Medial to Lateral Mobilization of Sigmoid & Descending Colon
Extent of the dissection is superiorly for the inferior border of the pancreas, laterally following Gerota’s fascia and inferiorly for the psoas muscle where the ureter crosses the iliac vessels. Anatomical overview and arm set-up shown below [Figures 24 and 25].
Figure 24: Anatomy overview for procedure step 3 |
Figure 25: Arms (1), 2) and (3) aligned for lateral colon mobilization |
- Instrumentation: 0° endoscope, Fenestrated Maryland Bipolar (left (3)), Hot Shears™ (Monopolar Curved Scissors) (right (1)), Grasping Retractor or Cadiere Forceps (in arm (2)) - if visualization is compromised, switch to a 30° endoscope down for a more topographical view.
- Elevate the rectosigmoid mesentery superiorly and anteriorly following the IMA.
- Identify and bluntly dissect on the avascular plane between the Toldt’s fascia and the left colonic mesentery.
- Identify the hypogastric nerve plexus, gonadal vessels and ureter beneath the Toldt's fascia [Figure 26].
Figure 26: Avascular dissection plane beneath Toldt’s fascia with ureter and gonadal vessels identified
- Avoid injury to the gonadal vessels and the ureter by maintaining exposure and the anterior avascular dissection plane above Toldt's fascia during the dissection
- Continue dissection laterally toward Toldt's line.
- Next, detach adhesions at the sigmoid-descending colon junction.
- Retract the free sigmoid loop toward the right upper quadrant (laparoscopic retraction by the assistant) to apply tension on the "white line" of Toldt.
- Incise "white line" and dissect (sharp and blunt) lateral attachments of descending colon just anterior to Toldt's fascia.
- Once dissection joins the previously performed medial dissection, the sigmoid colon is completely mobilized.
View Surgical Steps:
- Initial Exposure
- Primary Vascular Control
- Medial to Lateral Mobilization of Sigmoid & Descending Colon
- Splenic Flexure Mobilization
- Rectal Dissection & Division
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