Create space at laparoscopy

Tagged laparoscopy, bowel retraction, Endo Loop, Endo Close, Hysterectomy, Training; Posted 11 years ago by Donal Brennan

Adequate exposure is a key aspect of any surgical procedure, and this is particularly true in laparoscopy. When operating in the pelvis, visualisation of key anatomical landmarks such as the sacral promontory, the iliac vessels and the ureters is usually necessary to perform a safe procedure. Whilst placing the patient in the Trendelenberg position will often provide adequate exposure for pelvic surgery this is not always the case and simply asking your anaesthetic colleagues for  “more head down” may not improve visualisation, particularly in obese patients or in patients who have had a complex surgical history.

A number of pre-operative steps can be taken to improve visualization at laparoscopy. In the morbidly obese patient a weight loss program can improve visualization as even a 5 to 10kg weight loss can lead to a significant decrease in the size of the liver which can provide more space for small bowel to sit when the patient is placed in the Trendelenberg position. The use of mechanical bowel preparation to improve visualization is controversial and we do not routinely use pre-operative bowel preparation for laparoscopic cases.

Intra-operatively we have found a number of approaches helpful to improve exposure in the pelvis and abdomen. Careful mobilization of sigmoid colon is an important initial step for total laparoscopic hysterectomy. Division of the congenital adhesions between the sigmoid colon and left pelvic sidewall will often enable the surgeon to move a redundant sigmoid colon out of the pelvis. When dividing these adhesions, it is important try to remain within the peritoneal cavity. Migration into the retroperitoneum will decrease the degree of mobilization achieved and increases the risk of damaging the infundibulopelvic vessels and the ureter. In addition to the mobilisation of the sigmoid colon, mobilization of the caecum will often ensure that the small bowel remains in the upper abdomen during gynaecological laparoscopy. If small bowel continues to obscure your view, it is possible to use laparoscopic bowel retractors however these often require an additional port and can be quite cumbersome.

Despite using these measures a redundant sigmoid colon will often continue to enter the operative field and require further retraction. A simple measure to retract the sigmoid is to use an Endo Loop (Ethicon), which can be attached to an appendix epiploica (see video). A key step in this approach is not to use the Endo Loop to retract the colon, but to move the colon into your desired position and then use the Endo Loop to keep it there. By applying this technique you are much less likely to damage the appendix epiploica. Some surgeons choose to bring the Endoloop back out through an operating port, usually in the left iliac fossa, however this can have a number of disadvantages. It can lead to loss of CO2 from the pneumoperitoneum and it can also draw the colon towards the port putting it at risk of damage when changing instruments. Finally the port placement may not provide the best axis for bowel retraction.

Another approach is to use an Endo Close (Covidien) suturing device to bring the endoloop out through the abdominal wall at a point that provides a better axis for bowel retraction. This is often at more superior point on the left flank than where many people will place their usual working port. This approach will not only provide better retraction, it also moves the bowel away from the working port and should minimize the risk of injury when changing instruments. In this situation we initially pass the Endo Loop through a normal working port, attach it to the sigmoid, and pass the entire Endo Loop into the peritoneal cavity, we can then assess the best point on the abdominal wall to insert the Endo Close. The surgeon then passes the Endo Close through the abdominal wall and an assistant places the free end of the Endo Loop on the suturing device, which is then withdrawn back through the abdominal wall.  The Endo Loop can then be held at the desired tension on the skin using an artery forceps.

Careful preparation of the operative field is an important part of many open surgical procedures and should be considered just as important when performing laparoscopic surgery. Taking a few minutes to provide adequate exposure will allow a surgeon to create a safe working area and perform the procedure in a consistent and controlled manner. 

To subscribe and receive regular blog posts through email - leave your email address here.

Feel free to pass this blog on to colleagues.