Midline laparotomy, paramedian laparotomy and middle abdomen transverse laparotomy are most common approaches. All these incisions permit an adequate exploration. We believe that vertical incisions are more advantageous for patients with narrow inferior thoracic aperture. Contrary we prefer transverse laparotomy for obese patients with a broad distance between the right and le anterior axillary lines.

28.1.2 Exploration

For an adequate exploration, dierent wound retractor systems (Omni-Tract, Bookwalter, Rochard, Mercedes, etc.) will be used. In the abdominal exploration, a local tumour extent and availability of distant metastasis or peritoneal carcinomatosis will be evaluated. In dependence on the intraoperative ndings, the perioperative dened strategy will be upgraded. Technical difculties by this step can occur in patients with previous abdominal surgery and depend on the extent of abdominal adhesions. Accordingly a sufcient adhesiolysis is necessary for the adequate exploration. Strategical diculties related to the extent of resection can occur in patients with locally advanced tumours (see below).

28.1.3 Right Colon Mobilisation

This step consists from mobilisation of the terminal ileum, caecum, ascending colon and the right part of transverse colon. The technical and tactical problems can occur for the most part in patients with locally advanced tumours with infiltration of neighbouring organs especially the superior mesenteric vessels, duodenum and pancreatic head. In this regard, the preoperative performance of abdominal CT scan is obligated. With the planning of operation, the following questions should be discussed already preoperatively:

1. How extent should be applied en bloc resection (wedge resection or complete resection of involved neighbouring organs or structures)? In case of the correlation between an intraoperative nding and preoperative CT scan, the operation will be performed as planned. In case of deviation between CT scan results and intraoperative nding (intraoperative tumour adhesions or inltration is more extent than expected), en bloc resection should be aimed independent from inammatory or malignant type of inltration.

2. What kind of mobilisation (from lateral to medial or opposite) should be favoured for the locally advanced tumours? In such cases, we recommend using of “classic” mobilisation from lateral to medial.

3. When is a patient locally inoperable? From our point of view, an expanded tumour inltration of mesenteric vessels is a limited factor for R0 resection. Also a widespread tumour inltration of pancreatic lower edge is a risk factor for intraoperative tumour cell dissemination.

For the local, not advanced, tumour without serosal inltration, the most dicult situations can occur during the mobilisation of the right part of the transverse colon. Not gentle tractions can lead to tear of gastrocolic trunk of Henle with severe bleeding. For the better control of this complication, we recommend to perform a mobilisation of the right part of the transverse colon from medial to lateral. An opening of the bursa omentalis in the middle of the transverse colon allows a good exploration and dissection from all vascular gastrocolic structures from the middle of the transverse colon to the right colon exure.

Introduction

28.1.4 Transection of Vessels

e transection of vessels (ileocolic vessels, right colic vessels as well as colica media vessels in case of extended right hemicolectomy) is technically the most unproblematic; dicult decision situations are not common. Because of oncological requested high arterial ligation increases a risk of accidental injury of the superior mesenteric vessels. In order to avoid this complication, arterial and vein mesenteric superior should be identied for the transection.

28.1.5 Creation of Ileotransverse

Anastomosis

231

An ileotransverse anastomosis can be created using suture sewn by the hand or stapled end-toend, end-to-side and side-to-side anastomosis. is part of the operation is usually not connected with technical or strategical diculties.

Handsewn anastomosis will be created using one or two rows of sutures. Depending on the surgeon preference, dierential suture materials (resorbable, non-resorbable, mono- or multilament) will be used.

Stapled anastomosis will be created with a linear or circular stapler side to side or end to side. For the enterotomy closure, also a stapler but not a handsewn is recommended. With the creation of circular-stapled anastomosis, an anvil of circular stapler (25mm mostly) will be introduced in a terminal ileum. A stapler stab will be introduced in the transverse colon whereon a stapler pin will be broken through a tenia libera and end-to-side anastomosis will be created (. Fig. 28.1).

By using linear stapler, an ileotransverse anastomosis will be side to side with antiperistaltic position of the ileum created (. Fig. 28.2). An enterotomy will be also closured with linear stapler (. Fig. 28.3).

Dicult situations occur mostly in patients with a chronic small bowel ileus due to stenotic tumours. In such situation, it is sometimes problematic to create a safe anastomosis with severe dilatated terminal ileum with an oedematous and fragile wall. e question on “stapled anastomosis completely” or “handsewn anastomosis completely” or “mixed handsewn/stapled anastomosis” depends on intraoperative situation and surgeon preference and will be solved individually.

. Fig. 28.1 Creation of ileotransverse end-to-side

anastomosis with circular stapler

. Fig. 28.2 Creation of antiperistaltic ileotransverse

side-to-side anastomosis with linear stapler

. Fig. 28.3 Enterotomy closure

M. Korenkov et al.232

28.2 Laparoscopic Right

Hemicolectomy for Colon Cancer

Intraoperative steps are similar to the open

approach procedure; however, their order can con-

siderably deviate. Locally advanced tumours are a

contraindication for laparoscopic approach for

many surgeons. e technical performance of lap-

aroscopic right hemicolectomy is much more dif-

cult compared to an open approach. Accordingly,

this operation is related to more intraoperative

problems and dicult decision situations

28.2.1 Trocar Placement

e optic trocar will be placed most commonly

infra- or supraumbilical. Two working trocars will

be placed le from the midline. Number position

and size of trocars are very variable and depend

on the anatomical particularities and personal

surgeon preferences.

28.2.2 Transection of Vessels

A lot of surgeons started the right hemicolectomy

with transection of ileocolic vessels. It is almost

always possible to identify an ileocolic pedicle if a

patient will be placed in Trendelenburg position and

turned on the le. ereby the caecum should be

pulled in ventrolateral direction. Transection of ves-

sels can be performed between the clips, with energy

devices or with vascular stapler. e preparation of

ileocolic vessels can be performed as follows:

kPreparation Along the Ileocolic Pedicle from

Peripheral to Central

will be cut on both sides from the middle of the

vascular pedicle. Further preparation should be

performed in central direction to mesenteric

vessels. Aer the identication of it, the central

transection of ileocolic vessels should be performed.

is step is especially useful in patients with a fatty

mesocolon because it is easier to nd an ileocolic

pedicle than mesenteric vessels.

kPreparation Along the Mesenteric Vessels

ereby the mesenteric and colica media pedicles

will be identied at rst. en the peritoneum will

be cut along the mesenteric pedicle and the lateral

ereby the peritoneum

side of them will be prepared. Aer that, the ileocolic and right colic (if available) vessels will be centrally transected.

Technical problems and dicult situation can occur because of bleeding due to vessel injury. Venous vessels can be injured frequently due to a blind preparation, not gentle traction or thermic damage. Particular dicult intraoperative situation can take place during the injury of mesenteric vessels. Predisposing factors for these complications are very fatty meso and a bad exposition of a preparation plain.

28.2.3 Right Colon Mobilisation

is step has a lot of technical varieties as follows:

1. From medial to lateral

2. From lateral to medial

3. From bottom to top

4. From top to bottom

5. Combination from one to four

e most common combinations are from medial to lateral and from bottom to top. e best conditions for such preparation are a good exploration of ileocolic, mesenteric and colica media pedicles as well as the lower part of the duodenum. Aer transection of the ileocolic vessels, the preparation along a mesenteric pedicle has been carried out between the meso of the right colon and parietal sheet of the retroperitoneum in the direction of colica media pedicle. Depends on volumes of resection (standard or extended right hemicolectomy) the mobilisation of the transverse mesocolon will be performed oral- or aboral sides from the colica media pedicle. Aer division of peritoneal sheet, a mesocolon “window” will be created near the bowel wall and bursa omentalis will be opened. e greater omentum will be divided at the resection level. A farther mobilisation takes place either from top to bottom (right transverse colon → right colic exure → ascending colon → caecum → ileo- cecal area) or from bottom to top.

Technical problems and dicult decision situation can occur in the following cases:

1. Duodenal injury

2. Pancreatic injury

3. Vessel injury in the right part of the gastro-

colic ligament

4. Opening of the posterior peritoneal sheet and

retroperitoneal preparation

Introduction

233

28.2.4 Creation of Ileotransverse

Anastomosis

An ileotransverse anastomosis can be created either intra- or extracorporeal. For an extracorporeal anastomosis, a minilaparotomy (median supraumbilical or transverse in upper right abdomen) will be performed. is technique does not dier from the above described open technique. In obese patient, it is sometimes necessary to prolong a minilaparotomy incision that almost negates the advantages of laparoscopic technique. We recommend an extracorporeal approach for surgeons with not completed learning curve. With more experience, an intracorporeal anastomosis is preferable.

Technical problems and dicult decision situ-

ation can occur in the following cases:

1. Anastomotic tension

2. “Blue” anastomosis

3. Anastomotic torsion or kinking

4. Small diameter by end-to-end technique

In all these situations, a creation of a new anastomosis is necessary. In doubts about the quality of anastomosis, the indication to conversion should be given generously.

An intracorporeal ileotransverse anastomosis will be performed most commonly with a linear stapler side to side iso- or antiperistaltic. In isoperistaltic technique, an enterotomy closure will be performed with hand sewing. An enterotomy

aer antiperistaltic anastomosis will be closed with a linear stapler. We performed no preoperative colon cleansing for intracorporeal anastomosis.

An intraoperative testing of anastomotic leak with coloscopy is laborious and not routinely recommended. But meticulous visual inspection of all anastomotic segments is essential.

28.2.5 Removing of Specimen

e removing of specimen takes place via minilaparotomy by extracorporeal anastomosis technique or via a suprapubic approach by intracorporeal technique. Transumbilical, transvaginal or transrectal removing is not established as a standard access for oncological surgery. Technical problems and dicult situations may occur by discrepancy between the size of specimen and diameter of minilaparotomy. Because of a risk of tumour cell dissemination, every “powerful” traction of specimen should be avoided. If necessary, a minilaparotomy access can be adequately extended.

28.2.6 Classiﬁcation of

Intraoperative Diﬃculties

e operative diculty for oncological right hemicolectomy can be classied as summarised in . Table 28.1.

. Table 28.1 Grading of operative diﬃculties for oncological right hemicolectomy

Grading Case type

I (ideal cases) It is easy to operate; every operative technique is technically unproblematic

II (not quite ideal) Some minor technical diﬃculties may occur; some operative techniques can be more diﬃcult as others

III (problematic) Diﬃcult to operate, some operative techniques are considerably more diﬃcult than others

IV (very problematic) Every operative step is very diﬃcult

Slender or normal-weight patient No previous abdominal surgery

Moderate obese patient (BMI around 30 kg/m Cholecystectomy as a previous surgery Otherwise similar to grade I

Overweight patient (BMI > 35 kg/m Locally advanced tumours with: Inﬁltration of the right ﬂank peritoneum Inﬁltration of the duodenum Probable inﬁltration of mesenteric vessels or mesenteric root Probable pancreatic inﬁltration Previous oncological colorectal resection especially on combination with radiotherapy Previous extended upper abdomen surgery

Extreme form of grade III factors

)

235

Surgical Technique and Diﬃcult Situations from Roberto Bergamaschi (Laparoscopic)

SethA.Stein andRobertoC.M.Bergamaschi

29.1 Introduction – 236

29.2 Operating Room – 236

29.3 Surgical Technique – 236

29.4 Pros and Cons of Intracorporeal Ileocolic Anastomoses – 239

29.4.1 Pros of Intracorporeal Ileocolic Anastomosis – 239

29.4.2 Cons of Intracorporeal Ileocolic Anastomosis – 239

29.4.3 Totally Stapled Versus Stapled/Handsewn Intracorporeal Ileocolic Anastomosis – 240

29.4.4 Iso- Versus Antiperistaltic Intracorporeal Ileocolic Anastomosis – 240

29.4.5 Should the Mesenteric Defect Be Closed? – 240

29.5 Conclusions – 240

29.6 T4 Tumors and Alteration of the Standardized Surgical Approach – 240

References – 241

236

S.A. Stein and R.C.M. Bergamaschi

29.1 Introduction

Although laparoscopic-assisted right colectomy was first reported in 1991 [5], descriptions of a standardized surgical technique became available in recent years. The first, termed laparoscopic facilitated, consisted of a five-step lateral-to- medial approach with extracorporeal vascular ligation and ileocolic anastomosis [7]. The second, termed laparo- scopic assisted, included eight steps with a medial-to-lateral approach in which vascular ligation was performed intracorporeally while the anastomosis was fashioned extracorporeally [6]. Laparoscopic intracorporeal right colectomy entails ten steps with intracorporeal anastomosis followed by specimen removal in a bag [1].

29.2 Operating Room

Before starting the surgery, the patient is identified with a time-out prior to the induction of general anesthesia with endotracheal intubation. Patients then undergo placement of a nasogastric tube and urinary catheter. If the patient cannot tolerate general anesthesia, the procedure can be performed with a spinal or epidural with the addition of a transverse block. A mechanical bowel preparation is achieved by using 2 l of polyethylene glycol ingested orally during the day before surgery. Adequate intravenous access should be ensured. Broad-spectrum intravenous antibiotics are given. Sequential compression devices are applied to the legs. Patients are supine in a bean bag with the right arm abducted and the left arm tucked. The patient should be securely strapped to the table at the chest since tilting the table will be necessary. The abdomen is prepped and draped sterile. The surgeon and the scrub nurse stand on the patient’s left side, and the assistant stands on the patient’s right side (. Fig. 29.1) with equipment, including monitors, being placed on the patient’s right side in clear view of the surgeon. One assistant is needed to control the camera unless a robotic camera holder is available.

29.3 Surgical Technique

e abdomen and perineum are prepped and draped sterilely. e instruments used are all 5mm in diameter and over 40cm long including bowel graspers, scissors, right-angle forceps, and needle holders. An electrosurgical vessel-sealing device is used for division of vascular pedicles. e peritoneal cavity is accessed in an open fashion at the umbilicus. A reusable 10 mm port is placed at the umbilicus. A reusable 5mm port is placed in the right lower quadrant lateral to the rectus muscle sheath and at least 3cm medial to the right anterior superior iliac spine. A disposable threaded 12 mm port is placed in the le upper quadrant lateral to the rectus muscle sheath and rostral to the umbilicus. A reusable 5mm port is placed 3cm rostral to the pubic tubercle just le to the midline. A 30° scope (10mm in diameter) is placed at the umbilicus.

All steps of the operation are performed laparoscopically, including an intracorporeal handsewn anastomosis. e ten standardized sequential steps include:

1. Identication and division of the ileocolic

vessels (. Fig. 29.2).

2. Identication of the right ureter (. Fig. 29.3a, b).

3. Continued dissection along the SMV in a ros-

tral direction to Henle’s gastrocolic trunk

(. Fig. 29.4).

4. Division of the omentum and opening of the

lesser sac (. Fig. 29.5).

5. Identication and division of the right branch

of the middle colic (. Fig. 29.6).

6. Transection of the proximal transverse colon

with a laparoscopic stapler (. Fig. 29.7).

7. Hepatic exure mobilization and mobiliza-

tion of the mesentery of the ascending colon

as well as division of the line of Toldt

(. Fig. 29.8).

8. e terminal ileum is transected with a laparo-

scopic stapler and held by the assistant to pre-

vent rotation of its mesentery (. Fig. 29.9).

9. e table is leveled from the le lateral tilt; the

antimesenteric side of the stapled ends of the

transverse colon and terminal ileum is approx-

imated by a stay suture tied intracorporeally

and then held by the assistant; an antimesen-

teric enterotomy and an antimesenteric colot-

Surgical Technique and Diﬃcult Situations from Roberto Bergamaschi (Laparoscopic)

HEATING

CAMERA HOLDER

237

ULTRASONIC

DEVICE

IRRIGATION

WATER

. Fig. 29.1 Operating room setup

. Fig. 29.2 Ligation of ileocolic vessels

SURGEON

SCRUB NURSE

INSTRUMENTS

omy are made 10cm proximal and distal to the stapled ends of the terminal ileum and transverse colon, respectively; a side-to-side anastomosis is fashioned with a laparoscopic stapler; aer stapler extraction, the enterocolotomy is closed by two layers of sutures tied intracorporeally (. Fig. 29.10a, b): the rst of which is a continuous layer of 3-0 absorbable sutures and the second is a layer of interrupted 3-0 silk sutures; the mesenteric defect is le open.

10. e specimen is delivered in a bag through an enlarged umbilical port site.

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Further Reading

Individual Surgery for Right Hemicolectomy

Introduction

28.1.1 Approach

28.1.2 Exploration

28.1.3 Right Colon Mobilisation

28.1.4 Transection of Vessels

28.2.1 Trocar Placement

28.2.2 Transection of Vessels

28.2.3 Right Colon Mobilisation

28.2.5 Removing of Specimen

29.1 Introduction

29.2 Operating Room

29.3 Surgical Technique