83 © Springer International Publishing AG 2018 D.P. Geisler et al. (eds.), Operative Techniques in Single Incision Laparoscopic Colorectal Surgery, DOI 10.1007/978-3-319-63204-9_13 Reduced Port Sigmoid and Left Colectomy Deborah S. Keller 13 Procedure Steps 1. Insert port-4 cm Pfannenstiel incision for SILS port and optional 5 mm umbilical incision for trocar (recom- mended) 2. Position omentum over the transverse colon and deliver SB out of the pelvis to the right of the midline (L side elevated, Trendelenburg) 3. Tent rectosigmoid anterolateral to expose the mesentery by the sacral promontory (L side elevated, Trendelenburg) 4. Incise the peritoneum at the pelvic brim (L side elevated, Trendelenburg) 5. Develop the retroperitoneal plane deep to the Superior Rectal Artery to the lateral sidewall (L side elevated, Trendelenburg) 6. Vascular isolation (L side elevated, Trendelenburg) (a) If malignant disease, isolate the Left Colic Artery from its origin at the I Inferior Mesenteric Artery (b) If benign disease, make a window around the Superior Rectal Artery at the desired point of transection in the mesentery 7. Vascular division (L side elevated, Trendelenburg) (a) For malignant disease, divide the base of the Inferior Mesenteric Artery below the takeoff of the Left Colic Artery (b) For benign disease, divide the Superior Rectal Artery in the open, mesenteric window 8. Divide white line of Toldt, lateral to medial dissection from the descending/sigmoid colon to the splenic flexure (L side elevated, Slight Trendelenburg) 9. Splenic flexure takedown (L side elevated, Slight Reverse Trendelenburg) 10. Mobilize rectosigmoid junction depending on distal extent of disease, divide bowel and mesentery (L side elevated, Trendelenburg) 11. Exteriorize and resect specimen, prepare for anastomo- sis (Supine) 12. Intracorporeal anastomosis (Steep Trendelenburg) 13. Close Pfannenstiel and umbilical incisions (Supine) Tips and Tricks • This exact procedure can be done through a single inci- sion port at the Pfannenstiel or at the umbilicus. We advise the use an additional 5 mm port at the umbilicus for the operative camera to effectively widen the visual field. This approach has been labeled the “SILS + 1 technique”. The procedure steps are otherwise identical. • After tenting the rectosigmoid, if the sacral promontory is not visible, as can occur in the obese or patients with a floppy sigmoid, grasp the mesentery closer to the pelvic brim, and flop the sigmoid over closer to the retractor, taking care not to avulse the mesentery • When difficult to get the small bowel out of the pelvis, position in steeper Trendelenburg and incise the ileocolic attachments in an inferior to superior direction to move the cecum out of the pelvis. If small bowel is still in view, have an assistant gently grasp the terminal ileum in a superolateral direction after releasing the attachments • Use caution in thin patients, when incising the peritoneum over the pelvic brim, as the Left Iliac Vein and gonadal vessels, para-aortic autonomic nerves, and left ureter may be attached to the tissue due to absence of the sacral fat D.S. Keller, MS, MD (*) Division of Colorectal Surgery, Department of Surgery, Baylor University Medical Center, Dallas, TX, USA e-mail: debby_keller@hotmail.com Electronic Supplementary Material: The online version of this chapter (doi:10.1007/978-3-319-63204-9_13) contains supplementary material, which is available to authorized users.