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Right Hemicolectomy
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periumbilical vertical incision that will be later incorporated with the extraction
incision. A 5mm 0 degree laparoscope is used within a 5 mm direct visualizing
trochar to dissect the layers of the abdominal wall until omental fat is seen below the
trochar and the peritoneal layer is seen above. The abdomen is insufated to 15mm
Hg. The laparoscope is inserted, and the abdomen is inspected for injury during
insertion and for other intra-abdominal pathology which may preclude resection.
Additional 5mm ports are placed in the supra-pubic midline and in the left lower
quadrant; a third port can be placed for assistance in the left upper quadrant or in the
right lower quadrant, depending on the need during dissection.
The colon may be mobilized using either medial to lateral or lateral to medial
(Figs.6, 7, and 8) approach; we favor the medial to lateral approach. Advantages of
Fig. 6 Laparoscopic
lateral-to-medial
mobilization: the right
colon lateral peritoneal
attachments are incised
and the colon retracted
medially, anteriorly, and
cephalad to allow
dissection from underlying
retroperitoneal structures
including the right ureter
and gonadal vessels. The
psoas muscle and right
iliac vessels are also seen
Fig. 7 As with the open
dissection, the right colon
is lifted medially and
anteriorly, allowing
dissection of the third
portion of the duodenum,
which falls posteriorly as
the retroperitoneal
attachments to the colon
are divided
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Fig. 8 Lateral-to-medial
mobilization: after the
right colon has been
mobilized laterally, the
ileocolic vessels are
identied by elevating the
terminal ileum and cecum.
This allows creation of
mesenteric windows on
either side of the vessels
prior to division at their
origin
Fig. 9 Laparoscopic
medial-to-lateral
mobilization: after
identifying the terminal
ileum and cecum, the
vascular pedicle containing
the ileocolic vessels is
identied and elevated
C. Feizpous et al.
the medial to lateral approach include easier mesenteric dissection as the colon is
tethered to the abdominal wall rather than being free to move, earlier identication
and preservation of the ureter and gonadal vessels, decreased bleeding from early
control of vascular pedicles, and decreased manipulation of the diseased portion of
colon [14].
The operation is started by placing the omentum into the upper abdomen, and
completely unfolding the transverse colon if needed. The small bowel is retracted to
the right hemiabdomen, and these maneuvers together should expose the right
mesocolon. The patient may require a slight Trendelenberg position with the left
side tilted down to help facilitate this. The terminal ileum or ileocecal region is
grasped with an atraumatic grasper and elevated to the right lower quadrant, which
should place the ileocolic vascular pedicle under tension (“bowstring”), facilitating
its identication (Fig.9). The peritoneum overlying the mesentery is incised at the
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groove below the vessel in a parallel direction along the vessel. The avascular fusion
plane between the mesentery and the retroperitoneal fat is identied and swept
down. During this process the duodenum will be identied on the medial side of
dissection and care should be taken protect the duodenum and minimize manual
manipulation (Fig.10). Dissection is considered adequate at this point if the duodenum is separated well enough away from the base of the ileocolic artery so that a
high ligation of the vessel can be performed safely. We also will usually extend our
medial dissection our to the hepatic exure and along the proximal transverse colon
and we are able to identify the back wall of the transverse colon. The ileocolic vessels are then divided with a stapler or energy sealing device (Fig.11). Once they are
divided, medial dissection continues to further separate the retroperitoneum off of
the mesentery.
Fig. 10 Medial-to-lateral
mobilization: the
mesentery is incised
around the vessels. Careful
dissection is carried out to
identify the duodenum and
sweep the retroperitoneal
structures posterior
Fig. 11 Medial-to-lateral
mobilization: the ileocolic
vascular pedicle is isolated
allowing safe division of
the vessels at their
mesenteric origin. Once
divided, mobilization of
the lateral peritoneal
attachments of the right
colon is performed
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C. Feizpous et al.
Attention is then turned to the lateral portion of the dissection. The colon is
returned to its normal anatomic position, and then the cecum and appendix are
retracted anteriorly and to the right to allow incision of the lateral peritoneal attachments. As these are taken down, this allows the surgeon to join the prior medial
dissection. This is taken up to the hepatic exure where the duodenum is again
identied and protected as dissection proceeds cephalad. The patient is then transitioned to slight reverse trendelenberg if needed to mobilize the omental attachments
off of the proximal transverse colon. If the omentum will be included in the specimen, the distal division point on the transverse colon is used as a landmark, and the
omentum is split using the energy device up to this point. This dissection is begun
at approximately mid transverse colon and taken proximally back towards the
hepatic exure. The colon should then be retracted towards the feet to help gain
traction on the hepatic exure. Again care is taken to identify the rst portion of the
duodenum as it will be posterior to this dissection. Mobilization is adequate when
the right colon is separated from its lateral attachments and can be brought towards
the midline.
The proximal colon is then secured with laparoscopic graspers and the periumbilical port site incision is extended to create space for specimen extraction. A
small wound protector is placed and the specimen is extracted. After conrming that
a tension free anastomosis can be performed, then this is done using the Barcelona
technique or the surgeon’s preferred technique, as described previously. Closure of
the large mesenteric defect is not necessary and can be left open with very low risk
(−0.5%) of internal hernia [15]. The anastomosis is then replaced back into the
abdomen, which is irrigated and inspected for bleeding. The fascial incision is
closed with absorbable suture, and the skin and remaining port sites are closed. The
anastomosis may also be performed intracorporeally which allows for a more exible choice of extraction site, such as via a. Pfannenstiel incision, to reduce incisional hernia rate. After the specimen is mobilized it can be divided intracorporeally.
On the proximal transection point at the small bowel the peritoneum overlying the
mesentery is scored up towards the edge of the bowel wall. A vessel sealing device
is used to divide the mesentery from the cut edge of the ileocolic artery up towards
the bowel wall at the planned transection point. A laparoscopic stapler is then used
to divide the small bowel. This is similarly done on the colonic distal transection
point. Once the specimen is separated, it is placed up over the liver for later retrieval.
The anastomosis can be performed in a side-to-side iso-peristaltic or antiperistaltic fashion. The two stapled ends of the bowel are aligned to allow for an
approximately 6cm anastamosis. Optional stay sutures can be placed to facilitate
this placed on either side. A small enterotomy and colotomy are made through
which the stapler is passed through and red. This is typically done via a 12mm
trocar in the left upper quadrant. The common enterotomy is then closed with a 2-0
or 3-0 absorbable, barbed suture in two layers. The rst layer is a running full thickness layer directed away from the surgeon and then the second layer ran back
towards the surgeon in a Lembert fashion. Alternatively, the common enterotomy
can be closed with stay sutures and another stapler re.
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5 Robotic-assisted Right Colectomy
Use of the robotic platform is growing in popularity. The advantage over laparoscopy
includes endowrist manipulation and full control over all instruments including the
camera which can be helpful where there is limited assistance. In a large comparison
of robotic versus laparoscopic colectomy from a cancer database, the robotic approach
was associated with slightly shorter length of stay and lower conversion to an open
operation. Short and long term survival were similar as well as complication and
readmission rates [16]. In morbidly obese patients with foreshortened, thickened
mesenteries, there may a technical advantage with the robotic approach, assuming an
intracorporeal anastomosis is planned. In this case, exteriorization of the specimen
for the anastomosis is not required. As a result, surgeon does not need to mobilize the
transverse colon extensively, nor does he/she have to contend with short mesentery.
However, a key disadvantage of the robot is the lack of haptic sense requiring
increased reliance on visual cues. A key change in set up for robotic case compared
to laparoscopy is the port placemen [17]. We choose to place the ports in an oblique
line across the abdomen from the left upper quadrant to the a supra-pubic position.
We will generally begin in the left upper quadrant with a closed technique entry, using
a Veress needle. Once abdominal access and pneumoperitoneum have been established via an 8mm robotic trocar in that same position, we then array our ports into
the aforementioned oblique line, beginning in the suprapubic position, along a
planned Pfannensteil extract site. The distance between these two ports is then evenly
split for the remaining 8mm robotic trocar, and 12mm robotic trocar to allow for the
stapler, targeting 6–10cm between each port. Optionally, an assistant 5mm trocar or
Airseal device is placed in the left lower quadrant. The omentum is place cephalad
and the small bowel moved down into the pelvis laparoscopically before docking the
robot from the patient’s right side. The patient is then positioned appropriately and the
robot is docked. The remainder of the procedure is as described previously, including
an intracorporeal anastatomosis. Extraction can occur either via a Pfannensteil incision or via the 12mm robotic trocar site which would be opened further.
6 Further Innovations
Variations of minimally invasive surgery are also described. This has included a
single incision laparoscopic right hemicolectomy. For this technique, a gel port or
specially formatted port allowing insertion of multiple instruments is placed in the
abdomen at the umbilicus. The case is then performed as described above. The
specimen is then retrieved through the umbilicus, with the bowel exteriorized and
anastomosis performed. A recent meta-analysis of nine comparative studies revealed
no signicant difference in postoperative outcomes or oncologic results with single
incision laparoscopic right hemicolectomy compared to the standard laparoscopic
approach, though prospective randomized studies are lacking [18].
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C. Feizpous et al.
7 Postoperative Care
Patients are admitted to the general care oor for postoperative monitoring and pain
control. A nasogastric tube is not utilized. Early mobilization should be encouraged,
and deep vein thrombosis prophylaxis should be continued. In appropriate patients,
non-steroidal anti-inammatory medications and other non-narcotic modalities of
analgesia should be included to minimize narcotic requirements. A liquid diet can
be started early postoperatively, and the diet advanced upon full return of bowel
function. Patients can anticipate a 3–5day hospital stay and are ready for discharge
upon return of bowel function, tolerating oral intake, ambulating, and appropriate
pain control. Complications include wound infection, prolonged ileus, and anastomotic leak.
References
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11. Toyota S, Ohta H, Anazawa S.Rationale for extent of lymph node dissection for right colon
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13. Russell KW, O’Holleran BP, Bowen ME, Mone MC, Scaife CL. The Barcelona technique
for ileostomy reversal. J Gastrointest Surg. 2015;19(12):2269–72. https://doi.org/10.1007/
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Sigmoid Colectomy
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MariaUnuvar andRebeccaL.Hoffman
1 Indications
The sigmoid colon, named for its characteristic “S” shape, is subject to various
benign and malignant pathologies. A sigmoid colectomy (also known as sigmoidectomy) is removal of this portion of the colon. The most common indications for this
procedure include malignancy (Fig.1) and diverticulitis. Other indications include
sigmoid volvulus, polyps, ischemic or infectious colitis, and rectal prolapse. The
Fig. 1 Axial slice of CT
abdomen/pelvis with
intravenous (IV) contrast.
Dotted circle highlights an
“apple core” lesion as an
example of malignant
pathology requiring
sigmoid colectomy
Sigmoid
M. Unuvar (*) · R. L. Hoffman
Department of Surgery, Division of Colon & Rectal Surgery, Geisigner Medical Center,
Danville, PA, USA
e-mail: munuvar@geisinger.edu; rlhoffman@geisinger.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_26
Rectum
321© The Author(s), under exclusive license to Springer Nature
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extent of sigmoid resection (i.e., focal or complete) is determined by the presenting
pathology. Complete segmental resection is performed for malignant conditions and
includes transecting the inferior mesenteric artery (IMA) at its origin. This provides
superior lymph node harvest for pathologic examination. Focal segmental resection,
in contrast, is performed for benign conditions and includes division the vessels
closer to the bowel wall without the need for high ligation of the IMA.There are
also a variety of surgical approaches to sigmoid resection including open (exploratory laparotomy), laparoscopic, hand-assisted laparoscopic, and robotic. The
choice of procedure depends on the acuity of the patient’s disease (i.e., elective vs
emergent), the degree of technical challenge due to adhesive disease and/or longterm inammation, and the surgeon’s preference.
M. Unuvar and R. L. Hoffman
2 Preoperative Evaluation andPatient Preparation
Preoperative evaluation starts with a history and physical exam. History taking
should elicit patients’ prior issues with incontinence, sexual dysfunction, personal
and family history of polyps or cancer (including gynecologic cancers), inammatory bowel disease, or diverticulitis. A focused abdominal exam should be performed, taking care to identify any surgical scars present on the abdomen. A digital
rectal exam should be performed and sphincter function assessed, specically noting the patient’s level of sensation, tone, and voluntary contraction of the anus.
In-ofce rigid proctoscopy can be considered for lesions within 20 cm of the
anal verge.
A pre-operative CT of the abdomen and pelvis should be obtained with intravenous (IV) contrast, at minimum, but preferably also with oral (PO) contrast. In
cancer cases, a CT chest should also be obtained for staging purposes. If the procedure is to be done on an elective basis, preoperative endoscopy is key. When feasible, a complete colonoscopy should be performed rather than limited evaluation
with exible sigmoidoscopy. Biopsy of any lesions encountered should be performed with tattooing distal to any lesions that are likely to require resection based
on appearance. Marking lesions with ink at 3 points circumferentially is critical for
intraoperative tumor localization. If not completed at the initial diagnostic colonoscopy, repeat endoscopy is often indicated for this purpose. Additional endoscopic
ultrasound (EUS) or magnetic resonance imaging (MRI) may be benecial for
tumors near the rectosigmoid junction to properly characterize them as either colon
cancer or rectal cancer. Barium enema may also be indicated in the workup of a
sigmoid volvulus.
Enhanced recovery after surgery (ERAS) programs have standardized pre-,
intra-, and post-operative care of colorectal surgery patients. Implementation of
these protocols are associated with accelerated recovery and reduced length of stay,
decreased complications and morbidity, reduced readmission rates, and cost savings
when compared with traditional care [1–6]. The goal of these programs is to improve
overall post-operative outcomes by minimizing the stress response and reducing
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end organ dysfunction perioperatively. Preoperative strategies include medical risk
assessment and optimization when indicated, patient education including stoma
management (if planned), and mechanical bowel preparation. Patient education is
central to the success of these programs. A patient’s social and behavioral habits
such as tobacco use should also be addressed. The patient should be encouraged to
stop use of tobacco at least 6–8weeks prior to surgery to minimize the negative
effects on anastomosis and wound healing. Patients should also be given information on routine postoperative care and a list of signs or symptoms that would warrant prompt evaluation after discharge. The preoperative fasting guidelines should
be discussed. ERAS protocols minimize the fasting period. Although no solid foods
or full liquids are allowed within 6–8h, clear liquids are encouraged up to 2 h before
surgery. Some protocols prescribe a carbohydrate-rich drink 2 h prior to the procedure in order to reduce insulin resistance and post-operative weight loss, without a
demonstrated increase in complication rates [7, 8]. Mechanical bowel preparation
before colorectal surgery has been shown to reduce surgical site infections, anastomotic leakage, and hospital readmission [9]. This is usually accomplished with a
polyethylene glycol solution in combination with oral antibiotics the day prior to
planned surgery. Alvimopan is a medication given to patients before surgery to
reduce opioid-associated ileus post-operatively, though this cannot be used for
patients on chronic opioid medications [10]. Multimodal pain control strategies also
start in the preoperative period to minimize the need for perioperative narcotics.
These strategies include administration of combinations of acetaminophen, gabapentinoids, and opioids such as tramadol, which have a reduced side effect prole.
As always, informed consent should be obtained by giving patients important information regarding the planned procedure, including risks, benets, and alternative
options. Deep venous thrombus prophylaxis is initiated preoperatively by placement of sequential compression devices (SCDs) and subcutaneous heparin injection.
General anesthesia is induced on arrival to the operating room with placement of
an endotracheal tube. An orogastric tube is typically placed for decompression of
the stomach, and a Foley catheter is placed for decompression of the bladder and
intraoperative monitoring of uid and resuscitation status. The patient’s arms are
generally tucked at their side. For all operative approaches, access to the anus for
colorectal anastomosis is achieved by placing the patient in a modied lithotomy
position with the toe, knee, and contralateral shoulder aligned and thighs parallel to
the ground. The legs should be padded to cushion any pressure points, with special
attention paid to the posterolateral leg to protect the peroneal nerve from palsy or
injury. Alternatively, a split leg table attachment may also be used to facilitate access
to the anus. The patient should be placed on a pad which reduces slippage when
steep Trendelenburg is introduced. Prophylactic antibiotics must be administered
within 60 min prior to skin incision. For colorectal surgeries, the recommended
agents include cefazolin, ceftriaxone with metronidazole, cefoxitin, cefotetan,
ampicillin-sulbactam, or ertapenem [11]. These should be re-dosed as needed during the procedure. The indications for placement of ureteral stents to assist with
intraoperative identication of the ureter or inadvertent ureteral injuries are not
clearly dened, but is often performed in re-operative cases, patients with history of
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