Patients <7 kg should be placed in the supine position on the table with the legs abducted to ensure access to the anus. Children >7 kg should be placed in the modified Lloyd-Davies position (with access to the anus). Start with the operating table horizontal, but move the table during the operation to maximise visibility: head up for dissection of the transverse colon, head down for rectal dissection, left side up during dissection of descending colon, and right side up for dissection of the caecum and ascending colon.

See Fig. 27.1 for the locations of the port sites. The difference between total colectomy and other laparoscopic procedures is that the operative field keeps changing; the ergonomics may be perfect during some stages of the procedure and dire in other parts, so placing the ports is crucial if the ergonomics are going to be optimal for most of the procedure. It is not possible for the ergonomics or port sites to be perfect for the whole procedure. In general, keep the port sites as lateral and peripheral as possible to maximise the working space. The umbilicus is seldom a useful site for a port.

A local anaesthetic (bupivacaine) should be applied to the port sites before the incision and more injected at the end of the procedure, if indicated.

Start by placing the right upper quadrant port site as high and lateral as possible without going above the liver edge. Use a cut-down technique (modified Hasson entry). Place the right lower quadrant port between the anterior superior iliac spine and the umbilicus (slightly lateral to McBurney’s point) so that this port site may be extended (medially) to bring out the ileostomy if required. Place the left upper quadrant port as high and lateral as possible, just under the costal margin, and place the left lower quadrant port as low and lateral as possible (just above the anterior superior iliac spine). Place all additional ports under laparoscopic vision to avoid complications.

For children <7 kg, start with low flow and 7 mmHg CO₂ insufflation pressure. This may be increased as required up to a maximum of 12 mmHg. For older children, e.g. adolescents, start with low flow and 10 mmHg, which may be increased to 15 mmHg. If greater pressures are needed, the surgeon should reassess the situation―i.e., optimise the patient’s position, determine the need for more muscle relaxant, and check for any gas leak.

The surgeon’s position changes continually. Remember that the surgeon should move to the position that optimises the ergonomics for the part of the dissection he or she is performing.

It is helpful to start with dissection of the sigmoid colon, as it is the easiest part of the operation and gets the surgeon off to a good start and into the correct tissue planes. For this part of the dissection, the surgeon should stand on the patient’s right looking towards the patient’s left iliac fossa (Fig. 27.2). The camera is inserted via the right upper quadrant port, and the left upper quadrant and right lower quadrant ports are used as working ports. The assistant places a laparoscopic Babcock forceps through the left lower quadrant port and lifts the sigmoid (Fig. 27.3). Dissection starts by making a window in the middle of the sigmoid mesocolon (quite close to the vascular arcade), which is best done using a hook diathermy. Once the hole has been made in the sigmoid mesocolon, monopolar hook diathermy, bipolar diathermy, or an ultrasonic dissector may be used for the main dissection (Fig. 27.4). The surgeon moves retrogradely up the sigmoid to the proximal sigmoid colon and distally along the sigmoid as far as the pelvic brim, as indicated. Dissection stops at the pelvic brim if a subtotal colectomy is being performed.