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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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attachments of right colon and right colonic mesocolon to the lateral side
wall are divided with scissors cautery (Fig. 22-33).
FIGURE 22-33 Lateral side wall peritoneal attachments to cecum.
The surgeon grasps the right colonic appendages more distally, and the
dissection continues upward as far as the hepatic flexure (Figs. 22-34 to
22-35).
FIGURE 22-34 Lateral side wall peritoneal attachments to ascending colon.
FIGURE 22-35 Lateral side wall peritoneal attachments to hepatic flexure.
The cecum and right colon are now completely mobile. The right ureter is
not routinely searched for unless concern of breached planes exists.
The right colon should be fully mobile and able to stretch easily across the
midline exposing the first and second parts of the duodenum (Fig. 22-36).
FIGURE 22-36 Fully mobilized right colon and hepatic flexure.
A ratcheted bowel grasper is secure to the base of the appendix (Fig. 22-
37).
FIGURE 22-37 Ratcheted bowel grasper secured to the appendix.
Transversus Abdominis Plain Block
At this point, a spinal needle is blunted and inserted under direct
laparoscopic vision into all four quadrants of the abdomen in line with the
anterior superior iliac spine.
The operator is feeling for two pops before they are in the correct plane.
Upon injection the local anesthetic (15 mL 0.25% bupivacaine with
epinephrine 1:100 000, 60 mL total), a smooth indentation should be seen
laparoscopically as the transversus abdominis is pushed away from the
internal oblique.
If a peritoneal bleb is visualized, the operator has pushed the needle in too
far and should bring the needle back subcutaneously before reintroducing
through the fascial layers again.
Umbilical Incision and Exteriorization of the Right Colon
The periumbilical incision is extended vertically to a size to safely extract
the specimen.
A wound protector is inserted (Fig. 22-38), with two large towels placed
underneath to protect surrounding drapes and skin from potential fecal
contamination.
FIGURE 22-38 Wound protector for extraction.
The laparoscopic bowel grasper delivers the cecum to the midline to allow
it to be pulled out using a Babcock clamp through the midline.
The surgeon is cognizant not to twist the bowel, tear specimen, or
mesentery.
If the specimen appears too big for the extraction, the incision can be
extended or the terminal ileum can be transected with the linear stapler,
grasped with a long Babcock, and pushed back in the abdomen. The
surgeon is cognizant of the orientation of the Babcock, such to not to twist
the small bowel mesentery.
Standard Extracorporeal Resection and Anastomosis
(Also See Chapter 19)
The marginal artery is ligated proximally and divided with sharp
dissection to test for pulsatile blood flow.
The transection point is moved distally if necessary.
The orientations of both the terminal ileum and the transverse colon are
carefully scrutinized before decided to proceed with the anastomosis (Fig.
22-39).
FIGURE 22-39 Colon and ileum exteriorized prior to resection and anastomosis.
A side-to-side stapled anastomosis is completed with a linear GIA stapler
(Fig. 22-40).
FIGURE 22-40 Side-to-side anastomosis using linear stapler.
Two 3/0 polyglactin reinforcing crotch sutures are placed prior to firing
the GIA, giving time for tissue of squeeze edema out.
Following GIA deployment, the internal mucosal staple line is visualized,
and any bleeding is sutured with 3/0 polyglactin.
The enterotomy is closed with a TA stapler (Fig. 22-41).
FIGURE 22-41 Closure of enterotomy with TA stapler.
Any staple line bleeds are oversewn in a figure-of-eight manner, and the
entire TA staple line is oversewn with interrupted 3/0 polyglactin (Fig. 22-
42).
FIGURE 22-42 Ileocolic anastomosis.
The mesenteric defect is not closed.
The anastomosis is reduced gently back into the abdomen.
Free omentum is placed to overlying the anastomosis.
Wound retractors, towels, and dirty instruments are removed from the
field, and gloves changed.
The midline fascia is closed with continuous 1 polydioxanone suture and
skin closed with an absorbable subcuticular suture (Fig. 22-43).
FIGURE 22-43 Closed wounds.
Postoperative Care
We follow our published standardized enhanced recovery perioperative
care plan.
Orogastric tubes are removed prior to extubation, intravenous fluids are
minimized, diet is given day 0, and urinary catheters are removed day 1.
Opioids are minimized, and patient-controlled analgesia is avoided.
Nonsteroidal anti-inflammatories are permitted and combined with oral
acetaminophen.
Subcutaneous heparin and intermittent pneumatic compression are
continued following surgery for deep vein thrombosis prophylaxis.
Suggested Readings
Crawshaw BP, Steele SR, Lee E, et al. Failing to prepare is preparing to fail: a single-blinded
randomized controlled trial to determine the impact of a preoperative instructional video on
residents’ ability to perform laparoscopic right colectomy. Dis Colon Rectum. 2016;59(1):28-
34.
Reynolds HL, Delaney CP. Laparoscopic right hemicolectomy. In: O’Connell PR, Solomon R, eds.
Rob and Smith Colorectal Surgery. London, England: Hodder and Stoughton Ltd; 2010.
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