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40
R
ight Colectomy for Cancer
22
23
F
1
F
20
ig. 2–
ig. 2–
ig. 2–
ig. 2–2
References
41
COMPLICATIONS
Leakage from an ileocolonic or colocolonic anastomosis may manifest as peritonitis, colocutaneous
fi stula, or localized intraperitoneal abscess. Localized
or spreading peritonitis should be managed by
prompt relaparotomy and exteriorization of both
ends of the anastomosis.
Sepsis in the subhepatic, subphrenic, or pelvic
areas is an occasional complication of anastomoses
of the colon, even in the absence of leakage. CT of
the abdomen generally provides the diagnosis, and
percutaneous drainage is usually successful.
Wound infection requires prompt removal of all
overlying skin sutures to permit wide drainage of the
entire infected area.
REFERENCES
Furstenberg S, Goldman S, Machado M, Jarhult J. Minilapa-
rotomy approach to tumors of the right colon. Dis
Colon Rectum 1998;41:997.
Heili MJ, Flowers SA, Fowler DL. Laparoscopic-assisted col-
ectomy: a comparison of dissection techniques. J Soc
Laparoendosc Surg 1999;3:27.
Leung KL, Meng WC, Lee JP, et al. Laparoscopic-assisted
resection of right-sided colonic carcinoma: a casecontrol study. J Surg Oncol 1999;71:97.
Metcalf AM. Laparoscopic colectomy. Surg Clin North Am
2000;80:1321.
Schirmer BD. Laparoscopic colon resection. Surg Clin
North Am 1996;76:571.
Young-Fadok TM, Nelson H. Laparoscopic right
colectomy: fi ve-step procedure. Dis Colon Rectum
2000; 2:267.
Young-Fadok TM, Radice E, Nelson H, Harmsen WS. Ben-
efi ts of laparoscopic-assisted colectomy for colon
polyps: a case-matched series. Mayo Clinic Proc 2000;
75:344.
Laparoscopic Right Hemicolectomy
3
Steven D. Wexner, MD
Susan M. Cera, MD
INDICATIONS
Ileocolic Crohn’s disease
Endoscopically irretrievable adenomatous polyps
Arteriovenous malformations
Cecal volvulus
Ischemia
Carcinoma
Right-sided diverticulitis
PREOPERATIVE PREPARATION
Preoperatively, patients undergo an appropriate
medical evaluation. Imaging studies including CT
scan, barium studies, and colonoscopy are undertaken for preoperative planning to assess the location of disease, review any associated complications,
and identify any synchronous lesions. Preoperative
marking of polyps by endoscopic tattooing using
India ink is necessary to ensure intraoperative
identifi cation of the lesion and to avoid the need
for intraoperative colonoscopy. In patients with
recurrent Crohn’s disease or history of multiple
laparotmoies, imaging studies are particularly
important in providing “roadmaps” to defi ne extent
of previous resections, length of remaining bowel,
and degree of previous mobilization of fl exures.
Preoperative mechanical and antibiotic bowel
preparation consists of 45 cc sodium phosphate
solution (Fleets phosphosoda; C.B. Fleet Co., Inc.,
Lynchburg, VA) PO at 4 pm and at 9 pm, each followed by 3–8 oz glasses of water, and 1 gm neomycin with 500 mg metronidazole at 7:00 and 11:00
pm. In addition, 2 gm of cefotetan are administered intravenously and 5000 units of heparin
injected subcutaneously at the start of the
operation.
PITFALLS AND DANGER POINTS
Injury to liver, duodenum, or contents of the hepatoduodenal ligament
Hemorrhage from epigastric, mesenteric, iliac, or
gonadal vessels
Inadvertent enterotomy or colotomy
Inadvertent retrorenal dissection
Anastomotic insuffi ciency or twist
OPERATIVE STRATEGY
Elective laparoscopic right hemicolectomy is performed in a laparoscopic-assisted fashion with intracorporeal mobilization of the ileum, cecum, and
hepatic fl exure medially to the level of the duodenum and middle colic vessels. The bowel is then
exteriorized through a small midline port incision
extended to approximately 4 cm. Extracorporeal
division of the mesentery is followed by resection of
bowel and creation of a side-to-side functional endto-end ileocolic anastomosis. The bowel is returned
to the abdomen and re-insuffl ation allows fi nal inspection of the intraperitoneal contents.
For patients with primary or recurrent Crohn’s
ileitis, signifi cant infl ammation and adhesions may be
encountered. Dissection is initiated in areas free of
infl ammation to identify appropriate planes. Thorough inspection of the small bowel from the ileocecal valve to the jejunoduodenal junction using a
two-instrument technique is essential to assess synchronous locations of disease which are addressed
after maximal mobilization is accomplished laparoscopically. Resections, anastomoses, enterotomy
repairs, and stricturoplasties are most easily performed extracorporeally through a limited incision,
preferably midline to preserve future potential
ostomy sites.
42
E
t
A
ed lithotomy position with the
-
1
prepp
-
fl
ated to an intraabdominal pressure of
Op
erative Technique
43
OPERATIVE TECHNIQU
Room Setup and Trocar Placemen
fter the induction of general anesthesia, the patient
lower extremities in padded stirrups placed low for
unimpeded movement of the instruments. Both arms
are tucked at the patient’s sides and extra care is
aken to secure the patient to the bed because of the
otation and tilt required during surgery. A minimum
of two monitors is needed and are placed one on
each side of the patient at the head of the bed
3 –1). Bilateral ureteral stents are placed by a urolo
ist, followed by insertion of a urinary catheter and
Fig.
n orogastric tube. The patient’s abdomen is shaved,
ed with povodine-iodine solution, and appro
priately draped.
For port placement, the assistant stands to the
right of the patient while the surgeon stays to the
left. Three to four 10 mm trocars are employed for
most procedures (Fig. 3 –2a and 3 –2b) Initially, a
0 mm trocar is placed by the open Hasson technique in the supraumbilical position through which
the camera is inserted. In the reoperative abdomen,
the initial trocar can be placed in the left upper
quadrant in a site remote from scars. The abdomen
is insuf
5 mm Hg. Two additional trocars are placed along
the lateral edge of the left rectus muscle, 8–10 cm
Fig. 3–
44
L
aparoscopic Right Hemicolectomy
g
b
fi
guration allows adequate triangulation of
p
fl
exure. Once all ports are placed, the
.
Exp
n
u
e
fi
ne the extent of
fl
amma-
fl
ammation or stric-
h
.
A
Fi
part, in the midabdomen and iliac fossa positions.
This con
e instruments to facilitate the dissection. All port
lacements should take into consideration the poten-
ial for future ostomy or drain sites. In obese patients
r patients with extensive intraabdominal adhesions,
an optional port can be placed in the left upper
uadrant to assist in retraction during dissection of
e hepatic
assistant moves to the patients left to direct the
amera
loratio
Exploration is undertaken to assess for adhesions and
nexpected pathology and to d
B
. 3–2a
disease. In the cases of neoplasia, peritoneal surfaces
and the liver are inspected for metastases. Extensive
adhesions may require early conversion while large
phlegmons or masses may require long incisions
for removal obviating the need for a laparoscopic
approach. Unexpected complications of in
ory bowel disease mandates advanced laparoscopic
skills and may necessitate conversion to laparotomy.
Thorough inspection of the small bowel from the
leocecal valve to the jejunoduodenal junction using
a two-instrument technique is essential to assess
anatomy and identify pathology. Any synchronous
ip areas of disease, such as in
ures, can be marked with sutures for subsequent
esection or strictureplasty after the index resection
as been accomplished through the midline
ncision
Op
erative Technique
45
m
fi
eld of dissection.
-
ssectio
n
fl
ammation and adhesions
-
fl
exure
atera
fi
ed in the retro-
-
-
fi
culty in subsequent mobilization of the hepatic
fl
exure. Hemostasis of small vessels is important for
v
i
fi
cation of the duode-
-
h
n
fl
amma-
.
Th
fl
exure
p
3
Mobilization of the Cecu
The operating table is tilted toward the patient left
side and Trendelenberg position is used to facilitate
medial retraction of the right colon and prevent the
small bowel from entering the
The mesentery of the cecum is gently grasped and
etracted medially using Babcock clamps placed
hrough the left upper port. With the 10-mm ultra
sonic shears placed through the left lower port, the
peritoneum along the base of the terminal ileum
mesentery and around the cecum is opened expos-
ng the retroperitoneum(Fig. 3 –3a) Di
begun in an area free of i
and proceeds in the avascular plane medially under
he cecum to the level of the duodenum and superi
orly to the hepatic
Fig. 3 –3b) The l
peritoneal attachments of the cecum are incised
(Fig. 3 – 4a) The ureter is identi
peritoneum traversing the right iliac vessels in paral-
n is
l
lel with the gonadal vessels. Great care should be
taken to identify the correct plane of dissection ante
rior to Gerota
fascia as more lateral dissection
results in medial mobilization of the kidney with dif
isualization of the tissue planes during this portion
of the procedure. Early ident
num is imperative in preventing injury and inadver
tent electrocautery burns. For patients expected to
ave extensive intraabdominal adhesions and/or
intra
bdominal, pelvic, or retroperitoneal i
tion, ureteric catheters can be a valuable adjunct
Mobilization of the Hepatic Flexure
e surgeon often moves to a position between the
patient
and transverse colon. With the patient in stee
legs while working on the hepatic
B
A
Fig.
4
6
L
3
l
fl
exure dividing the hepatocolic ligament
fl
exure with the ultrasonic scalpel or
l
-
fi
cant obesity, in
fl
ammation, or adhesions
astomosis
aparoscopic Right Hemicolectomy
A
B
reverse Trendelenberg position, dissection of the
ateral attachments is continued around the hepatic
Fig. 3 –
b) With the transverse colon retracted caudad and
he greater omentum retracted cephalad, the
mentum is separated from the midtransverse colon
o the hepatic
cissors through the avascular omental-colic junction
Fig. 3 –5a and 3 –5b) An optional fourth upper
eft-sided port may be placed to provide upward trac
ion on the omentum and is particularly in the pres-
nce of signi
Fig 3
a and 3–2b). It is generally best to mobilize
ig.
e proximal transverse colon to the level of the
middle colic vessels to ensure optimal length for
mobilization into the midline. Upon completion of
e mobilization, the right colon is suspended by its
mesentery where the origins of the ileocolic, right
colic, and middle colic arteries reside.
Extracorporeal Resection
nd An
nce appropriate mobilization has been achieved,
e supraumbilical port site is extended to an approx-
Op
erative Technique
4
3
section on the
b
gh
-
fl
ammatory
b
Re-insuffl
ation and Inspection
Th
B
7
mately 4 cm midline incision. A plastic, impervious
wound drape is placed, the cecum is gently grasped,
and the right colon is easily delivered through the
wound (Fig. 3 – 6) Points of tran
leum and colon are chosen and marked. The mesen-
ery between these points is clamped, ligated, and
divided prior to bowel resection to prevent twisting
of the bowel and mesentery. Once the mesentery is
divided, closure of the mesenteric defect with absorb-
le suture is begun but left untied. Linear cutting
a
staplers are used to divide the ileum and transverse
colon and, subsequently, to perform the side-to-side
A
Fig.
ileocolic anastomosis. The anastomosis should be
tension-free, airti
t, and well-vascularized. Closure
of the mesenteric defect is then completed. Any syn
chronous lesions, strictures or phlegmons, can be
ddressed at this time. In patients with in
owel disease, it may be useful to inspect the entire
length of the small bowel through this incision.
e fascia of the midline incision is closed with
running absorbable sutures begun at each end but
48
L
aparoscopic Right Hemicolectomy
3
ig.
3
ated. Inspection
)
P
E
fi
rst postoperative day, the bladder catheter is
.
NS
astomotic leak
n
W
n
a
S
W
hn
4
9
.
M
d
h
4
.
k
).
W
p
b
.
W
p
,
.
Reference
s
49
nd covered with adhesive strips and gauze dressings
Fig. 3 –7
OSTOPERATIVE CAR
ostoperatively, the patient is begun on clear
liquids and a self-administered analgesic pump. On
removed and pain is controlled with oral medication. The diet advanced with onset of bowel
function and the patient discharged shortly
thereafter
COMPLICATIO
An
Small bowel obstructio
ound infectio
rt site herni
Fig.
left open in the midportion. The 10-mm cannula is
of the intraabdominal contents is undertaken to
ensure no twisting of the mesentery and absence
of hemorrhage in areas of pervious dissection. The
ports are removed under direct vision and the midline
fascia closed. The skin of the midline and port-site
wounds are reapproximated with absorbable sutures
REFERENCE
exner SD, Moscovitz ID. Laparoscopic colectomy in
diverticular and Cro
surgery, Part 1. Surg Clin North Am 2000;80(
319
iranda JA, Singh JJ. Laparoscopic right hemicolectomy.
In MacFay
Surgery of t
200
era C, Wexner SD. Diverticulitis. In Advanced Therapy of
Minimally Invasive Surgery. New Yor
press
exner SD (Guest Ed). Laparoscopy for benign disease.
Seminars in La
ster Pu
exner SD (Guest Ed). Laparoscopy for malignant disease.
Seminars in La
ster Publications
en B, Wexner SDW (eds) Laparoscopic
e Abdomen. New York, Springer-Verlag,
, pp 359363
aroscopic Surgery. New York, Westmin-
lications, 2003
aroscopic Surgery. New York, Westmin-
2004
disease: minimal access
):129
, B.C. Decker (in