanisolatedexcisionoftheDouglaspouch.Anassociatedrectalproblem,however,mayleadtoaconcurrentrectopexy.Thepropertensiononthemeshcanbecheckedbyvaginalexamination.TheextentoftheexcisionoftheDouglaspouchmayvary.Themaintenanceofaperirectalcollarappearstobeessentialforthequalityofthesubsequentperitonealclosure.LiteratureAddisonWA,LivengoodCH,SuttonGP,ParkerRT(1985)AbdominalsacralcolpopexywithMer-silenemeshintheretroperitonealpositioninthemanagementofposthysterectomyvaultpro-lapseandenterocele.AmJObstetGynecol153:140–146AlbalaDM,SchluesslerWW,VancaillieT(1992)Laparoscopicbladdersuspensionforthetreatmentofstressincontinence.SeminUrol10:22–26BlancB,LuneauF,BoubliL,BernardY(1990)L’élytrocèle.Aproposde45observations.Mémoireoriginal.Gynécologie,Masson,Paris41:171–176BrownWE,HoffmanMS,BouisPL,IngramJM,HopesSL(1989)Managementofvaginalvaultpro-lapse:retrospectivecomparisonofabdominalversusvaginalapproach.JFlaMedAssoc76:249–252BurchJC(1961)UrethrovaginalfixationtoCooper’sligamentforcorrectionofstressincontinence,cystoceleandprolapse.AmJObstetGynecol81:281–290ChapronC,LaforestL,AnsquerY,FauconnierA,FernandezB,BreartG,DubuissonJB(1999)Hys-terectomytechniquesusedforbenignpathologies:resultsofaFrenchmulticentrestudy.HumReprod14:2464–2470CornierE,MadelenatP(1994)HystéropexieselonM.Kapandji:techniquepercoelioscopiqueetrésultatspréliminaires.JGynecolObstetBiolReprod23:378–385CravelloL,deMontgolfierR,D’ErcoleC,RogerV,BlancB(1997)Endoscopicsurgery.Theendofclassicsurgery?[Review]EurJObstetGynecolReprodBiol75:103–106CuschieriA(1991)Minimalaccesssurgeryandthefutureofinterventionallaparoscopy.ObstetGynecol161:404–407CuschieriA,ShimiS,Vander-VelpenG(1994)Laparoscopicprosthesisfixationrectopexyforcom-pleterectalprolapse.BritJSurg81:138–139DenoitV,BigotteA,MiannayE,CossonM,QuerleuD,CrepinG(2000)Burchlaparoscopiccolposus-pension.Resultsof30-monthfollow-up.AnnChir125:757–763DorseyJH,CundiffG(1994)Laparoscopicproceduresforincontinenceandprolapse.CurrOpinObstetGynecol6:223–230DrancourtE,YouinouY,BrandtB,HerardA,LardennoisB(2000)TreatmentoffemalestressurinaryincontinencewithcystocelebyGoreTexcolpofixationandBurchoperation.ProgUrol10:211–218GlavindK,MouritsenAL,PedersenLM,BekKM(2000)Genitalprolapse[Review].UgeskrLaeger162:1542–1546HarewoodLM(1993)Laparoscopicneedlecolposuspensionforgenuinestressincontinence.JEndoUrol7:319–322HillD,MaherP,CarehM(1994)LaparoscopicretroperitonealBurchcolposuspension.GynaecologicEndoscopists1:339–349KriplaniA,BanerjeeN,KriplaniAK,RoyKK,TakkarD(1998)Uterovaginalprolapseassociatedwithrectalprolapse.AustNZJObstetGynaecol38:325–326 Literature219LiapisA,BakasP,PafitiA,HassiakosD,Frangos-PlemenosM,CreatsasG(2000)ChangesinthequantityofcollagentypeIinwomenwithgenuinestressincontinence.UrolRes28:323–326LimC,PackW(1993)Laparoscopicretropubiccolposuspension(Burchprocedure).JAmAssocGynecolLaparosc1:31–35LiuCY(1994)Laparoscopictreatmentforgenuineurinarystressincontinence.Baillere’sClinObstetGynecol8:789–798LiuCY,ReichH(1996)Correctionofgenitalprolapse[Review].JEndourol10:259–265MatysekP(1999)Presentviewsontreatmentofgenitalprolapse.CeskaGynekol64:390–393MoschcowitzAV(1912)Thepathogenesis,anatomyandcureofprolapseoftherectum.SaxGynaecolObstet15:7–21NezhatCH,NezhatF,NezhatC(1994)Laparoscopicsacralcolpopexyforvaginalvaultprolapse.ObstetGynecol84:885–888NicholsDH(1991)Surgeryforpelvicfloordisorder.SurgClinNorthAm71:927–946PowellJL,JosephDB(1998)Abdominalsacralcolpopexyformassivegenitalprolapse.PrimCareUpdateObGyns5:201QuerleuD(1994)Curedeprolapsusparvoiecoelioscopique:chirurgie-fiction.Lepelvisfémininstatiqueetdynamique.SocFrGynecol254–258RichardsonD,ScottiR,OstergardD(1989)Surgicalmanagementofuterineprolapseinyoungwom-en.JReprodMed34:388–392RichterK(1967)DieoperativebehandlungdesprolabierternScheidengrundersnachuterus-ex-tirpation.EinbietragzurvaginaefixationsacrotuberalisnachAmreich.GeburstshFrauenheilk27:941–954RoseCH,RoweTF,CoxSM,MalinakLR(2000)Uterineprolapseassociatewithbladderexstrophy:surgicalmanagementandsubsequentpregnancy.JMaterFetalMed9:150–152StantonSL,CardozoLD(1979)Acomparisonofvaginalandsuprapubicsurgeryinthecorrectionofincontinenceduetourethralsphincterincontinence.BrJUrol5:497–499TimmonsMC,AddisonWA,AddisonWA,AddisonSB,CavenarMG(1992)Abdominalsacralcol-popexyin163womenwithposthysterectomyvaginalvaultprolapseandenterocele.Evolutionofoperativetechniques.JReprodMed37:323–327ValaitisSR,StantonSL(1994)Sacrocolpopexy:aretrospectivestudyofaclinician‘sexperience.BritJObstetGynecol101:518–522VanCaillieTG(1994)Laparoscopyinurogynaecology.ProceedingsPGVAAGL111–141VanCaillieTG,SchuesslerW(1991)Laparoscopicbladdernecksuspension.JournalofLaparoendo-scopicSurgery1:169–173 16LaparoscopicAnteriorColpopexy16.1OperatingRoomSetup:PositionofthePatientThepatientisplacedina20°Trendelenburgposition.Thesurgeonandthescrubnursestandontheleftsideofthepatient.Thesecondassistantstandsbetweenthepatient’slegs.Thevideomonitorispositionedattherightofthepatient,laterallytotherightleg.Thepatientisundergeneralanaesthesiawithendotrachealintubation.Self-adhesivenon-wovendrapesareused,withattachedbagstoholdtheinstruments.16.2RecommendedInstrumentsTwo10-mmtrocarsTwo5-mmtrocarsThree5-mmJohannfenestratedgraspingforcepsA5-mmcoagulatingscissorsAstraight5-mmgraspingforcepsA5-or10-mmharmonicscalpelA10-mmdissectorA5-mmneedleholderA0°endoscope16.3PositionoftheTrocarsandExposureThepneumoperitoneumiscreatedwithaVeressneedleatthelowermarginoftheumbilicus.Alefttransrectaltrocarisinserted5cmoutsideoftheumbilicusfortheendoscope.Theotheroperatingtrocarsareinsertedafterinflationoftheabdomi-nalcavity:a5-mmmediansuprapubictrocar,a5-mmleftiliacfossatrocar,anda10-mmtrocaratthelowermarginoftheumbilicuswitha5-mmreducer.Theabdominalcavityisthenexplored.A20°Trendelenburgpositionenablespositioningofthesmallbowelintheupperquadrantsoftheabdomen.Afenestrat-edgraspingforcepsinsertedthroughthesuprapubicportprogressivelyexposestherectosigmoidjunction. 22216LaparoscopicAnteriorColpopexy16.4DissectionofthePromontoriumTheposteriorparietalperitoneumisopenedwiththecoagulatingshearslongitu-dinallyinlinewiththepromontorium,whichiseasilyidentified(>Fig.16.1).Asecondpre-promontoriumlayerisopened,enablingtheexposureofthevertebralligamentofthepromontoriumandofitsvessels.Thedissectioniscontinuedlater-ally(>Fig.16.2).16.5AnteriorVaginalDissectionAvaginalretractorpositionedundertractionbythesecondassistantenablestheexposureoftheanteriorvaginalwall(>Fig.16.3).Theperitoneumbetweenblad-derandvaginaisopenedmediallyandtransversallywiththecoagulatingshears.Thedissectionplanebetweenvaginaandbladderiseasilyidentified.Thean-teriorwallofthevaginaisfreedfromitsbladderattachmentswiththecoagulat-ingscissorsorbybluntdissection(>Fig.16.4).Thedissectioniscontinuedfor4–5cm,sometimesevenmoreincaseofalargecystocele.Fig.16.1.Peritonealincisiononpromontorium 16.5AnteriorVaginalDissection223Fig.16.2.MesorectaldissectionFig.16.3.Vaginalretractorliftinganteriorvaginalwall 22416LaparoscopicAnteriorColpopexyFig.16.4.Dissectionofanteriorvaginalwall16.6FixationoftheMeshAmersilenemeshisfixedtotheanteriorwallofthevaginaandonthecervixandisthmusportionoftheuterus,inthepresenceofauterus,or,aftertotalhysterec-tomy,ontheremainingcervix.Themeshandtwononabsorbablesutureswitha16-mmneedleareinsertedthroughthe10-mmtrocar.Astraightgraspingforcepsisinsertedattheleveloftheleftiliacfossaanda5-mmneedleholderisinsertedthroughtheumbilicaltrocar.Themeshissuturedtotheanteriorvaginalwallwithsixstitches(>Figs.16.5–16.7).Afinaldeepstitchsuturesthemeshtotheuterinecervix(>Fig.16.8).16.7TunnellingoftheMeshA10-mmdissectorinsertedthroughtheumbilicalportistunnelledundertheperitoneumparalleltotherightureter(>Figs.16.9–16.11).Thedissectoristhenpassedthroughtheuterineligamentfromunderneathintothepreviouslydissect-edplanebetweenbladderandvagina.Themeshisgraspedwiththedissectorandpassedthroughthisroutebacktothepromontorium.Thisstepisusuallyeasierafterprevioushysterectomy.Otherwise,theuteruscanbemobilizedwithvaginalinstruments(>Fig.16.12). 16.7TunnellingoftheMesh225Fig.16.5.StitchingtheanteriorvaginalwallFig.16.6.Meshsuturedtothevaginalwall 22616LaparoscopicAnteriorColpopexyFig.16.7.FinalsutureonanteriorvaginalwallFig.16.8.Additionalsutureonuterinecervix 16.7TunnellingoftheMesh227Fig.16.9.PosteriorextraperitonealtunnellingFig.16.10.Tunnellingperformedwithangulatinginstrument 22816LaparoscopicAnteriorColpopexyFig.16.11.TunnellingofthemeshFig.16.12.Anteriorcolpopexy 16.9TipsandComments22916.8StaplingtothePromontoriumandPeritonealClosureThemeshisappliedattherighttensiontothevertebralligament,andfixedwithhelicalTaksorwithseparatestitchesofnonabsorbable0sutures(>Fig.16.13).Peritonealclosureisperformedusingabsorbablesutures.Asuctiondrainagemaybeleft(>Figs.16.14,16.15).16.9TipsandCommentsItissometimesnecessarytomobilizethesigmoidcolontoobtainproperexpo-sureofthepromontorium.Averylargeandfibromatousuterusmayrenderhysterectomynecessary.How-ever,inmostcasesitisbesttokeeptheuterus.Themeshshouldneverbestapledtotheanteriorvaginalwall!Ananteriorcolpopexymaybecombinedwithaposteriorcolpopexy.Asecondmeshisthenneeded.Theretendstobealeftwardrotationoftheuterus;thiscanbecorrectedbyplicationoftheuterineligamentontherightside.Fig.16.13.Staplingmeshtovertebralligament 23016LaparoscopicAnteriorColpopexyFig.16.14.PeritonealclosureFig.16.15.Peritonealclosureonpromontorium Literature231Acervixfixationreducestheposteriorrotationoftheuterus.Therighttensiontobeexertedontheanteriorvaginalwallcanbeassessedbyvaginalexamination.Mediansacralarteriesandveinsshouldbeavoidedatthetimeofstaplingorsuturingthemeshtothevertebralligamentonthepromontorium.LiteratureAddisonWA,LivengoodCH,SuttonGP,ParkerRT(1985)AbdominalsacralcolpopexywithMer-silenemeshintheretroperitonealpositioninthemanagementofposthysterectomyvaultpro-lapseandenterocele.AmJObstetGynecol153:140–146AlbalaDM,SchluesslerWW,VancaillieT(1992)Laparoscopicbladdersuspensionforthetreatmentofstressincontinence.SeminUrol10:22–26BlancB,LuneauF,BoubliL,BernardY(1990)L’élytrocèle.Aproposde45observations.Mémoireoriginal.Gynécologie,Masson,Paris41:171–176BrownWE,HoffmanMS,BouisPL,IngramJM,HopesSL(1989)Managementofvaginalvaultpro-lapse:retrospectivecomparisonofabdominalversusvaginalapproach.JFlaMedAssoc76:249–252BurchJC(1961)UrethrovaginalfixationtoCooper’sligamentforcorrectionofstressincontinence,cystoceleandprolapse.AmJObstetGynecol81:281–290ChapronC,LaforestL,AnsquerY,FauconnierA,FernandezB,BreartG,DubuissonJB(1999)Hys-terectomytechniquesusedforbenignpathologies:resultsofaFrenchmulticentrestudy.HumReprod14:2464–2470CornierE,MadelenatP(1994)HystéropexieselonM.Kapandji:techniquepercoelioscopiqueetrésultatspréliminaires.JGynecolObstetBiolReprod23:378–385CravelloL,deMontgolfierR,D’ErcoleC,RogerV,BlancB(1997)Endoscopicsurgery.Theendofclassicsurgery?[Review]EurJObstetGynecolReprodBiol75:103–106CuschieriA(1991)Minimalaccesssurgeryandthefutureofinterventionallaparoscopy.ObstetGynecol161:404–407CuschieriA,ShimiS,Vander-VelpenG(1994)Laparoscopicprosthesisfixationrectopexyforcom-pleterectalprolapse.BritJSurg81:138–139DenoitV,BigotteA,MiannayE,CossonM,QuerleuD,CrepinG(2000)Burchlaparoscopiccolposus-pension.Resultsof30-monthfollow-up.AnnChir125:757–763DorseyJH,CundiffG(1994)Laparoscopicproceduresforincontinenceandprolapse.CurrOpinObstetGynecol6:223–230DrancourtE,YouinouY,BrandtB,HerardA,LardennoisB(2000)TreatmentoffemalestressurinaryincontinencewithcystocelebyGoreTexcolpofixationandBurchoperation.ProgUrol10:211–218GlavindK,MouritsenAL,PedersenLM,BekKM(2000)Genitalprolapse[Review].UgeskrLaeger162:1542–1546HarewoodLM(1993)Laparoscopicneedlecolposuspensionforgenuinestressincontinence.JEndoUrol7:319–322HillD,MaherP,CarehM(1994)LaparoscopicretroperitonealBurchcolposuspension.GynaecologicEndoscopists1:339–349KriplaniA,BanerjeeN,KriplaniAK,RoyKK,TakkarD(1998)Uterovaginalprolapseassociatedwithrectalprolapse.AustNZJObstetGynaecol38:325–326LiapisA,BakasP,PafitiA,HassiakosD,Frangos-PlemenosM,CreatsasG(2000)ChangesinthequantityofcollagentypeIinwomenwithgenuinestressincontinence.UrolRes28:323–326 23216LaparoscopicAnteriorColpopexyLimC,PackW(1993)Laparoscopicretropubiccolposuspension(Burchprocedure).JAmAssocGynecolLaparosc1:31–35LiuCY(1994)Laparoscopictreatmentforgenuineurinarystressincontinence.Baillere’sClinObstetGynecol8:789–798LiuCY,ReichH(1996)Correctionofgenitalprolapse[Review].JEndourol10:259–265MatysekP(1999)Presentviewsontreatmentofgenitalprolapse.CeskaGynekol64:390–393MoschcowitzAV(1912)Thepathogenesis,anatomyandcureofprolapseoftherectum.SaxGynaecolObstet15:7–21NezhatCH,NezhatF,NezhatC(1994)Laparoscopicsacralcolpopexyforvaginalvaultprolapse.ObstetGynecol84:885–888NicholsDH(1991)Surgeryforpelvicfloordisorder.SurgClinNorthAm71:927–946PowellJL,JosephDB(1998)Abdominalsacralcolpopexyformassivegenitalprolapse.PrimCareUpdateObGyns5:201QuerleuD(1994)Curedeprolapsusparvoiecoelioscopique:chirurgie-fiction.Lepelvisfémininstatiqueetdynamique.SocFrGynecol254–258RichardsonD,ScottiR,OstergardD(1989)Surgicalmanagementofuterineprolapseinyoungwom-en.JReprodMed34:388–392RichterK(1967)DieoperativebehandlungdesprolabierternScheidengrundersnachuterus-ex-tirpation.EinbietragzurvaginaefixationsacrotuberalisnachAmreich.GeburstshFrauenheilk27:941–954RoseCH,RoweTF,CoxSM,MalinakLR(2000)Uterineprolapseassociatewithbladderexstrophy:surgicalmanagementandsubsequentpregnancy.JMaterFetalMed9:150–152StantonSL,CardozoLD(1979)Acomparisonofvaginalandsuprapubicsurgeryinthecorrectionofincontinenceduetourethralsphincterincontinence.BrJUrol5:497–499TimmonsMC,AddisonWA,AddisonWA,AddisonSB,CavenarMG(1992)Abdominalsacralcol-popexyin163womenwithposthysterectomyvaginalvaultprolapseandenterocele.Evolutionofoperativetechniques.JReprodMed37:323–327ValaitisSR,StantonSL(1994)Sacrocolpopexy:aretrospectivestudyofaclinician’sexperience.BritJObstetGynecol101:518–522VanCaillieTG(1994)Laparoscopyinurogynaecology.ProceedingsPGVAAGL111–141VanCaillieTG,SchuesslerW(1991)Laparoscopicbladdernecksuspension.JournalofLaparoendo-scopicSurgery1:169–173 17LaparoscopicBurchColposuspension17.1OperatingRoomSetup:PositionofthePatientThepatientisplacedsupineina20°Trendelenburgposition.Thesurgeonstandstotheleftofthepatientwiththescrubnursetothesurgeon’sleft.Theassistantstandsbetweenthepatient’slegs.Theabdominalwallandperinealregionarepre-pared.Thevideomonitorispositionedonthepatient’srightside.17.2RecommendedInstrumentsA0°endoscopeTwo10-mmtrocarsTwo5-mmtrocarsThree5-mmfenestratedgraspingforcepsA5-mmstraightgraspingforcepsA5-mmneedleholderA10-mmdissectorA5-mmcoagulatingshearsA5-or10-mmharmonicscalpelFive-millimetrehelicalstaplesMersilenemeshNonabsorbablesutures17.3PositionoftheTrocarsandExposureThepneumoperitoneumiscreatedwithaVeressneedleatthelowermarginoftheumbilicus.Alefttransrectaltrocarisinserted5cmoutsideoftheumbilicusfortheendoscope.Theotheroperatingtrocarsareinsertedafterinflationoftheabdomi-nalcavity:a5-mmmediansuprapubictrocar,a5-mmleftiliacfossatrocar,anda10-mmtrocaratthelowermarginoftheumbilicuswitha5-mmreducer.Theabdominalcavityisthenexplored.A20°Trendelenburgpositionenablespositioningofthesmallbowelintheupperquadrantsoftheabdomen.Therem-nantoftheleftumbilicalarteryiseasilyidentified.Theperitoneumisincisedlat-eraltotheumbilicalartery(>Fig.17.1). 23417LaparoscopicBurchColposuspensionFig.17.1.Peritonealincisionleftofbladder17.4ExtraperitonealDissectionoftheBladderTheperitoneumisincisedwiththecoagulatingshearsandRetzius’spaceisopenedeasily.Cooper’sligamentisthefirstlandmark.Thepubicboneisexposed.BothCooper’sligamentsaredissectedtothebaseofthefemoralcanal(>Fig.17.2).17.5LateralBladderDissectionAbladdercatheterisinplaceandhelpstoidentifytheurethra.Theanteriorwallsofthevaginaarecarefullydissectedlaterally,withcoagulatingshears.Thevaginahasawhitishappearance(>Fig.17.3). 17.5LateralBladderDissection235Fig.17.2.ExtraperitonealdissectionofRetzius’spaceFig.17.3.Vaginalwalldissectionleftofurethra 23617LaparoscopicBurchColposuspension17.6MeshFixationTwononabsorbable2/0sutureswitha26-mmneedleandtwomersilenemeshes3×1cmareintroduced.Theneedleholderisinsertedthroughtheumbilicalport.Twostitchesareplacedonbothsideslaterallytotheurethraintothefullthicknessofthevaginalwall(>Figs.17.4,17.5).Afingerinsidethevaginamaychecktherightpassingofthesestitches.Oneendofthemeshissuturedtothevaginalwall,onbothsides(>Figs.17.6,17.7).Bothmeshesshouldbeplacedsymmetrically.17.7MeshFixationtoCooper’sLigamentBothmeshesarethenstapledtoeitherCooper’sligamentinturn.ThemeshisstraightenedwithagraspingforcepsandthreehelicalTaksareappliedtoCooper’sligament(>Figs.17.8,17.9).Propertensionshouldbegiventothemesh,sym-metricallyonbothsides(>Figs.17.10,17.11).17.8PeritonealClosureTheoperativefieldischeckedforbleedingandtheperitoneumisclosedwitharunningsuture(>Fig.17.12).Fig.17.4.Firststitchrighttotheurethra 17.8PeritonealClosure237Fig.17.5.Suturingright-sidedmeshFig.17.6.Suturingleft-sidedmesh 23817LaparoscopicBurchColposuspensionFig.17.7.Secondstitchonleft-sidedmeshFig.17.8.Tractiononright-sidedmesh 17.8PeritonealClosure239Fig.17.9.RightmeshstapledtoCooper’sligamentFig.17.10.Left-sidedmeshstapledtoCooper’sligament 24017LaparoscopicBurchColposuspensionFig.17.11.FinalresultFig.17.12.Peritonealclosure Literature24117.9TipsandCommentsTheendoscopeinaleftlateralpositionleavestheumbilicalportfordissectingandeasiersuturing,butthispeculiardisposurehastoberememberedateverystepoftheprocedure.Anadditionalstitchcanbemadehigheruponthevaginalsurfacestocontrolanyslightcystocele.Asuctiondrainagecanbeleftintheextraperitonealspace.Thebladdercatheterisleftinplacefor24h.Theverticalopeningperitoneumleavesthebladderinplaceandfacilitatesclosing.Thetensiononthemeshesmustbeperfectlysymmetrical.LiteratureAddisonWA,LivengoodCH,SuttonGP,ParkerRT(1985)AbdominalsacralcolpopexywithMersilenemeshintheretroperitonealpositioninthemanagementofposthysterectomyvaultprolapseandenterocele.AmJObstetGynecol153:140–146AlbalaDM,SchluesslerWW,VancaillieT(1992)Laparoscopicbladdersuspensionforthetreatmentofstressincontinence.SeminUrol10:22–26BlancB,LuneauF,BoubliL,BernardY(1990)L’élytrocèle.Aproposde45observations.Mémoireoriginal.Gynécologie,Masson,Paris41:171–176BrownWE,HoffmanMS,BouisPL,IngramJM,HopesSL(1989)Managementofvaginalvaultpro-lapse:retrospectivecomparisonofabdominalversusvaginalapproach.JFlaMedAssoc76:249–252BurchJC(1961)UrethrovaginalfixationtoCooper’sligamentforcorrectionofstressincontinence,cystoceleandprolapse.AmJObstetGynecol81:281–290ChapronC,LaforestL,AnsquerY,FauconnierA,FernandezB,BreartG,DubuissonJB(1999)Hys-terectomytechniquesusedforbenignpathologies:resultsofaFrenchmulticentrestudy.HumReprod14:2464–2470CornierE,MadelenatP(1994)HystéropexieselonM.Kapandji:techniquepercoelioscopiqueetrésultatspréliminaires.JGynecolObstetBiolReprod23:378–385CravelloL,deMontgolfierR,D’ErcoleC,RogerV,BlancB(1997)Endoscopicsurgery.Theendofclassicsurgery?[Review]EurJObstetGynecolReprodBiol75:103–106CuschieriA(1991)Minimalaccesssurgeryandthefutureofinterventionallaparoscopy.ObstetGynecol161:404–407CuschieriA,ShimiS,Vander-VelpenG(1994)Laparoscopicprosthesisfixationrectopexyforcom-pleterectalprolapse.BritJSurg81:138–139DenoitV,BigotteA,MiannayE,CossonM,QuerleuD,CrepinG(2000)Burchlaparoscopiccolposus-pension.Resultsof30-monthfollow-up.AnnChir125:757–763DorseyJH,CundiffG(1994)Laparoscopicproceduresforincontinenceandprolapse.CurrOpinObstetGynecol6:223–230DrancourtE,YouinouY,BrandtB,HerardA,LardennoisB(2000)TreatmentoffemalestressurinaryincontinencewithcystocelebyGoreTexcolpofixationandBurchoperation.ProgUrol10:211–218GlavindK,MouritsenAL,PedersenLM,BekKM(2000)Genitalprolapse[Review].UgeskrLaeger162:1542–1546 24217LaparoscopicBurchColposuspensionHarewoodLM(1993)Laparoscopicneedlecolposuspensionforgenuinestressincontinence.JEndoUrol7:319–322HillD,MaherP,CarehM(1994)LaparoscopicretroperitonealBurchcolposuspension.GynaecologicEndoscopists1:339–349KriplaniA,BanerjeeN,KriplaniAK,RoyKK,TakkarD(1998)Uterovaginalprolapseassociatedwithrectalprolapse.AustNZJObstetGynaecol38:325–326LiapisA,BakasP,PafitiA,HassiakosD,Frangos-PlemenosM,CreatsasG(2000)ChangesinthequantityofcollagentypeIinwomenwithgenuinestressincontinence.UrolRes28:323–326LimC,PackW(1993)Laparoscopicretropubiccolposuspension(Burchprocedure).JAmAssocGynecolLaparosc1:31–35LiuCY(1994)Laparoscopictreatmentforgenuineurinarystressincontinence.Baillere’sClinObstetGynecol8:789–798LiuCY,ReichH(1996)Correctionofgenitalprolapse[Review].JEndourol10:259–265MatysekP(1999)Presentviewsontreatmentofgenitalprolapse.CeskaGynekol64:390–393MoschcowitzAV(1912)Thepathogenesis,anatomyandcureofprolapseoftherectum.SaxGynaecolObstet15:7–21NezhatCH,NezhatF,NezhatC(1994)Laparoscopicsacralcolpopexyforvaginalvaultprolapse.ObstetGynecol84:885–888NicholsDH(1991)Surgeryforpelvicfloordisorder.SurgClinNorthAm71:927–946PowellJL,JosephDB(1998)Abdominalsacralcolpopexyformassivegenitalprolapse.PrimCareUpdateObGyns5:201QuerleuD(1994)Curedeprolapsusparvoiecoelioscopique:chirurgie-fiction.Lepelvisfémininstatiqueetdynamique.SocFrGynecol254–258RichardsonD,ScottiR,OstergardD(1989)Surgicalmanagementofuterineprolapseinyoungwom-en.JReprodMed34:388–392RichterK(1967)DieoperativeBehandlungdesprolabiertenScheidengrundesnachUterusextir-pation.EinBeitragzurVaginalfixationsacrotuberalisnachAmreich.GeburstshFrauenheilk27:941–954RoseCH,RoweTF,CoxSM,MalinakLR(2000)Uterineprolapseassociatedwithbladderexstrophy:surgicalmanagementandsubsequentpregnancy.JMaterFetalMed9:150–152StantonSL,CardozoLD(1979)Acomparisonofvaginalandsuprapubicsurgeryinthecorrectionofincontinenceduetourethralsphincterincontinence.BrJUrol5:497–499TimmonsMC,AddisonWA,AddisonWA,AddisonSB,CavenarMG(1992)Abdominalsacralcol-popexyin163womenwithposthysterectomyvaginalvaultprolapseandenterocele.Evolutionofoperativetechniques.JReprodMed37:323–327ValaitisSR,StantonSL(1994)Sacrocolpopexy:aretrospectivestudyofaclinician’sexperience.BritJObstetGynecol101:518–522VanCaillieTG(1994)Laparoscopyinurogynaecology.ProceedingsPGVAAGL111–141VanCaillieTG,SchuesslerW(1991)Laparoscopicbladdernecksuspension.JLaparoendoscSurg1:169–173 SubjectIndexAFaccessport73fundoplication41achalazia77fundus49adrenalvein192,194,204adrenalectomy189,203Gappendectomy103gallbladder4,12,25,35,38BHband62,64–66,68–71heller77bladder234hepaticflexure138,141,190burch233hernia–repair171C–sac174,176–178Calot’striangle4,10,11,24,25cholangiography7,8,26–28Icholangioscopy29,32–34ilealJ-pouch149cholecystectomy10,12,13,35,37ileocaecalvessel142,143choledocholithotomy28ileostomy149choledochotomy28–30,35ileotransverseanastomosis145,146colorectalanastomosis134inferiormesentericvessel122,125colpopexy209,217,221,228Cooper’sligament172,173,179,236,L239lateralligament156cysticduct4–8leftcolectomy119,126,149lithotripsy29DDouglaspouch155,156,165,213MDouglassectomy155,165mesh158,160,162,179,214,215,224,228,236E–3-Dmesh179,181–184epigastricvessel174mesorectalexcision128,132mesorectum128,132,156morbidobesity57myotomy81,84,85 244SubjectIndexNsplenectomy91Nissen41,54,55splenic–artery92O–flexure93,126,128orrloygue153,158–vein92,95stapling111–113Ppancreas126,142Tpromontorium160,165,210,216,TEPA171222,229totalvolectomy149psoasmuscle174,179Toupet41,52–54RUrectalultrasound7,9–prolapse153ureter122,156,160–resection149rectopexy153Vrectum153vagus82renalvein191,192,194,204–nerve47,48,54Retzius’space172,235vasdeferens176rightcolectomy137,149venacava190,191,194,196rightcolicvessel142,144WSWells153,162shortgastricvessel49,93,95,96spermaticvessel176
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