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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 22-19 Dissection of the plane.
A window is fashioned in the peritoneum immediately superior to the
ileocolic pedicle.
A bipolar energy sealant device skeletonizes each side of the ileocolic
vasculature (Fig. 22-20).
FIGURE 22-20 Skeletonized proximal ileocolic vasculature.
The sealant then seals the vessels twice, moving 5 mm distal after the
proximal seal, and sealing and dividing at the distal site, dividing
approximately 1 cm from the superior mesenteric artery (Fig. 22-21). It is
important to do this maneuver without tension on the vessel or the seal is
shortened and bleeding more likely.
FIGURE 22-21 Sealing and division of the ileocolic artery.
The surgeon’s left hand is positioned to grab the proximal ileocolic stump
in the rare case of bleeding that may occur on release of the pedicle
following the seal.
Mobilization of the Ascending Colon and Hepatic Flexure
Frequently repositioning the assistant’s grasper more medially along the
ileocolic pedicle allows better visualization for the surgeons to lift the
mesocolon from the retroperitoneum and aid dissection.
The cecum and hepatic flexure are then mobilized from this medial
approach, extending out toward the lateral attachments and fully
mobilizing the posterior attachments of the colon.
As much mobilization as possible of the posterior attachments
significantly aids the dissection from above later. The flexure is fully
dissected off the duodenum and pancreas (Fig. 22-22), such that the liver
is often visible through a thin leaf of residual peritoneum, or the dissection
may even come through completely, exposing the liver in thinner patients.
FIGURE 22-22 Dissected mesocolon off the duodenum and pancreas.
The right branch of the middle colic artery can be easily identified as the
vessel with the maximal point of tension on the right side of the transverse
mesocolon identified typically anterosuperior to the duodenum and head
of pancreas (Fig. 22-23).
FIGURE 22-23 Right branch of the middle colic.
This right branch of the middle colic travels toward the proximal
mesocolon. If the vessel is traveling toward the mid ascending colon, it’s
most likely that a right colic is present. The right branch of the middle
colic is divided for right-sided colon cancers as well as the right colic, if
present, at this point in a similar manner as the ileocolic vessel is taken
with the bipolar energy sealant device (Fig. 22-24).
FIGURE 22-24 Division of the right branch of the middle colic.
Unless an intracorporeal anastomosis is being performed, generally
reserved for obese males with a thick abdominal wall, the marginal vessel
is left intact so that pulsatile flow can be tested when the specimen is
exteriorized.
If the cancer is more distal than the hepatic flexure and the transverse
colon is short, or is close to the middle colic vessels, an extended right
hemicolectomy is performed. The middle colic vessel is skeletonized and
taken at its origin. This is described in detail in our transverse colectomy
chapter.
The patient is moved to steep reverse Trendelenburg.
The omentum is redraped inferiorly to the transverse colon to its normal
anatomical position to allow en bloc resection with the specimen for
cancers.
The assistant grasps the omentum superiorly approximately one-third of
the way along the transverse colon with the surgeon’s left hand counterretracting the transverse colon inferiorly to cause tension across the
omentum covering the lesser sac.
The omentum is divided immediately superior to the transverse colon to
gain entry to the lesser sac (Fig. 22-25), except for transverse colon tumors
where the plane of dissection is along the gastroepiploic arcade.
FIGURE 22-25 Dissection into lesser sac.
The greater omentum is further mobilized en bloc and divided off stomach
(Figs. 22-26 and 22-27), until the plane along superior surface of proximal
transverse mesocolon is clearly displayed, down to base of mesentery.
FIGURE 22-26 Lesser sac entered.
FIGURE 22-27 Lesser sac exposure extended.
This allows the dissection to continue on the superior aspect of the
transverse mesocolon, and one rapidly encounters the space created by the
previous medial-to-lateral dissection anterior to the pancreas.
This dissection is continued laterally mobilizing superior aspect of the
flexure and joins the plane of medial-to-lateral dissection to expose the
duodenum (Fig. 22-28).
FIGURE 22-28 Mobilization of hepatic flexure.
The hepatic flexure and proximal transverse colon are now mobilized (Fig.
22-29).
FIGURE 22-29 Mobilized hepatic flexure.
Mobilization of the Cecum and Small Bowel Mesentery
At this point, using the energy device, the small bowel mesentery is
ligated and divided close to the most likely transection point. The
proximal part of the ligament of Treves is a good consistent point of
reference to aim for.
The patient is moved to a steep Trendelenburg position, keeping the right
side up.
The small bowel mesentery is moved entirely out of the pelvis to the
patient’s left flank and left upper quadrant, and the cecum is retracted
supero-antero-medially by the assistant.
The plane between the small bowel mesentery and retroperitoneum is
divided with scissors cautery lateral to medial (Figs. 22-30 and 22-32)
until the duodenum and head of pancreas are visualized.
FIGURE 22-30 Dissection of small bowel mesentery from retroperitoneum lateral to
medial.
FIGURE 22-31 Further dissection of small bowel mesentery from retroperitoneum
lateral to medial.
FIGURE 22-32 Dissection of small bowel mesentery from retroperitoneum to
duodenum.
The assistant then retracts the cecum anteromedially. Any remaining
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