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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_665_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 1 • Open Right Colectomy 5
Figure 1-2
Figure 1-3
Figure 1-4
A
Figure 1-5A
B
Figure 1-5B
6 Chapter 1 • Open Right Colectomy
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The colon is returned to its anatomic position with the right colon along the right gutter and
the hepatic flexure up in the right upper quadrant. The SMA is identified in its tract to the
terminal ileum; a window is seen in the base of the mesentery of the right colon proximal
and distal to a large vascular trunk. This trunk is the ileocolic artery and vein arising from
the SMA and superior mesenteric vein (Figure 1-6). An incision is made at the base of this
window to expose and divide the ileocolic vessels at their origin (Figure 1-7).
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The vessels of the terminal ileal mesentery are divided; the terminal ileum is transected with
a linear cutter stapler, and the transverse colon is divided in its proximal portion just distal
to the hepatic flexure, also using a linear cutter stapler (Figures 1-8A and B and 1-9).
Chapter 1 • Open Right Colectomy 7
Figure 1-6
A
Figure 1-8A
Figure 1-7
B
Figure 1-8B
Cecum
Terminal
ileum
Figure 1-9
Terminal ileal
branch of SMA
Right colic
Ileocolic
artery and vein
artery
Middle colic
artery
Tumor
Transverse colon
8 Chapter 1 • Open Right Colectomy
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Once the specimen has been passed off, the corners of the antimesenteric end of the transverse
staple lines on the transverse colon and terminal ileum are removed, and the separated arms
of the linear cutter stapler are passed into the lumen of the aligned loops of bowel. A sideto-side anastomosis is constructed between the terminal ileum and the transverse colon with
the lumen aligned as a functional end-to-end anastomosis (Figures 1-10 and 1-11A-F). The
internal staple line is distracted as widely as possible (Figure 1-11E, inset).
Figure 1-10
Deliver specimen
Chapter 1 • Open Right Colectomy 9
Transection of
proximal bowel
Small intestine
Wound protector
A
Side-to-side
anastomosis
Terminal ileum
C
Transverse closure
Transverse colon
Taenia
Ileum
B
Side-to-side
anastomosis
with GIA stapler
D
Oversewn transverse
staple line
Colon
E
Figure 1-11A-F
F
10 Chapter 1 • Open Right Colectomy
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The transverse opening of the anastomosis is stretched to spread the “V” of the GIA staple
line and increase the transverse opening as widely as possible before placing a second staple
line across the transverse opening (Figure 1-12A and B). The mesenteric defect can be closed
with a running suture to prevent torsion or internal hernia.
Step 4: Postoperative Care
The abdomen is generally closed with a running No. 1 looped absorbable suture and staples,
and a sterile gauze is applied. Patients are ambulated early. Intravenous fluid replacement is
given to maintain a urine output of greater than 30 mL/hr. Nasogastric decompression is not
required unless the patient becomes nauseated. Most patients tolerate clear liquids within 24
to 48 hours, and the diet can be advanced as tolerated. Patients should be given prophylactic
antibiotics for 24 hours, incentive spirometry, and deep vein thrombosis prophylaxis and
encouraged to ambulate as much as possible during the early postoperative period. The usual
hospital stay after an open right colectomy is 4 to 5 days; the hospital stay is shorter when the
patient is placed on a fast-track postoperative regimen. Postoperative analgesia is usually
managed with patient-controlled analgesia followed by a switch to oral analgesics.
Step 5: Pearls and Pitfalls
The most common and most feared complication after a right colectomy is anastomotic leak.
These leaks can be prevented if the staple line at the apex of the GIA stapler is protected with
a suture placed in a Lembert fashion with seromuscular depth to close the crotch between the
two portions of bowel. The transverse staple line can be oversewn with a running 3-0 absorbable suture using Lembert suture placement (seromuscular rather than full-thickness oversewing). To prevent twisting at the anastomosis, the mesentery defect can be closed with a running
absorbable suture when the anastomosis is complete; this also prevents herniation or volvulus
at the anastomotic site. This closure is not required, but it is a safety procedure that has been
shown to be effective. The anastomosis can be covered with a portion of the remaining
omentum. Adhesion barriers can be used to prevent adhesions and to prevent the development
of small bowel obstruction in the future. Powderless gloves and good surgical technique can
also help avoid adhesions.
Selected Readings
West NP, Hohenberger W, Weber K, et al. Complete mesocolic excision with central vascular ligation produces an oncologically superior
specimen compared with standard surgery for carcinoma of the colon. J Clin Oncol 2010;28:272–8.
West NP, Sutton KM, Ingeholm P, et al. Improving the quality of colon cancer surgery through a surgical education program. Dis Colon
Rectum 2010;53:1594–603.
Chapter 1 • Open Right Colectomy 11
A
Figure 1-12A
B
Figure 1-12B
Step 1: Clinical Anatomy
C H A P T E R
2
Laparoscopic Right
Colectomy
Steven R. Hunt
The right colon lies on the patient’s right side suspended laterally by peritoneal attachments to
the right side of the abdominal wall, superiorly by attachments to the undersurface of the liver
and posterior diaphragm, and medially by its mesentery. The ileocolic artery and vein and the
right colic vessels, if they are present, run through this leaf of mesentery. The colon is adherent
to the retroperitoneum on the right side of the abdomen and covers the right gonadal vessels
and right ureter. The inferior vena cava is the next most medial structure on the right side. The
hepatic flexure, the fold at the junction between the right colon and transverse colon, is adherent to the anterior surface of the kidney by avascular attachments to Gerota’s fascia. The first
and second portions of the duodenum are adherent to the undersurface of the mesentery of the
right colon and proximal transverse colon. The gallbladder is sometimes adherent to the cephalad surface of the transverse colon at the hepatic flexure. The space behind the right colon is
triangular shaped with the flat horizontal surface at the hepatic flexure running from the
abdominal side wall toward the midline along the line of the greater curve of the stomach. The
vertical axis follows the right lateral side wall of the abdomen. The hypotenuse runs from the
fusion plane of the cecum at the pelvic brim over the top of the right iliac artery and vein at
about the point where the ureter passes over the iliac vessels toward the midline over the aorta
up to the base of the pancreas along the third portion of the duodenum. This triangular retroperitoneal area is a potential space with avascular attachments and allows the right colon to be
lifted completely from the retroperitoneum during dissection. Release of all suspensory attachments allows the right colon to be made into a midline structure. The ileocolic artery and vein
arise from the superior mesenteric artery (SMA) and superior mesenteric vein in the midportion
of the SMA below the duodenum. The right colic artery is a variable structure and may be
present as a separate structure or as part of the ileocolic trunk. The right branch of the middle
colic artery exits through the pancreatic tissue from its origin on the SMA as a portion of the
middle colic trunk at the base of the transverse mesocolon (Figure 2-1).
12
Transverse colon
Straight arteries
Chapter 2 • Laparoscopic Right Colectomy 13
Middle colic artery
Tumor
Right colic artery
Ileocolic artery
Ascending colon
Anterior cecal
artery
Posterior cecal
artery
Appendicular artery
Appendix
Figure 2-1
Marginal
artery
Jejunum
Superior
mesenteric
artery
Ileum
14 Chapter 2 • Laparoscopic Right Colectomy
Step 2: Preoperative Considerations
The clinical anatomy for laparoscopic colectomy is the same as an open right colectomy. The
indications for laparoscopic resection are also similar to indications for open right colectomy
with the restriction that laparoscopy cannot be done as easily in the setting of large inflammatory masses or large advanced tumors. The amount of colon resected depends on the blood
supply of the segment. The tumor determines the amount of bowel resected only if it is at the
extremes of the right colon, either at the hepatic flexure or at the cecum near the ileocecal valve.
In these circumstances, there should be an added proximal or distal margin to ensure adequate
bowel and mesentery removal. A mid right colon tumor requires a right colectomy with removal
of the entire right colon and anastomosis of the terminal ileum to the transverse colon. This
procedure results in removal of the entire lymph node–draining area of the bowel segment.
As with open colectomy, there is no need for bowel preparation. The same type of antibiotic
and deep vein thrombosis prophylaxis should be used. Laparoscopy adds the additional risk of
decreased blood flow through the inferior vena cava under a pneumoperitoneum of 15 mm Hg,
and sequential compression of the legs and proper positioning become critical. The laparoscopic
procedure is performed in the modified lithotomy position using Allen’s stirrups with the legs
flexed no more than 5 degrees at the hips and the knees flexed at 90 degrees to keep the legs
out of the field of the instruments as they traverse the lower quadrants during dissection. Figure
2-2 shows the positioning of the patient with leg flexion.
Step 3: Operative Steps
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The patient is positioned in the modified lithotomy position with the legs in Allen’s stirrups
with sequential compression boots in place. A beanbag, attached directly to the operating
table with Velcro, is rolled around the patient and deflated to fix the patient in position. The
beanbag keeps the arms at the patient’s side and allows the table to be placed in steep Trendelenburg and airplaned (tilted) to the left during the operation. The trocar site placement
is typically at the um bilicus and the suprapubic and left flank positions. The camera operator
stands at the patient’s left shoulder and operates the camera through the umbilical port. The
operating surgeon stands at the patient’s left hip or between the legs as needed and operates
instruments through the left flank and suprapubic ports (Figure 2-3).