Above the Pelvic

After packing the small bowel into the upper abdomen, the operation starts with the mobilisation of the left and sigmoid colon by developing the embryonic plane between the mesocolon and the abdominal wall (white line of Toldt). By staying in this plane close to the bowel wall, damage to the gonadal vessels, which can lead to annoying bleeding, can be avoided. In most cases a complete mobilisation of the left colonic flexure is necessary to achieve enough length for a tension-free anastomosis. I prefer an approach from lateral and medial (through the lesser sack) to achieve a bloodless dissection of the greater omentum and splenic flexure mobilisation. It should be mentioned that this can also be done nicely with the laparoscopic assisted technique. Technical devices like Ultracision® or Ligasure® are very useful. It seems that if a J-pouch for a better functional outcome is planned, a segment of descending colon should be used rather than the sig-moid colon, which demands extensive left colon mobilisation [15]. Furthermore the sigmoid colon is more prone to colon wall irregularities like diverticu-lar disease. Next the incision of the serosa from the medial (right) side of the left colon should be done continuing upwards to the inferior mesenteric artery, downwards to the pelvis until the cul-de-sac is reached. There is still no proof that high ligation (close to the aorta) of the inferior mesenteric artery is better than low ligation (after turn off of the left colonic artery) [16]. The inferior mesenteric vein should be divided close to the lower edge of the pancreas. At this point of the operation I prefer to divide the bowel (proximal dissection margin) so as to have good vision and access for the next step.

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