Taking the ‘S’ out of Intestine: Performing Laparoscopic Sigmoidectomy

by Brie Eteson, Medical Communications, Digital Surgery

The Long and Winding Bowel

Sigmoidectomy is the excision of the sigmoid colon. This procedure is often performed for colorectal cancer, one of the most commonly diagnosed cancers in the world.1

The surgery can be performed using either a minimally invasive or open method. The uptake of laparoscopic sigmoidectomy for colorectal cancer was slow due to initial concerns of recurrence of port-site metastasis, the procedure’s complexity, and longer duration.2 However, recent studies have demonstrated excellent results with a low risk of recurrence and metastasis, suggesting the minimally invasive method is a well-standardized procedure.2,3 This new simulation, free from Touch Surgery™, demonstrates a laparoscopic technique for a distal sigmoid carcinoma.

This simulation also demonstrates how to ligate the sigmoid artery and superior rectal artery, exteriorize the bowel, transect the proximal colon, and perform a side-to-end colorectal anastomosis.

Before performing a sigmoidectomy, it is important to correctly identify the rectosigmoid junction and the exact location of the tumor, whether it resides in the sigmoid or rectum. Treatment plans vary according to the tumor, which affects patient outcomes.

The white line represents the Sigmoid take-off. S: Sigmoid, R: Rectum

Sigmoid take-off

This landmark is used to identify the junction of the mesocolon with the mesorectum, and the sigmoid with the rectum. It is defined as “the point where the fixed mesorectum ends and no longer tethers the rectum to the sacrum, and the mesocolon elongates”.4

This simulation follows a Laparoscopic Sigmoidectomy for a distal sigmoid tumor. To learn more about the case depicted in this simulation, go to the Overview for a detailed case presentation.

The nine key objectives for this procedure are briefly outlined below:

Patient Preparation

Position the patient in modified lithotomy, with the left arm abducted at 90°. Ensure the patient is stabilized in this position and that the legs are placed in the lithotomy stirrups. Further preparation includes placing a patient return electrode and draping the patient.

Modified lithotomy, with the left arm abducted at 90°

Port insertion

Port insertion

The camera port in the simulation is an 11 mm VersaOne™ bladeless trocar inserted at the umbilicus. Insufflation of the abdomen is then performed to achieve pneumoperitoneum.

Diagnostic laparoscopy and operating field exposure

Insert a laparoscope into the trocar to explore the abdominal cavity. The other trocars are then inserted under direct vision into the right iliac fossa, and the right and left upper quadrants just above the level of the umbilicus. To better expose the sigmoid and pelvic area, the patient is repositioned in Trendelenburg with a tilt to the right, and the greater omentum is also retracted. The tumor site is localized and the length of the bowel needed for tension-free anastomosis is assessed.

Localization of the tumor site

Dissection and mobilization of the right and posterior side of the rectum

Vascular pedicle dissection and ligation (medial-to-lateral mobilization)

An incision is made medially in the mesocolon. Medial dissection is performed in the correct avascular ‘holy’ plane. 

Lateral adhesiolysis was needed in this case to help expose the left ureter and retract the sigmoid from the pelvis. 

The lateral peritoneal attachments are dissected along the white line of Toldt. The left lateral rectosigmoid is mobilized and the right and posterior side of the rectum are mobilized via medial dissection.

The peritoneum was incised anteriorly at the point of planned rectal transection, due to tumor location in the lower sigmoid.

The sigmoid artery and superior rectal artery are then ligated and divided. The simulation demonstrates this surgical step with the LigaSure™ Maryland jaw laparoscopic sealer/divider and clips.

Colon mobilization

Mobilize the colon and rectum further, then dissect the mesorectum at the level of rectum transection.

Rectal transection

Transect the rectum using a Signia™ stapling system with Tri-Staple™ 2.0 purple reload, 60mm.

Transection of the rectum

Anvil insertion and colon transection

Specimen extraction

A Pfannenstiel incision should be made above the pubic bone for extraction. The transected colon should then be exteriorized and extracted through the incision.

Divide the mesentery proximal to the base of the ligated vascular bundle.

Insert the anvil of a circular stapler through an enterotomy. Position and secure it 5 cm proximal to the planned division point.

Transect the colon at the point of mesentery division using a DST™ Series GIA™ single-use reloadable stapler or GIA™ stapler with Tri-Staple™ technology. After checking the staple line for hemostasis, the colon is placed back into the abdomen. The wound protector is closed, and the pneumoperitoneum is reestablished.

Anastomosis

Insert a 31 mm EEA™ Circular Stapler with DST Series™ Technology or EEA™ Circular Stapler Tri-Staple™ technology transanally. Grasp the anvil and attach it to the integrated trocar of the stapler. Ensure the proximal sigmoid is not twisted, check the position of the mesentery and taenia coli, then approximate the bowels.

In female patients, the dorsal border of the vagina should be checked to ensure it is not included in the anastomosis.

Create a side-to-end anastomosis using a circular stapler. Upon removal of the instrument, inspect the tissue donuts.

Tissue donuts

Leak test

Check there is no anastomotic leakage by performing a leak test. One method to perform a leak test is by compressing the bowel and introducing high-pressure methylene blue transanally.

Port removal and closure

Ensure the greater omentum is returned to its anatomical position. Remove the lateral ports, followed by the laparoscope, umbilical trocar, and wound protector. Deflate the abdomen and close all incisions.

This simulation was authored by Jurre van Kesteren, MD, and Daan Moes, MD, and reflects the authors’ preferences in performing this procedure.

To learn more about the key objectives, common indications, and contraindications for a Laparoscopic Sigmoidectomy, view the free simulation in the Touch Surgery™ app now.

Anatomy is key to performing a sigmoidectomy correctly. Each case is different and can affect the indicated treatment plan. Learn how to tell where the sigmoid ends and the rectum begins in the latest simulation from Touch Surgery™.

Launch in App

How to cite this simulation:
van Kesteren J, Moes D. Laparoscopic Sigmoidectomy. Touch Surgery Simulations. http://dx.doi.org/10.18556/touchsurgery/2021.s0181. Published Apr. 21, 2021.

References

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2. Morneau M, Boulanger J, Charlebois P, et al. Laparoscopic versus open surgery for the treatment of colorectal cancer: a literature review and recommendations from the Comité de l’évolution des pratiques en oncologie. Can. J. Surg. 2013;56(5):297.

3. Marcellinaro R, Lisi G, Mastrangeli MR, Spoletini D, Grieco M, Carlini M. Preservation of inferior mesenteric vessels. Laparoscopic sigmoidectomy for cancer–a video vignette. Colorectal Dis. 2020;22(12):2348-50.

4. Ross H, Lee SW, Mutch MG, et al. Minimally Invasive Approaches to Colon and Rectal Disease. Technique and Best Practices. New York, NY: Springer; 2015.

5. D’Souza N, Lord A, Shaw A, et al. The sigmoid take-off: An anatomical imaging definition of the rectum validated on specimen analysis. Eur J Surg Oncol. 2020;46(9):1668–1672.

6. Givel JC, Mortensen NJ, Roche B. Anorectal and colonic diseases: a practical guide to their management. 3rd ed. Heidelburg, Germany: Springer-Verlag GmbH; 2009.

7. D’Souza N, de Neree tot Babberich MP, Lord A, et al. The rectosigmoid problem. Surg Oncol. 2018;27(3):521–525.

8. DʼSouza N, de Neree Tot Babberich MPM, d’Hoore A, et al. Definition of the Rectum: An International, Expert-based Delphi Consensus. Ann Surg. 2019;270(6):955–959.

9. Gustafsson U, Scott M, Schwenk W, et al. Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg. 2013;37(2):259–284.

10. Balli JE, Franklin ME, Almeida JA, Glass JL, Diaz JA, Reymond M. How to prevent port-site metastases in laparoscopic colorectal surgery. Surg Endosc. 2000;14(11):1034–1036.