The patient should be placed in a standard supine position for induction of anesthesia.

Following induction and securing of the endotracheal tube, a Foley catheter should be inserted.

The patient is then placed in a low lithotomy position (FIG 1). Special care should be given to the positioning of the patient’s legs in the stirrup devices; adequate padding and symmetrical positioning can minimize nerve injury.

The arms should ideally be tucked at the sides with appropriate padding to afford the surgeons adequate space during the procedure and to prevent neurovascular injuries.

Once the patient has been positioned and secured to the operating table, the rectum should be irrigated with saline solution using a piston syringe to evacuate remnant stool and bowel prep fluid.

The patient can then be cleaned and draped. The drape should have a cut-out section to allow for easy access to the perineum without disrupting the sterile field of the abdomen.

The surgeon stands to the patient’s right side, with his or her assistant standing to the patient’s left side and with the scrub nurse standing to the surgeon’s right side. A second assistant, if available, stands between the patient’s legs (FIG 2).

A midline incision from the umbilicus to the pubis is usually sufficient to begin the procedure. Additional access can be gained by extending the incision cranially toward the xiphoid process as necessary. Care should be taken to stay within the midline of the rectus sheath (linea alba) on opening.

In patients with previous abdominal surgery, adherent bowel can complicate entry into the peritoneal cavity and meticulous dissection may be warranted. If possible, it might be easier to gain access into the abdomen by going above the previous scar where adhesions may be less tenuous.

Upon entry into the peritoneal cavity, moist laparotomy pads placed around the wound edges can serve as wound protectors to reduce the likelihood of wound infection.

A self-retaining retractor (e.g., a Balfour or Bookwalter retractor) can then be placed for adequate exposure.

A careful and thorough examination of the abdominal cavity is critical. Evidence of metastatic disease or carcinomatosis must be appreciated before proceeding with the procedure. If present, these significantly impact both management and prognosis.

The colon should be palpated in cases involving tumors to verify the position of the disease and assess the extent of resection. In procedures for diverticular disease, the state of the entire colon should be investigated, as this may impact the optimal scope of resection.

Following inspection, if the decision is made to proceed, the small bowel should be eviscerated and packed to the right upper quadrant using a moist laparotomy pad or a moist towel to better facilitate exposure.

Once this has been confirmed, the supplying vessels and lymph basins should then be identified. Sigmoid colectomy usually entails resection of the sigmoid artery branches coming off of the IMA and the left colic artery with the accompanying lymph nodes that reside within that basin. The IMA or the left colic artery should be carefully identified along with the path of planned resection along the mesentery; the extent of the planned resection along the length of the sigmoid will dictate the degree to which the left colon must be mobilized.

The patient is placed on a Trendelenburg position with the left side up to facilitate exposure.

Mobilization of the colon is facilitated by retracting the sigmoid colon toward the midline.

Using a combination of electrocautery and blunt dissection, release the lateral attachments of the sigmoid and descending colon by transecting the line of Toldt (FIG 3).