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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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Senagore AJ, Delaney CP, Brady K, Fazio VW. A standardized approach to laparoscopic right
colectomy: outcome in 70 consecutive cases. J Am Coll Surg. 2004; 199: 675-679.
Chapter 23
Approaching the Transverse Colon
ARJUN JEGANATHAN
JEREMY M. LIPMAN
Perioperative Consideration
The transverse colon runs across the abdomen from the hepatic flexure to
the splenic flexure.
The transverse colon has a covering of visceral peritoneum and has an
associated mesentery.
The mesentery has a variable thickness and size—this is important
when identifying the vessels.
There may be significant redundancy of the transverse colon.
Be aware of the posterior gastric wall and the ligament of Treitz when
dividing the mesentery to the transverse colon to avoid iatrogenic damage.
The transverse colon can be mobilized as a part of an operation (eg, low
anterior resection) or resected (eg, total abdominal colectomy).
TIPS
It is important that you do not inadvertently divide the mesentery when
you mean to mobilize alone. Understand the anatomy!
Anesthesia and Patient Positioning
General anesthesia with orogastric tube and Foley catheter
Complete paralysis for appropriate relaxation.
Modified lithotomy with legs in stirrups (knees and hips slightly flexed) to
permit the surgeon to stand between the patient’s legs
Alternatively, split-leg position allows for easier maneuverability if
access to the anus is not anticipated.
Both arms tucked at the patient’s side to facilitate access to the abdomen
and increase surgeon comfort.
The patient must be secured to the bed with straps, pads, or tape.
The patient should not move during the extreme positioning that can be
used to facilitate exposure.
Reverse Trendelenburg with right or left lateral rotation is useful to
improve visualization of the splenic and hepatic flexures, respectively.
Instruments and Equipment
Hasson port (12-mm diameter)
10-mm 30-degree laparoscope
At least two 5-mm operating ports
Two 5-mm laparoscopic bowel graspers (atraumatic)
5-mm laparoscopic curved scissors with attachment for electrocautery
5-mm vessel sealing device
Technique
Port Placement
A periumbilical camera port with at least two working ports is necessary
(Fig. 23-1).
FIGURE 23-1 Periumbilical 10-mm camera port with suggested 5-mm working port
positions.
The location of the ports must be such that triangulation of the camera and
working ports to the hepatic flexure, mid-transverse colon, and splenic
flexure will be optimized.
Typically, a right and left lower quadrant location for working ports
provides adequate needs, although upper abdominal port placement may
be useful for challenging exposures.
Surgical Approaches
Approaching the transverse colon is most often performed as a component
of right, left, or total colectomy (Fig. 23-2).
The indicated procedure will usually direct the approach to transverse
colon.
FIGURE 23-2 Range of approaches to transverse colon include lateral-to-medial
from right or left, as well as supramesocolic and inframesocolic approaches via the
ileocolic artery, inferior mesenteric artery, or inferior mesenteric vein.
If access to other areas of the colon is compromised, a supramesocolic
approach may be useful.
Right-Sided Medial-to-Lateral Dissection Approach
The mobilized right hemicolon is retracted inferiorly and medially.
This will expose the gastrocolic ligament (Fig. 23-3).
FIGURE 23-3 Hepatic flexure placed on tension by drawing right hemicolon inferiorly
and medially.
The ligament is then divided moving medially (Fig. 23-4).
Care must be taken to avoid damage to the gallbladder.
FIGURE 23-4 Division of gastrocolic ligament with identification of gallbladder.
As dissection proceeds medially, the duodenum (Fig. 23-5) is exposed.
FIGURE 23-5 Division of gastrocolic ligament with identification of duodenum.
If not already completed from the medial dissection, the duodenum and
pancreas are bluntly mobilized from the transverse colon mesentery by
sweeping them posteriorly (Fig. 23-6).
The pancreatic head can bleed easily. This dissection is carried out just
anterior to the duodenum without ever actually contacting it.
FIGURE 23-6 Blunt posterior mobilization of the duodenum creation separation
from the mesocolon.
This will expose the head of the pancreas (Fig. 23-7).
FIGURE 23-7 Division of gastrocolic ligament with identification of pancreatic head.
Dividing the Transverse Mesocolon from the Right
A grasper is swept posterior to the cut edge of the colonic mesentery and
lifted anteriorly (Fig. 23-8).
FIGURE 23-8 Complete mobilization of hepatic flexure with dissection to the level of
the falciform ligament.
This will reflect the transverse colon mesentery and middle colic artery
distribution anteriorly and leave the superior mesenteric artery safely
posterior (Fig. 23-9).
FIGURE 23-9 Identification of peritoneal reflection at the takeoff of the middle colic
artery from the superior mesenteric artery.
Dissection then proceeds across the transverse colon mesentery (Fig. 23-
10).
FIGURE 23-10 Division of transverse colon mesentery from right to left.
The duodenojejunal junction will come into view and must be avoided
(Fig. 23-11).
FIGURE 23-11 Division of transverse colon mesentery past the duodenojejunal
junction.
If the omentum is to be preserved, it should be separately dissected from
its attachments to the colon (Fig. 23-12).
Alternatively, it can be dissected from the stomach and excised with the
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