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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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FIGURE 22-5 Patient positioning.
An orogastric tube is inserted, as well as a Foley catheter that comes out
under the patient’s right leg.
The operative technician is typically positioned between the legs.
The primary working monitor is on the patient’s right side.
Approach and Equipment
A medial-to-lateral laparoscopic right hemicolectomy is our preferred
approach, as we have not found single port, hand-assist, robotics or open
surgery to add value; though each may be indicated in select conditions,
patients and institution protocols.
If progress is not being made utilizing the described technique, an open
approach is considered.
Technique
Port Insertion
The procedure begins with a surgical huddle and time-out to confirm
patient identity, procedure, allergies, history, and imaging and medication
required.
The surgeon stands on the patients left, with the assistant opposite.
A vertical 10-mm incision is made immediately below the umbilicus.
A 10-mm port is inserted using Hasson technique. Two small Kocher
clamps grasp and lift the exposed fascia. The fascia and underlying
peritoneum are carefully opened.
A 2/0 polyglactin suture is placed with a U needle around the fascia.
The 10-mm port is inserted, and a Rommel tourniquet is used to facilitate
securing adequate seal, and carbon dioxide is insufflated to a pressure of
15 mm Hg.
A 5-mm port is inserted two fingerbreadths distance medial and superior
to the left anterior superior iliac spine under direct vision, taking care not
to damage the inferior epigastric arteries (Fig. 22-6).
FIGURE 22-6 Inferior epigastric vessels.
A second 5-mm port is inserted similarly a handbreadth superior to this
(Fig. 22-7).
FIGURE 22-7 Port insertion.
A third 5-mm port is similarly inserted into the right flank (Fig. 22-8).
FIGURE 22-8 Port site positioning.
Left-sided ports are placed more medially and more superiorly for taller
more obese patients to avoid difficulties with reach to the hepatic flexure
(Fig. 22-9).
FIGURE 22-9 High left lateral port placement in obese patient.
Laparoscopic Assessment of Resectability
Right hemicolectomy is mainly performed for cancer, endoscopically
unresectable polyps, or terminal ileal Crohn disease.
The abdomen is inspected for tumor spread, including the liver,
peritoneum, ovaries, uterus, adhesions, tattoo, fixity to retroperitoneum,
and/or tethering to other organs (Figs. 22-10 and 22-11).
FIGURE 22-10 Liver.
FIGURE 22-11 Tattoo on right colon.
The extent of adhesions, inflammatory phlegmon, and the tumor size and
fixation are important considerations to help decide if the operation should
be done laparoscopically.
Patients with malignancy or Crohn’s disease have the entire abdomen,
including the intestine, inspected at this stage, and any suspicious areas are
palpated after exteriorizing the specimen.
The patient is then tilted into approximately 10 degrees Trendelenburg and
maximum right side up.
The assistant moves to the patient’s left side below the surgeon to hold the
camera (Fig. 22-12).
FIGURE 22-12 Positioning of staff in relation to patient.
The surgeon positions the small intestine with two atraumatic bowel
graspers to allow the distal ileum to stay in the pelvis with the remainder
in the left flank and left upper quadrant.
The omentum is laid superior to the transverse colon (Fig. 22-13).
FIGURE 22-13 Omentum being laid superiorly to transverse colon.
Tattoo and tumor characteristics can often be examined more thoroughly
at this point.
Isolation of the Ileocolic Pedicle
The mesentery of the ileocecal valve is lifted antero-infero-laterally to
help delineate the ileocolic vessels (Fig. 22-14).
FIGURE 22-14 Tension on the ileocolic mesentery to delineate ileocolic vessels.
This is then handed off to the assistant who retracts it in a similar position
with a ratcheted bowel grasper through the right flank port.
The scissors cautery divides the peritoneum immediately posteromedially
to the ileocolic vasculature for benign disease, and close to and parallel to
the superior mesenteric artery for malignant disease (Fig. 22-15).
FIGURE 22-15 Scoring of the peritoneum posteromedial to the ileocolic vasculature.
The incision is extended toward the origin of the ileocolic artery.
The surgeon’s left hand then inserts the bowel grasper into this dissection
plane, allowing exposure to be able to dissect out the plane between the
mesocolic fascia and the retroperitoneal or Toldt fascia. This plane is often
easiest to find near the origin of vessels (Figs. 22-16 to 22-18).
FIGURE 22-16 Window behind ileocolic vessels.
FIGURE 22-17 Tenting of ileocolic vessels upward to expose duodenum.
FIGURE 22-18 Dissection of the plane between the mesocolic fascia and the
retroperitoneum.
The duodenum and pancreas head are exposed and clearly visualized. If
the plane is challenging to identify (very obese patient, for example),
going anterior to the duodenum is always a good guide (Fig. 22-19).
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