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238
S.A. Stein and R.C.M. Bergamaschi
a
29
b
. Fig. 29.3 Lifting the ileocolic vessel stump a to
identify the right ureter (arrow) b
. Fig. 29.6 Division of right branch of middle colic
vessels (arrow)
. Fig. 29.7 Transection of the transverse colon
. Fig. 29.4 Dissection along the superior mesenteric
vein up to Henle’s gastrocolic trunk. Duodenum (arrow)
. Fig. 29.5 Division of the omentum. Hepatic flexure (arrow)
. Fig. 29.8 Mobilization of the right colon
. Fig. 29.9 Transection of the terminal ileum
ab
Surgical Technique and Difficult Situations from Roberto Bergamaschi (Laparoscopic)
239
29
a
b
. Fig. 29.10 Stapled ileocolic anastomosis a and hand
sewing of enterotomy after stapler removal b
29.4 Pros and Cons of
Intracorporeal Ileocolic
Anastomoses
29.4.1 Pros of Intracorporeal
Ileocolic Anastomosis
Intracorporeal ileocolic anastomoses have the following potential advantages:
1. No need for mobilization of the transverse
colon to reach the abdominal wall allowing
anastomosing through a limited laparotomy as
in the case of laparoscopic-assisted technique.
2. Anastomosing away from the abdominal
(. Fig. 29.11a) wall could reduce the rates of
supercial and/or deep surgical site infection
(SSI).
3. No manipulation of the abdominal cavity by
the surgeon’s hands could reduce formation
of adhesions and hopefully rates of adhesive
small bowel obstruction.
4. A 50 % reduction of the extraction site incision length could lead to clinical benets such
as decreased pain and supercial and/or deep
SSI rates.
5. Laparoscopic visualization during the creation
of the anastomosis could reduce unrecognized
twisting of the terminal ileum mesentery.
29.4.2 Cons of Intracorporeal
Ileocolic Anastomosis
Intracorporeal ileocolic anastomoses have the following potential disadvantages:
1. Performing an intra-abdominal colotomy on
the transverse colon could increase the rates of
organ space SSI rates.
2. Patients undergoing intracorporeal ileocolic
anastomosis must drink and evacuate a bowel
preparation before surgery in order to minimize
fecal spillage through transverse colotomy and
contamination of the abdominal cavity.
3. Surgeons must have undergone training and
be procient in laparoscopic suturing with
intracorporeal knot tying.
. Fig. 29.11 Stapled/
handsewn anastomosis a
and anastomosis totally
stapled b
240
S.A. Stein and R.C.M. Bergamaschi
29
4. Longer operating time as compared to extracorporeal ileocolic anastomosing increases
indirect cost and may potentially lead to
higher complication rates.
5. Direct cost of intracorporeal anastomoses
may be increased when compared to its
extracorporeal counterpart, by the usage of
laparoscopic staplers instead of conventional
staplers and plastic bags for specimen
extraction instead of wound protectors,
respectively.
29.4.3 Totally Stapled Versus Stapled/
Handsewn Intracorporeal
Ileocolic Anastomosis
Potential disadvantages of totally stapled intracorporeal ileocolic anastomoses [4] include:
1. Everted anastomoses have potentially increased
risk of complications as opposed to their handsewn inverted counterpart.
2. It requires usage of 60mm long cartridge for
side-to-side anastomosing as stapling enterocolotomy inevitably excises tissue and
thereby reduces the nal size of the anastomosis.
3. It most likely requires an additional port if
performed on the transverse colon
(. Fig. 29.11b).
4. It does not obviate the need for intracorporeal
suturing as stay stitches are required to ensure
safe stapler application on the enterocolotomy.
5. It may require multiple rings depending on
the size of the enterocolotomy or whether the
previous stapled line is being excised.
6. It may lead to higher direct cost due to the
requirement of additional cartridges.
29.4.4 Iso- Versus Antiperistaltic
Intracorporeal Ileocolic
Anastomosis
29.4.5 Should the Mesenteric Defect
Be Closed?
Cabot et al. [2] published a 7-year prospective
review of 530 patients who underwent laparoscopic right colectomy in which the mesenteric
defect was not closed. During the 20-month
(median) follow-up period, 26 patients (4.9 %)
developed small bowel obstructions (SBO). Of the
26, 12 were treated nonoperatively and 14 underwent surgery. At re-operation, 4/14 (0.8 % of all
patients) were found to have an SBO due to the
unclosed mesenteric defect; (1) internal herniation and (2) torsion of the anastomosis through
the defect. ree of the four patients presented
with an SBO within 10 days of their initial surgery
and the fourth at 8 months aer surgery. e
authors concluded that their data do not support
routine closure of the mesenteric defect aer laparoscopic right colectomy for neoplasia.
29.5 Conclusions
Over time the surgical approach to right colon
resection has drastically changed, from open to
laparoscopic technique and from lateral to medial
to medial to lateral. As surgeons rene their laparoscopic skills and become experts, the prior
extracorporeal steps of the operation are being
performed intracorporeally. Change in a surgical
approach comes with close scrutiny and requires
support with literature. is paper broadly summarizes the surgical literature in regard to the
journey from facilitated laparoscopic to total laparoscopic right colectomy with intracorporeal
anastomosis. e literature has shown that a total
laparoscopic right colectomy is cost-eective and
reproducible and has similar complication rates
as laparoscopic right colectomy with extracorporeal anastomosis.
e conguration of intracorporeal ileocolic
anastomoses has been described as isoperistaltic
[3] and antiperistaltic [1]. It is unknown what
impact iso- and antiperistaltic congurations may
have on the likelihood of potential complications
such as anastomotic volvulus, leakage, internal
hernia, or others.
29.6 T4 Tumors and Alteration
of the Standardized Surgical
Approach
In the current literature, a controversy exists
between laparoscopic and conventional open
surgery for T4 tumors. In our experience, there
Surgical Technique and Difficult Situations from Roberto Bergamaschi (Laparoscopic)
241
29
exist ve instances with T4 tumors that require a
conversion of the standardized surgical
approach. For the rst three, we recommend
conversion from laparoscopic to conventional
open surgery:
1. T4 tumor invading the abdominal wall.
2. T4 tumor invading the kidney requiring en
bloc right nephrectomy.
3. T4 tumor invading the pancreas requiring en
bloc Whipple resection. e last two instances
in our experience are potentially able to be
performed in a laparoscopic manner.
4. T4 tumor invading the greater omentum
requiring complete omentectomy.
5. T4 tumor invading Gerota’s fascia requiring
enbloc resection of the right colon and the
fascia.
References
1. Bergamaschi R, Schochet E, Haughn C, Burke M, Reed J,
Arnaud JP. Standardized laparoscopic intracorporeal
right colectomy for cancer: short-term outcome in 111
unselected patients. Dis Colon Rectum. 2008;51:1350–5.
2. Cabot JC, Lee SA, Yoo J, Nasar A, Whelan RL, Feingold
DL. Long-term consequences of not closing the mesenteric defect after laparoscopic right colectomy. Dis
Colon Rectum. 2010;53:289–92.
3. Grams J, Tong W, Greenstein AJ, Salky B. Comparison of
intracorporeal versus extracorporeal anastomosis in
laparoscopic-assisted hemicolectomy. Surg Endosc.
2010;24:1886–91.
4. Ho Y. Laparoscopic right hemicolectomy with intracorporeal anastomosis. Tech Coloproctol. 2010;14:
359–63.
5. Schlinkert RT. Laparoscopic-assisted right hemicolectomy. Dis Colon Rectum. 1991;34:1030–1.
6. Senagore AJ, Delaney CP, Brady KM, Fazio VW. Standardized approach to laparoscopic right colectomy:
outcomes in 70 consecutive cases. J Am Coll Surg.
2004;199:675–9.
7. Young-Fadok TM, Nelson H. Laparoscopic right colectomy. Dis Colon Rectum. 2000;43:267–73.
Surgical Technique
and Difficult Situations
from Alain Gainant
(Conventional)
AlainGainant
30.1 Introduction – 244
30.2 Preparation – 244
30.3 Technique – 244
30.4 Intraoperative Complications – 246
243
30
30.5 Difficult Situations – 246
30.6 Conclusion – 247
References – 247
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI 10.1007/978-3-662-49878-1_30
30
A. Gainant
244
30.1 Introduction
e right hemicolectomy is dened as the excision of the colon vascularised by the superior
mesenteric artery. e resection includes the last
10 cm of the terminal ileum, the cecum, the
ascending colon, the hepatic exure and the right
third of the transverse colon. We carry out a
mobilisation of the colon before the ligation and
section of the vascular pedicles. In fact, the notouch isolation technique has not demonstrated
its ecacy [1]. One study suggests that it could
enable a reduction in frequency of hepatic metastases, but would increase that of systemic and
local relapses, and would have no eect on survival [2]. For these reasons, the initial ligation of
the vessels is not routinely recommended in
curative colectomies for cancer by the French
Society of Digestive Surgery [3]. e ileocolic
and right vessels are ligated at the origin from the
superior mesenteric artery and vein, respectively.
e central ligation of blood vessels which results
in an increased retrieval of lymph nodes and the
complete excision of the mesocolon (CME in
analogy to the TME concept) is recommended.
e CME is performed by carrying out a sharp
separation of the perineum of the mesocolon
(visceral fascia) from the retroperitoneal plane
with preservation of this fascia. With this concept, lymph node harvesting is maximised [4],
and the visceral fascia of the specimen of colonic
resection is intact. is is of prognostic relevance
[5]. is surgical technique has been shown to
decrease local recurrence rates [6]. Intestinal
continuity is then established by a side-to-side
stapled anastomosis.
. Fig. 30.1 Surgical approach. Patient in supine posi-
tion, transverse horizontal laparotomy
kThe surgical approach
is a horizontal incision of the right ank located
on a line passing two to three cm above the umbilicus (. Fig. 30.1). It runs from the right anterior
axillary line to 2cm to the le of the umbilicus.
is incision may be modied in its location and
its dimensions according to the shape of the abdomen. e peritoneal cavity is exposed via two
Rochard valves, one retracting the upper edge and
the other the lower edge of the incision.
kThe exploration of the abdomen
is the rst part of the procedure. It includes palpation of the liver looking for metastases not diagnosed preoperatively, examining the gallbladder
for stones, the whole of the colon to locate the
lesion and search other tumours and the peritoneum for carcinomatous nodules. e section of
any parietal adherences allows the exposure of the
whole right colon.
30.2 Preparation
No colon preparation is necessary for the right
colectomy. Intravenous antibiotic prophylaxis
with 2g of cefoxitin is given routinely at the time
of the abdominal wall incision. A nasogastric
tube is only inserted in the event of occlusive
syndrome.
30.3 Technique
e patient is placed in supine position. e surgeon stands on patient right side.
kMobilisation of the right colon
is starts with dissection of the terminal ileum,
by incision of the peritoneum at the pelvic brim.
en the caecum and the ascending colon are
mobilised by incision of the right parietal peritoneum by electrosurgical knife towards the hepatic
exure. e right mesocolon is then progressively
detached medially and upwards. is dissection
separates the visceral fascia and the extension of
the Gerota’s prerenal fascia (. Fig. 30.2). Leaving
intact the prerenal fascia and not visceral fascia
containing the ureter and the genital vessels, thus
preventing their injury. So it is possible to resect
the whole of the mesocolon. is detachment is
Surgical Technique and Difficult Situations from Alain Gainant (Conventional)
the colon is completed by the ligation and section
of the vessels of the transverse mesocolon and the
right branches of the middle colic artery. e
transection of the mesocolon is terminated at the
point chosen for the colic section. e great
omentum appended to the transverse colon is sectioned vertically opposite to this zone. Haemostasis
is carried out by suture ligation or thermofusion.
kThe ileo-colic anastomosis
is then performed. e terminal ileum and the
transverse colon are freed up from fatty attachments at the site of the future transection. Correct
. Fig. 30.2 Mobilisation of the right mesocolon: sepa-
ration of the visceral fascia of the Gerota prerenal fascia
( posterior)
continued up to the median line to the right of the
superior mesenteric vessels. e second and third
portions of the duodenum and the head of the
pancreas are visualised and separated from the
mesocolon and the mesentery.
e gastrocolic ligament is sectioned whilst preserving the right gastroepiploic artery and the
accompanying vein and nerve branches.
Haemostasis can be performed either by vascular
ligation or by using sealing device, Ultracision® or
LigaSure®. is section is continued as far as the
future transverse colic section, at the junction of its
right third and its middle third. is section meets
the previous plane of dissection.
kVascular sections
e terminal ileum, the ascending and transverse
colon, the right mesocolon and the transverse
mesocolon are exposed. e mesentery is transected 10 cm from the ileocolic junction. e
transection of the right mesocolon follows parallel to the right side of the superior mesenteric vessels. e incision extends vertically over the
transverse mesocolon. e superior mesenteric
vein is identied under the third portion of the
duodenum. e ileocolic vein is controlled with
suture ligation close to the superior mesenteric
vein. e ileocolic artery is individualised distal to
its origin and divided between sutures of slow
resorbable thread n°0. An intermediate artery
which is encountered in 10 % of cases is thus sectioned. ese vessels present anatomical variations which involve the ligation of all vessels
identied in the mesocolon to the right of the
superior mesenteric artery. e mobilisation of
vascularisation of the transverse colon opposite the
anastomosis zone is checked by viewing the arterial pulses. e lumen of the viscera is open on the
antimesenteric border with a cold scalpel so as to
view the satisfactory bleeding of the sections. e
intestinal openings are cleaned with antiseptic
solution, and any stool is removed from this zone.
e branches of the linear cutting stapler are introduced into the intestine. Interposition of the mesentery is ruled out. e stapler is closed and its
activation makes it possible to perform an ileotransverse side-to-side anastomosis. A slow resorbable monolament 4/0 suture is placed at the le
end of the staple line so as to secure it. Presentation
threads are then passed into the proximal extremities of the anterior and posterior staple lines and at
the lateral exures of the colic and ileal openings.
Staple lines are inspected intra-luminally. Bleeding
is common at the posterior staple line. is is why
the haemostasis is completed routinely by oversewing this staple line with a continuous suture of
slow resorbable thread 5/0 (. Fig. 30.3). If necessary, an identical continuous suture is passed over
the anterior staple line. e threads previously
placed enable the presentation of the staple zone of
the linear stapler. e non-cutting stapler is placed
horizontally, crossing the horizontal staple lines
so as to carry out an anastomosis in a closed V
(. Fig. 30.4) During this procedure, it must be
veried that the horizontal staple lines exceed the
linear stapler by 1–2mm and by palpation that the
lateral anastomosis has a diameter of at least
40mm. e colon and the ileum are sectioned with
Mayo scissors against the anvil of the linear stapler.
e section of the horizontal staple lines must be
observed. e completely released resected specimen is removed. e section is cleaned with antiseptic solution. Aer having removed the stapler,
the staple line is oversewn by a continuous suture
245
30
A. Gainant
246
. Fig. 30.3 Ileocolic side to side anastomosis: 4 presen-
tation threads allowed the intra luminal haemostasis on
the staple lines
kDuodenal injury
is due to excessive posterior dissection of the right
mesocolon. is risk is limited by the initial
mobilisation of the colon and the detachment of
the mesocolon, which makes it possible to
approach the second portion of the duodenum
from right to le. When a wound occurs, it must
be identied and sutured with separate stitches or
a continuous suture of slow resorbable thread 4/0.
Drainage via Delbet drain is le close to the
suture. If the wound is longitudinal, the transverse
suture avoids the risk of stenosis. If the suture is
not perfect, it is preferable to place into the duodenal perforation a biliary T tube (Kehr drain) n°
18, secured with a purse string suture and exteriorised transcutaneously.
30
. Fig. 30.4 Ileocolic anastomosis: stapled closure of the
colic and ileal openings, resulting in a functional end to
end anastomosis
of slow resorbable thread 4/0in order to complete
the haemostasis of the sections.
kThe mesenterico mesocolic breach
is closed with separate sutures of slow resorbable
thread. e intestinal loops are put back in order.
e preserved great omentum is placed against
the anastomosis. A non-aspirating drainage is
optional. e abdominal wall is closed layer by
layer with continuous sutures of slow resorbable
threads 0 and 1. A Blair Donati continuous suture
approximates the cutaneous edges.
30.4 Intraoperative Complications
e intraoperative complications that can occur during the right colectomy are injury to the duodenum,
the right ureter or the superior mesenteric vein.
kInjury to the r ight ureter
or the genital vessels is prevented by avoiding
opening of the retroperitoneum during mobilisation of the right mesocolon. e integrity of the
ureter must be checked routinely at the time of
this mobilisation. In the event of injury, repair is
carried out by suture with slow resorbable thread
5/0 over a ureteral drain. A bladder catheter will
be le in place for 8–10 days.
kInjury to the superior mesenteric vessels
can occur upon section of the right colic artery.
e superior mesenteric artery must therefore be
identied routinely and the section of its branches
performed 2cm to the right.
30.5 Difficult Situations
kTumours adherent to adjacent organs
Abdominal wall, stomach, bile duct, ileum, urinary tract, duodenum and pancreas. An en bloc
resection entails a total resection of the viscera
concerned, away from the tumour. ese resections are contraindicated in the event that the
superior mesenteric vessels are aected.
kInvasion of the abdominal wall
requires peritoneal and sometimes muscular
resection. e condition of the sections may be
checked by an extemporaneous anatomopathological examination, involving if necessary an
enlargement of the excision. In the event of stulisation of the skin, all the parietal layers must be
Surgical Technique and Difficult Situations from Alain Gainant (Conventional)
247
30
resected. e parietal reconstruction then requires
implanting a bioprosthesis in order to avoid evisceration and prevent the risk of incisional hernia.
kInvasion of the greater gastric curve
is conned to cancers of the transverse colon. An
atypical gastrectomy must then be carried out in
the zone of invasion within a safety margin of
3–4cm. In this circumstance, the section of the
gastrocolic ligament entails the right gastric vessels. e stomach is closed by continuous sutures
of slow resorbable thread or using a stapler. A
nasogastric tube is le in place.
kInvasion of the small intestine
requires a segmental resection, either by enlargement of the ileal resection or by segmental resection followed by an end-to-end anastomosis.
kInvasion of the gallbladder
is resolved by a cholecystectomy.
kAdherence to the liver
in the V segment indicates an atypical resection.
is is carried out aer colic mobilisation. e
liver parenchymatous section is performed in
accordance with the techniques of liver surgery,
usually without vascular clamping.
kInvasion limited to the second or third
duodenum
can be treated by atypical duodenal resection.
Digestive continuity is re-established by simple
suturing if the defect is less than 5cm. If it exceeds
this, it is necessary to carry out a duodenojejunal
Roux-en-Y anastomosis.
kInvasion of the duodenum or the pancreas
requires a cephalic duodenopancreatectomy.
Considering the extent of this excision, it must
only be considered if the patient’s condition
allows so and if the curative nature of the excision is certain. Otherwise surgery becomes
palliative.
One particular situation is represented by the
history of le colic resection for cancer that has
involved the sacrice of the inferior mesenteric
vessels. As the le colon is vascularised by the
superior mesenteric artery, it is imperative to preserve this and therefore to ligate the right colic
vessels close to the colon, verifying correct vascularisation of the remaining colon. e le colic
ischaemia would involve a total colectomy and an
ileorectal anastomosis.
30.6 Conclusion
e right hemicolectomy is a standardised procedure, carried out in the majority of cases for a
malignant lesion. e main diculties encountered are extension of the tumour to the neighbouring viscera, which involves an en bloc
resection in order to prevent perforation of the
colon and tumour cell spillage. Digestive continuity is re-established routinely. Open approach
is still indicated. Whilst the laparoscopic route
has demonstrated its feasibility and its safety, its
superiority over the transverse incision of the
right ank has not been established [7].
References
kInvasion of the urinary tract
can aect the right kidney or the ureter. If the renal
parenchyma is invaded, a nephrectomy must be
carried out once the presence and functionality of
the le kidney are ascertained. When the tumour
of the ascending colon is of posterior development,
the ureter must be identied above and below the
zone of adherence and dissected at this level. If the
invasion is suspected, a resection is necessary. If its
length is less than 5cm, ureteral reconstruction on
a ureteral catheter is possible aer mobilisation of
the ureter. If this cannot be done, a cutaneous ureterostomy can be carried out, with urinary continuity being re-established later.
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Cifuentes J. Experimental evidence does not support
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HM, Luyk CI, et al. No-touch isolation technique in
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1988;75:409–15.
3. Guidelines of the French Society of Digestive Surgery
and the French association of hepatobiliary surgery
and liver transplantation. 2009. Online. Thesaurus
national de cancérologie digestive. Chap 7. SNFGE.org
4. Mammen JM, James LE, Molloy M, Williams A, Wray
CJ, Sussman JJ. The relationship of lymph node
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5. Bokey EL, Chapuis PH, Dent OF, Mander BJ, Bissett IP,
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