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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_670_Библиотеки_им_академика_М_И_Перельмана
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312 Atlas of Gastrointestinal Surgery: The Colon
6
The final step is removal of the appendix through a 10-mm
port using a laparoscopic specimen pouch (6). The
abdomen is irrigated and the wounds are closed.
It is necessary to close all port sites larger than
5 mm. The inferior port may be closed under direct
laparoscopic visualization using a port closure device.
Alternatively, the fascia may be closed after removal of
the pneumoperiteum by gently lifting up and approximat-
ing the edges of the anterior fascia with suture on a GU
(UR-6) needle. The skin edges are closed with subcuticular
sutures. Local anesthetic (25% Marcaine) can be applied for
additional postoperative pain management.
Right Hemicolectomy
Operative Indications
A malignant neoplasm arising anywhere from the
appendix to just proximal to the hepatic flexure is
the most common indication for resection of the right
colon (1). Benign polyps are also an indication for a
right hemicolectomy. Because this portion of the large
Right
colon
Cecum
Right
colic a.
Ileocolic a.
1
Middle colic a.
SMA
intestine is relatively thin walled, endoscopists are reluc-
tant to be as aggressive with benign polyp removal as in
other sections of the colon, and thus surgery is more
frequently recommended. Other indications for resec-
tion of the right colon include inflammatory bowel
disease, right-sided diverticular disease, and
bleeding vascular ectasia. The open right
hemicolectomy has been the standard
operation for these indications for years;
however, this operation now is being per-
formed frequently by minimally invasive tech-
niques. The operation includes division of the
ileocolic artery, the right colic artery (variable) and
the right branch of the middle colic artery and a midtrans-
verse colon anastomosis. Preoperative preparation of the patient
includes an optional mechanical bowel preparation, antibiotics, and
prophylaxis for deep vein thrombosis.
314 Atlas of Gastrointestinal Surgery: The Colon
Operative Technique
The patient is positioned supine, with the right arm
tucked. A midline incision is used. Alternatively, in a
thin, older individual a transverse incision can be used.
A self-retaining retractor is used to assist with exposure.
The patient’s abdomen is thoroughly explored for
metastatic disease. The liver and periaortic regions are
palpated, and the small intestine and colon are inspect-
ed in a systematic fashion. During exploration, the sur-
geon should assess for evidence of locally advanced dis-
The small bowel and its mesentery are retracted
toward the midline, and gentle traction is placed on
the right colon to expose its lateral peritoneal attach-
ments. These attachments are divided with
the electrocautery (2). One must be
careful when mobilizing the right colon
out of the retroperitoneum to avoid
ease involving the omentum, gall bladder, duodenum, or
pancreas. If locally advanced disease is found, every
effort is made to remove the involved structures en bloc.
Lateral
attachments
injury to the ureter and duodenum.
Right
colon
2
Cecum
The hepatic flexure is then
mobilized using the electro-
cautery (3).
Right Hemicolectomy 315
Hepatic flexure
attachments released
R. kidney
Duodenum
Right
colon
3
Mobilization continues by removing the
omentum from the right transverse
colon. Mobilization of the right
colon should expose the second
and third portions of the duode-
num. This allows for the liga-
tion of the ileocolic vessels at
their origin from the superior
mesenteric vessels. This also
insures that the ureter and
Right
ureter
injured during the division of
the mesentery (4).
4
duodenum will not be
316 Atlas of Gastrointestinal Surgery: The Colon
5
Ileocolic a.
Cecum
Ileum
Once the right colon is fully mobilized, the ileocolic, right colic (when present), and right branch of the middle colic
artery are clamped, divided, and either suture ligated or reinforced with a second tie (5). In the majority of individuals,
the right colic artery is a branch of the ileocolic artery and, therefore, both vessels are divided as one.
Ileum
Right Hemicolectomy 317
The mesentery between the ileocolic vascular pedicle
and the site of the small bowel division is scored with
the electrocautery. At least 10 cm of distal ileum
should be removed with the colon. A few small
vessels within this portion of the mesentery
are ligated and divided. The distal ileum is
divided with a linear stapler (6).
6
Once the right branch of the mid-
dle colic artery is divided (7), the
remaining mesentery to the transverse
7
Transverse
colon
Right branch
of middle colic a.
divided
colon is scored and divided.
Mesentery
318 Atlas of Gastrointestinal Surgery: The Colon
Transverse
colon
The transverse colon is divided with a linear
stapler (8), and the specimen is removed from
Right
colon
8
Gastrointestinal continuity is reestab-
lished by either a hand sewn or stapled
anastomosis. The most commonly employed
hand sewn techniques include end-to-end
Middle
colic a.
the operative field.
End-to-end
ileocolic anastomosis
9
(9 and 10), side-to-side (11), and side-
to-end (12) anastomoses. To perform an
end-to-end anastomosis, the stapled ends of
the bowel are inspected to ensure that the
mesentery has been adequately removed. Two
corner sutures are placed to hold the ends of the
bowel together. The posterior wall of the anastomo-
sis is created by placing an outer layer of interrupt-
ed 3-0 silk Lembert sutures. These sutures must be
placed far enough away from the staple line that it can
safely be removed. Once all sutures have been tied,
the anastomosis is quarantined from the rest of the
10
Side-to-side
anastomosis
Tr. colon
Ileum
Right Hemicolectomy 319
Tr. colon
Ileum
11
12
abdominal contents with lap sponges, and linen-shod clamps are placed on each end of the bowel to prevent leakage of
stool. The staple lines are then removed. The inner layer consists of a continuous 3-0 synthetic absorbable suture placed
in a locking fashion for the posterior inner layer (9). This is continued anteriorly with a continuous Connell suture. The
anterior outer layer consists of interrupted 3-0 silk Lembert sutures.
13
When performing an end-to-end anastomosis, a size
discrepancy may exist between the lumens of the small
14
and large bowel. To correct for this discrepancy, a
small perpendicular incision can be made along the
antimesenteric portion of the small bowel to
increase its lumen size (13 and 14).
320 Atlas of Gastrointestinal Surgery: The Colon
Alternatively, a stapled anastomosis can be
performed. This can be performed as a side-to-
side or end-to-side anastomosis. The side-to-
side technique is performed by aligning the antime-
senteric borders of the small bowel and colon and
removing the abutting corners of the staple lines. The
Ileum
linear stapler is introduced through these two entero-
tomies (15), positioned to avoid the mesentery,
closed, and fired, connecting the two lumens. The sta-
ple line is inspected for hemostasis.
Colon
15
Right Hemicolectomy 321
16
17
The enterotomies through which the linear stapler was intro-
duced are approximated with four Allis clamps, offsetting the
previous staple lines (16). The final closure is performed
by firing a linear stapler just below the Allis clamps.
Heavy scissors are used to remove the remaining
bowel along with the Allis clamps. The anastomosis
can be further secured with a row of 3-0 silk
Lembert sutures placed to bury the linear
staple line. An additional single stitch is
placed, to prevent tension at the apex of
the anastomosis (17).
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