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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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322 Atlas of Gastrointestinal Surgery: The Colon
Tr. colon
End-to-side
anastomosis
19
Ileum
18
20
Alternatively, an end-to-side anastomosis may be performed with a circular stapler.
The staple lines are removed from the small bowel and colon. Graduated sizers are used
to determine the width of the anvil to be introduced into the small bowel. A pursestring suture is placed in the open end
of the small bowel with 2-0 nonabsorbable synthetic suture. The appropriate sized anvil is introduced and the pursestring
is secured. The circular stapler is introduced through the open end of the colon. The head of the circular stapler is
positioned along the antimesenteric edge of the colon. The stapler is opened, which advances the trocar through the colon
wall (18). The anvil is attached to the trocar, and the circular stapler is closed and fired, creating the anastomosis (19).
The stapling device is removed through the open end of the colon, using a rotating motion. The two “donuts” of tissue
are inspected for completeness. The end of the colon is closed with a linear stapler (20). Reinforcement with Lembert
sutures is optional.
Upon completion of the anastomosis, the mesenteric defect is closed with interrupted 3-0 silk sutures. No drains are
necessary for this procedure. The abdomen is copiously irrigated with an antibiotic-containing solution. The abdominal
wound is closed by approximating the midline fascia with interrupted synthetic nonabsorbable sutures. The skin is closed
with a subcuticular stitch.
Extended Right Colectomy
Operative Indications
A malignant neoplasm arising from the
hepatic flexure to the mid transverse
colon is the most common indication for
performing an extended right colectomy
(1). This operation includes division
of the ileocolic and middle colic ves-
sels with distal transverse colon anas-
tomosis. Because of the concern of
full thickness penetration of the tumor
through the colonic wall into the sur-
rounding fat, the omentum is often
removed with this procedure.
Preoperative preparation of the
Omentum
Transverse
colon
Middle
colic a.
SMA
Ileocolic a.
Right
colon
patient includes an optional mechani-
cal bowel preparation, intravenous
antibiotics, and prophylaxis for deep
vein thrombosis.
Cecum
1
324 Atlas of Gastrointestinal Surgery: The Colon
Operative Technique
The patient is in the supine position with the right arm
tucked. This allows for a second assistant to retract the
abdominal wall if additional exposure of the right upper
quadrant is needed. A midline incision extending above
and below the umbilicus is made. A self-retaining retractor
is used to assist in exposure. The patient’s abdomen is
explored, the liver is palpated, and the small intestines and
colon are inspected. During exploration, the surgeon should
assess for evidence of locally advanced disease involving the
The procedure is begun in a similar
fashion to the standard right hemi-
colectomy. The small bowel and its
mesentery are gently retracted
toward the left upper quadrant.
Gentle traction is placed medial-
ly on the right colon, and the lat-
eral peritoneal attachments are
released with the electrocautery.
omentum, gallbladder, duodenum, or pancreas. If locally
advanced disease exists, every attempt should be made to
remove structures the tumor is invading en bloc.
In a thin patient, a right-angle
clamp is placed under the peri-
toneal attachments to prevent
injury to underlying structures
such as the ureter and duode-
num. The avascular plane
between the right colon
and the retroperitoneum
should be released extensively
up to the third portion of the
Omentum
Transverse
colon
Lesser sac
entered
2
Extended Right Colectomy 325
duodenum. This allows for ligation of the ileocolic vessels at their origin from the superior mesenteric artery in the case of
cancer and prevents inadvertent injury to the ureter or duodenum during division of the mesentery. The lesser sac is entered
where the left transverse colon will be divided (2).
Once the right colon is fully mobilized, ligation of the vascular supply is easily accomplished. The avascular window
between the ileocolic and the middle colic artery is opened with the electrocautery. With careful palpation, a second win-
dow is identified and created inferior to the ileocolic vessels. The ileocolic vessels are clamped, divided and either suture-
ligated or reinforced with a second tie. The mesentery
between the ileocolic vascular pedicle and the site of
small bowel division is scored and the mesentery is
End-to-end
ileocolic anastomosis
3
Ileum
Small bowel
Left
colon
Sigmoid
colon
divided. The distal ileum is divided with a linear sta-
pler. The middle colic artery is dissected to its origin
and clamped, divided, and either suture-ligated or rein-
forced with a second tie. The transverse mesocolon is fur-
ther mobilized with the anticipation of dividing the left
transverse colon. The distal transverse colon is divided with
a linear stapler and the specimen, including the terminal
ileum, the cecum, the ascending colon, the majority of
the transverse colon and the omentum, is removed.
The terminal ileum and the left transverse colon
are anastomosed using either a handsewn or sta-
pled technique as described in the Right
Hemicolectomy chapter. Upon completion of the
anastomosis, the remaining mesenteric defect is
closed with interrupted 3-0 silk suture (3). The
abdomen is copiously irrigated with antibiotic containing
solution and the abdominal wound is closed in layers.
Laparoscopic Right Hemicolectomy
Operative Indications
The results from the National Cancer Institute–supported randomized clinical trial of open versus laparoscopic colon resec-
tion for right-sided colon cancers demonstrates that the indications for laparoscopic right hemicolectomy are identical to
open right hemicolectomy. In general, laparo-
scopic surgery is performed in the same manner
as open surgery just through smaller incisions.
Laparoscopic resection may be contraindicated
in patients with previous abdominal surgery or in
locally advanced tumors invading surrounding
Right
colon
Cecum
Right
colic a.
Ileocolic a.
1
Middle colic a.
SMA
structures. The operation includes division of the
ileocolic artery, the right colic artery (variable),
and the right branch of the middle colic artery and
a midtransverse colon anastomosis (1).
When right colon tumors are being considered
for laparoscopic resection, the surgeon must be
confident of the exact tumor location.
Localization can be accomplished in
two ways, either through four-quad-
rant India ink tattooing of the tumor
endoscopically or by localization on a
barium enema. Preoperative preparation
of the patient includes an optional mechan-
ical bowel preparation, intravenous antibiotics,
and prophylaxis for deep vein thrombosis.
Laparoscopic Right Hemicolectomy 327
Operative Technique
As in all laparoscopic procedures, positioning of the
patient is paramount to performing the operation. Gastric
and bladder decompression are performed to minimize the
risk of bowel or bladder injury and to maximize visualiza-
tion. The patient is placed in the lithotomy position with
the left arm tucked. The abdomen is prepped and draped
widely. The video monitors are placed near the head or
foot of the bed, and the operating surgeon stands at the
patient’s left side. Laparoscopic right hemicolectomy can
usually be performed with four ports: either all 10-mm
ports or two 10-mm ports and two 5-mm ports. The cam-
era port is inserted first. A vertical midline incision is made
below or just above the umbilicus. A Veress needle can
then be inserted and when low intra-abdominal pressure is
achieved, the abdomen is insufflated. Alternatively,
entrance to the abdominal cavity can be obtained by dissecting down to the peritoneum and entering the abdomen under
direct vision (Hasson technique). The Hasson technique is favored over the blind insertion of the Veress needle and tro-
car in patients who have had previous abdominal surgery. Once the abdomen has been insufflated, a 30-degree camera is
placed through the trocar and the abdomen is systematically explored.
The remaining trocars are inserted in the suprapubic region, the epigastrum, and the left lateral abdominal wall. The
procedure begins like an open right hemicolectomy with mobilization of the lateral peritoneal attachments. This is best done
with the operating surgeon and assistant, who is running the camera, standing at the patient’s left side. For the initial part
of the procedure, an atraumatic bowel grasper is used through the left port and the endoshears are used through the supra-
pubic port. Placing the patient in reverse Trendelenberg, with the right side of the abdomen slightly higher than the left,
will improve exposure.
328 Atlas of Gastrointestinal Surgery: The Colon
Grasping the appendix and gently retracting toward the left upper quadrant
assists in exposure of the lateral peritoneal attachments. These are divided
up to the hepatic flexure with endoshears (2). Gentle traction of the
appendix or mobilized colon applied toward the left will assist in
further mobilization. The electrocautery is rarely needed for
mobilization of the lateral peritoneal attach-
ments. If the plane between the
cecum and the retroperitoneum is
not initially apparent, the
Right colon
mobilized
appendix can be retracted
Cecum
Appendix
using an additional grasper
placed through the epigastric
port. This allows both oper-
ating instruments to apply
opposing traction to define
the correct plane.
2
Laparoscopic Right Hemicolectomy 329
Once lateral mobilization is com-
plete and the right colon has been
released from its retroperitoneal
attachments, the surgeon’s atten-
tion is turned toward ligation of
the vascular pedicles. The right
mesocolon is lifted up with a
bowel grasper placed on the
mesentery directly above the
origin of the ileocolic vessel.
Mesenteric defects are cre-
ated and the ileocolic vessels are
skeletonized (3).
Mesentery
Ileocolic
vessels
Right
colon
3
4
Ileocolic
vessels
The vessels are divided with a vascular linear stapler
or endoclips brought throught the left port (4).
330 Atlas of Gastrointestinal Surgery: The Colon
The duodenum and right ureter
should be visualized through the
mesenteric window (5).
Mesentery
Duodenum
Right
ureter
Ileocolic
vessels
(divided)
5
Right branch
of middle
colic a.
Laparoscopic Right Hemicolectomy 331
The remaining ascending
colon mesentery is divid-
ed with a LigaSure or
Harmonic scalpel intro-
duced through the suprapu-
bic or left port (6). If the
disease within the right colon
involves the omentum, it should
be taken en bloc with the colon.
Middle
colic a.
6
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