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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_841_Библиотеки_им_академика_М_И_Перельмана.pdf
249
Surgical Technique
andDicult Situations
fromWerner Hohenberger
(Conventional)
WernerHohenberger
31.1 Introduction – 250
31.2 Preparation – 250
31.3 Surgical Technique – 250
31.4 Extended Right Hemicolectomy – 253
31
References – 253
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_31
31
250
W. Hohenberger
31.1 Introduction
With any operation, specically in oncologic surgery, one will frequently nd a diering individual situation, depending upon the site of a tumor,
its regional extension, anatomical variations, or
sequelae of previous operations. However, even
relevant comorbidity like right heart failure or
portal hypertension due to liver cirrhosis may
increase the complexity with dilated veins of the
intestine or in the retroperitoneum.
Nevertheless, despite all of that, any operation
needs to be accomplished in a standardized manner with a clear objective, strictly following the
demands of oncologic surgery. Unfortunately, this
is not yet achieved by far for right and transverse
colon cancer [1, 3–5].
31.2 Preparation
ere is increasing evidence that preoperative
bowel cleansing reduces postoperative complications, will avoid intra-abdominal stool contamination, and may even have an impact on oncologic
outcome.
e patient is positioned on a normal table.
e procedure starts with an adequately long
median incision, to get unrestricted access to all
quarters of the abdominal cavity, especially if individual circumstances need extended exposure.
31.3 Surgical Technique
ere is clear evidence that rst of all tears by
blunt dissection or incisions down to the muscularis propria plane of the colon involved by a
tumor or even more of the tumor itself during
developing the specimen reduce the prognosis of
these patients, tremendously.
erefore, any blunt preparation at any step
during the surgical procedure is strictly forbidden.
Only sharp dissection using diathermy, scissors, or
any other suitable instruments allowing calculated
separation of the anatomical layers can be accepted.
If there is a tumor xed to what neighboring
organ or structure ever, whether it is a small
bowel loop or the pancreatic head, from the
beginning a multivisceral en bloc resection has
to be started, without trying to resolve these
xations or “adhesions.” If the abdominal wall is
. Fig. 31.1 Mobilization of the right colon for a right
hemicolectomy. The tip of the forceps grasps the parietal
plane (Gerota’s fascia). The assistant provides countertraction and opens against the traction of the surgeon the
areolar tissue resulting from air sucked. This is the line to
be continuously incised by sharp dissection
involved, a circumferential margin of 1cm is
sucient. It is important that even during the
exploration careful maneuvers have to be
applied, including the assistant’s manipulations
to avoid any shaving or tearing of tumor invasions in the sense mentioned above.
5 is needs well-dosed traction and counter-
traction, to expose the incision line properly
. Fig.31.1). In this context, it increases safe
(
plane preservation, if the assistant uses a
compress, for example, to cover the tumor
under his ngers to avoid tears.
5 Personally, a later/caudal to medial/cranial
approach is performed, starting the incision
from the peritoneum lateral and parallel to
the cecum and the ascending colon and later
on along the descending part of the duodenum. Right from the beginning, the surgeon
has to have in his mind that with the rst
incision, the parietal plane and the ascending
mesocolon will be exposed and damage to
both may occur immediately by blunt or
crude dissection.
5 e correct plane for dissection presents as
areolar tissue (“angel’s hair”) due to air sucked
by the distraction. is is the line to follow
with additional incision of the mesentery
medially including the so-called Treitz ligament, which is nothing else but a duplication
of the mesentery. is procedure includes the
duodenum and the pancreatic head, which
are taken from the parietal plane, too
Surgical Technique andDicult Situations fromWerner Hohenberger (Conventional)
251
31
. Fig. 31.2 The entire right colon including the mesen-
teric root and the duodenum with the pancreatic head are
mobilized. The last bands of the Treitz ligament (= transition of the mesentery to the mesoduodenum) are going
to be divided. The forceps grasps the intact parietal plane
covering the retroperitoneal organs (kidney with the fat
around, gonadal vessels, ureter). Next, the aorta and the
vena cava will be visible. They all remain protected by this
plane, why the ureter does not need to be taped
(“Kocher maneuver”), also covered by the
mesoduodenum and mesopancreas as the
“meso” is a continuously running plane.
Finally, the entire right colon with the tumor
and the mesenteric root with the small bowel
loops are completely mobile and can be
brought in front of the abdominal wall
achieving absolutely free access even in very
obese patients (. Fig.31.2).
5 This dissection includes two important
issues:
5 Strict preservation of the mesocolon for onco-
logic reasons.
5 Also saving the parietal plane to avoid bleed-
ing, for example, by lesions of the gonadal vessels. As this plane covers a part from the aorta
and the vena cava also the ureter, it can never
be injured, if the plane of dissection was correctly followed, and therefore it must never be
taped in normal cases.
5 e next step is to take down the uncinate
process of the pancreas from the ascending
mesocolon until the sup. mesenteric vein is
exposed, just covered by the mesocolon. Frequently the exposure is better and orientation easier if simultaneously the greater
omentum is dissected o the right exure
and the transverse colon (see the following
steps).
. Fig. 31.3 The duodenum and pancreatic head includ-
ing the uncinate process are fully mobile; the superior
mesenteric vein lies right in front of the surgeon’s eyes,
without any twisting. The tip of the forceps keeps the
mesocolon, which needs to be split, actively, as it covers
in a semicircular manner the sup. mesenteric vein, to get
access to the root of the ileocolic vein, next
To get now access to the roots of the colic veins
and the corresponding arteries, thereaer, the
mesocolon covering the sup. mesenteric vein has
to be split, actively right over and not lateral to the
vessel (. Fig. 31.3), until the right and usually
aerward the middle colic vein, too, are exposed
right at their origin.
5 e greater omentum is taken down, now
from the hepatic exure and the right half of
the transverse colon. It must not be resected,
if it is not attached to the part of the ascending colon involved by the tumor. e preparation itself is again performed by sharp
dissection between the lower sheet of the
mesomentum attached to the mesocolon
until the lesser sac is completely open.
During this dissection on the right site close to the
hepatic exure, the surgeon must be alert and
aware of the detailed anatomy of the veins and their
conjunctions (Henle’s loop): in about 90 %, the
right colic vein is crossing the plane of dissection
joining the right gastroepiploic (= gastroomental)
vein, frequently together with the middle and an
accessory right one [2]. If the mobilization was not
performed as recommended above and the duodenum not taken down from the ascending mesocolon and the assistant did not relieve traction on the
mesocolon, severe bleeding by tearing o these
vessels may occur and may be dicult to stop. If,
however, all structures are fully exposed, even a
broad tear can be stopped by a vascular suture.
252
W. Hohenberger
a
31
b
. Fig. 31.4 a The variation shown in this case with
direct junction of the right colic vein with the superior
mesenteric vein, will be found in just about 10 %. In
the vast majority, these vessels join the right gastroepiploic vein creating the gastrocolic trunk (Henle’s loop)
b. Frequently, even the middle colic vein or additional
veins form the right side may even join. This junction has
to be precisely dissected with central tie of all colic veins
to get free access to the sup. mesenteric vein. Otherwise,
tears may happen with severe bleeding
Sudden bleeding during these steps from the depth
of the right upper abdomen always results from more
or less extended tears of these vessels due to inadequate
traction on the right colon. erefore, these veins must
be dissected completely and well exposed with central
tie mainly of the right colic vein at its conjunction with
the right gastroepiploic vein (. Fig.31.4).
5 Usually, the ileocolic vein is centrally divided
next. Quite frequently, the corresponding
artery crosses the sup. mesenteric vein from
below and presents, therefore, rst
(. Fig.31.5). en, the middle colic vein is
completely exposed; however, for a right
hemicolectomy (cecal and ascending colon
cancer), just the branches running to right
will be divided later on. Now, the anterior and
le lateral wall of the sup. mesenteric vein is
. Fig. 31.5 Central division of the ileocolic artery, which
frequently crosses the sup. mesenteric vein from below.
The ileocolic vein is behind and will be tied afterward
. Fig. 31.6 The middle colic vessels are exposed. The
branches running to the right will be divided next, ush
with the main trunks. The mesocolon toward the bowel is
already split, the sup. mesenteric vein freed; the stumps of
the ileocolic vessels are close to the nger of the assistant
with the central partly dissected already
freed and the sup. mesenteric artery exposed
with the central tie of the ileocolic artery. e
autonomous nerves covering the main artery
must be strictly preserved. Otherwise, intractable diarrhea will follow.
5 Aer the ileocolic vessels are divided and the
middle colic once exposed, the transverse
colon is transected, usually right over the root
of the middle colic vessels. en the branches
coming o to the right are centrally tied
. Fig.31.6). Sometimes it is helpful to tape
(
the root of the middle colic artery, mainly for
better manipulation.
5 Next, the terminal ileum is divided about
eight cm proximal to the Bauhin valve, with
Surgical Technique andDicult Situations fromWerner Hohenberger (Conventional)
. Fig. 31.8 A right hemicolectomy specimen for an
ascending colon cancer with invasion of the abdominal
. Fig. 31.7 Central lymph node dissection for a trans-
verse colon cancer is completed. Therefore, the middle
colic vessels are divided, too, with removal of the lymph
nodes over the pancreatic head and the inferior aspect of
the pancreas
wall. The planes are fully preserved (mesocolic plane
preservation) without any tear, complete “package” of the
tumor and long vascular pedicles
253
31
radial incision of the mesentery down to the
root of the sup. mesenteric artery with preservation of the autonomous plexus, which
may sometimes even serve as a plane-like
structure when dissecting centralward to the
root of the middle colic artery. e right colic
artery exists also infrequently with about
15 %. During this step, the central mesenteric
lymph node dissection is completed
(. Fig.31.7).
5 e following anastomosis is fashioned as an
end-to-end extramucosal running suture
with closure of the mesenteric slit.
Only if relevant intra-abdominal secretion is
assumed postoperatively, for example, if a patient
had liver cirrhosis with ascites or aer multivisceral
resections including the pancreas, an intraabdominal drain is applied. With a routine case,
however, this is not necessary.
31.4 Extended Right
Hemicolectomy
Cancer of the hepatic exure and the transverse
colon needs a more extended resection including the lymph nodes over the pancreatic head
and/or those along the inferior aspect of the
pancreatic corpus and tail and the greater omentum as well including the arcade of the right gastroepiploic artery (. Fig.31.8). e middle colic
artery is always divided, centrally. e extent of
colonic resection to the le side with central tie
of the supplying arteries is based on the 10cm
rule: there are never pericolic lymph node
metastases beyond this distance to both sides of
the tumor. e open question, however, is
whether the following vascular arcade needs to
be included or not. As demonstrated by this
specimen, the more radical approach is personally always performed.
References
1. Hohenberger W, Weber K, Matzel K, etal. Standardized
surgery for colonic cancer: complete mesocolic
excision and central ligation – technical notes and
outcome. Colorectal Dis. 2009;11:354–64.
2. Jin G, Tuo H, Sugiyama M, Oki A, Abe N, Mori T, Masaki
T, Atomi Y.Anatomic study of the superior right vein:
its relevance to pancreatic and colonic surgery. Am
JSurg. 2006;191(1):100–3.
3. Quirke P, Steele R, Monson J, et al. MRC CRO7/NCICCTG CO16 Trial Investigators; NCRI Colorectal Cancer
Study Group. Eect of the plane of surgery achieved
on local recurrence in patients with operable rectal
cancer: a prospective study using data from the MRC
CR07 and NCIC-CTG CO16 randomised clinical trial.
Lancet. 2009;373:821–8.
4. West NP, Kobayashi H, Takahashi K, Perrakis A, Weber
K, Hohenberger W, Sugihara K, Quirke P.Understanding
optimal colonic cancer surgery: comparison of
Japanese D3 resection and European complete
mesocolic excision with central vascular ligation. JClin
Oncol. 2012;30(15):1763–9.
5. West NP, Hohenberger W, Weber K, et al. Complete
mesocolic excision with central vascular ligation
produces an oncologically superior specimen compared
with standard surgery for carcinoma of the colon. JClin
Oncol. 2010;28:272–8.
255
Surgical Technique
andDicult Situations
fromStefano Saad
(Laparoscopic)
StefanoSaad
32.1 Introduction – 256
32.2 Patient Preparation – 256
32.3 Operation Technique – 256
32.4 Reconstruction Phase – 258
32.4.1 Intracorporeal Anastomosis (Ileotransversostomy) – 258
32.4.2 Extraction oftheColon Specimen – 258
32
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_32
32
S. Saad
256
32.1 Introduction
In case of colon cancer, the technique of right
laparoscopic hemicolectomy can be used with
curative and palliative intention. e indication
for laparoscopic colon resection for malignancy is
similar to the open approach. However, the surgeon has to be aware of the general contraindication for laparoscopic surgery like multiple
previous operations in the abdominal cavity. e
laparoscopic oncological colon resection may not
be considered in cases of T4 tumors with large
masses or inltration in neighboring organs.
32.2 Patient Preparation
e preoperative patient workup for laparoscopic
right hemicolectomy is similar to patients who are
planned for open right hemicolectomy. Usually total
colonoscopy with pathologic biopsy of the tumor is
performed preoperatively. Additionally abdominal
ultrasound and CT scan of the abdomen are done.
Aer radiologic imaging, the surgeon can decide
whether or not a laparoscopic approach for oncological right hemicolectomy can be performed.
When we plan to do an intracorporeal anastomosis of the bowel, we think that preoperative
bowel preparation of the patient is essential. In
selected cases, when tumor size is small, we ask
the gastroenterologist for an ink mark of the
tumor in order to easily identify the tumor during
the laparoscopic procedure.
In the operating room, the patient is placed in a
supine position on the operating table with the
right arm tucked to the side. In the modied lithotomy position with low stirrups, the patient position
can be changed during the operation. e operating table needs to be rotated to the le to move the
small intestine out of the pelvis. Most of the time
during the operation, the patient is in Trendelenburg
position. e surgeon stands on the right side of
the patient and the rst assistant between the legs
or vice versa. e monitor is positioned above the
head of the patient or on his right side.
32.3 Operation Technique
Pneumoperitoneum is induced with the help of a
Veres needle which is placed below the le rib bow.
e pressure induced by the pneumoperitoneum
. Fig. 32.1 Trocar placement for right hemicolectomy
(around 12–14mmHg) creates the operative space
for a good exposure.
e number of trocars varies from 3 to 5
depending on the surgeon and the operative anatomy. e rst port is placed 15cm le to the umbilicus. Aer skin incision, we dissect the abdominal
wall with scissors and open the abdominal cavity.
en the rst port is inserted. Two additional ports
are placed as seen in picture (
. Fig.32.1). We prefer
single-use ports for 5–12 mm instruments. is
allows the exible use of the 30–40° angled laparoscope, sealing devices, and staplers. In some cases,
three ports are not enough to allow an adequate dissection of the right colon. In these cases, another
one or even two 5mm ports are placed in the right
lower or right upper abdomen. Aer a complete
exploration of the abdominal cavity, the patient is
placed in the Trendelenburg position, and the operating table is tilt to the le, where by gravity the right
colon is exposed and the small intestine is placed in
the le lower part of the abdomen. e greater
omentum is retracted cranially toward the liver so
that the cecum, the ascending colon, and the transverse colon are easily visible. As in open approach,
we perform oncological right hemicolectomy with
complete mesenteric resection. e resection starts
medial to lateral with primary exposure of the main
blood supply of the right-sided colon.
e rst step is to identify the ileocolic vessels
as the rst landmark (
. Fig.32.2). With a laparo-
scopic grasper, the cecum is elevated and pulled in
direction to the right abdominal wall. With this
maneuver, the ileocolic vessels are easily identied.
Aer opening the peritoneal layer, the ileocolic
artery and vein are dissected in the direction
toward the superior mesenteric vein and artery.
Surgical Technique andDicult Situations fromStefano Saad (Laparoscopic)
257
32
. Fig. 32.2 Cecal traction to identify ileocolic vascular
pedicle
. Fig. 32.3 Preparation from medial to lateral with
identication of duodenum
Aer isolation of the ileocolic vessels, a blunt dissection of the right colon mesentery can be performed to identify the duodenum which is the
second important landmark (. Fig.32.3). is is
the rst key step for preparation and for avoidance
of duodenal injuries. Aer isolation of the arteria
and vena iliocolica (. Fig.32.4), these vessels can
be divided. We usually use the LigaSure sealing
device in the double-burn technique.
However, also clips or an Endo GIA, white cartridge, can be used for vessel division. Aer division
of the ileocolic vessels, we continue the blunt dissection below the right colon mesentery in direction of the right liver and toward the lateral
attachment of the ascending colon. Hereby we identify the right ureter and the gonadal vessels which
can be identied in the retroperitoneal space below
the dissection area. In the next step, we follow
the superior mesenteric vein toward the pancreas
head, which is the next important landmark. e
. Fig. 32.4 Central dissection of ileocolic artery and vein
. Fig. 32.5 Identication of right colic artery
gastrocolic trunk and its branches are identied,
and the right colic vein is divided aer isolation by
the LigaSure device or clips. At this point, the surgeon has to be aware of the dierent variations of
the venous branches of the gastrocolic trunk. In all
cases, pancreatic branches must be preserved.
In the next step, the right colic artery is iso-
lated and divided (
. Fig. 32.5). If an extended
right hemicolectomy is planned, the middle colic
artery and vein are then identied, isolated, and
divided.
Aer the blood supply of the right colon is
secured, the right colon mesentery can be dissected
and divided until the resection line of the transverse colon is reached. en the greater omentum
is also divided with the LigaSure device in the same
258
S. Saad
32
. Fig. 32.6 Transection of transverse colon with
Endo-GIA
. Fig. 32.7 Transection of terminal ileum with
Endo-GIA
dissection direction. Aer this step, we dissect the
lateral attachment of the ascending colon and the
ileum. e small bowel mesentery can usually be
divided with the sealing device. For complete resection and for gaining the specimen, the small bowel
is cut with an Endo GIA (white cartridge), and the
transverse colon is cut by an Endo GIA A with blue
cartridge (
. Figs.32.6 and 32.7). Aer the transec-
tion of the small and large bowel, the specimen is
freed and can be placed behind the right liver lobe.
32.4 Reconstruction Phase
. Fig. 32.8 Creation of ileotransverse seid-to-side
anastomosis with Endo-GIA
. Fig. 32.9 Closure of GIA-opening with a running
suture
sutures are placed to bring the small bowel along the
transverse colon. en the lumina of the small and
large bowel are opened, and a side-to-side anasto-
mosis is performed with the help of an Endo GIA
(blue cartridge) (
. Fig.32.8). Aer the inspection of
the anastomotic side, the openings are closed with
3-0 Vicryl running suture in double layer fashion
(. Fig.32.9). Some surgeons always close the mes-
enteric defect. is is usually done by a non-absorb-
able running suture. However, there seems no clear
scientic evidence for this step. Aer inspection of
the operating eld and exclusion of any bleeding
points, the specimen can be extracted.
32.4.1 Intracorporeal Anastomosis
(Ileotransversostomy)
We prefer to perform an intracorporeal anastomosis
between the ileum and the transverse colon. In order
to perform a side-to-side anastomosis, two stay
32.4.2 Extraction oftheColon
Specimen
As indicated, we prefer intracorporeal anasto-
mosis which enables us to extract the specimen
Surgical Technique andDicult Situations fromStefano Saad (Laparoscopic)
259
32
. Fig. 32.10 Removed right hemicolectomy specimen
through a Pfannenstiel incision. e advantage of
Pfannenstiel incision seems to be more favorable
since it creates lower postoperative pain and a lower
rate of hernia formation. Another argument for
Pfannenstiel incision is the better aesthetic result
of the minilaparotomy. Usually we perform a 4cm
Pfannenstiel incision and insert a wound protector.
With a grasper, we easily can extract the specimen
(. Fig.32.10). Aer closure of the minilaparotomy
usually with a 1-0 PDS running suture, we reestablish the pneumoperitoneum and check again the
operative eld. Usually we do not insert any drains.
Alternative dissection technique of laparo-
scopic right colectomy: lateral to medial.
Although we basically prefer the medial
approach with primary central vessel ligation,
there are some situations where this approach
cannot be done. If the patient is extreme, obese
identication of the ileocolic vessels can be
obscured by a very fatty mesentery. Sometimes also
the small bowel cannot be placed away from the
central mesenteric axis, and in that situation, it is
maybe preferable to dissect the right colon from
lateral to medial. e lateral to medial approach is
comparable to the traditional approach of open colectomy. e dissection starts at the terminal ileum
and the cecum, and the attachment of the colon of
the le lateral bowel is dissected (
. Fig. 32.11).
Aer the release of the right colon ascendens, the
patients will be placed in an anti-Trendelenburg
position. en the right hepatic exure can be
grasped with the laparoscopic grasper into the
medial-caudal position. en the hepatic exure
can be prepared with the LigaSure device. With
this approach, the duodenum must also be clearly
identied to avoid an injury. Aer mobilization of
. Fig. 32.11 Coecal mobilisation from lateral to medial
(like open surgery)
. Fig. 32.12 Extracorporal ileotransverse anastomosis
through minilaparotomy in right upper abdomen
the ileum, ascending colon, and transverse colon,
a minilaparotomy can be placed as a transverse
incision in the right upper abdomen. Aer insertion of a wound protector, the small and large
bowel can be delivered through the wound.
Vessel ligation and bowel dissection can be performed through the open incision similar to the
technique of open colectomy. Aer resection of the
colon segment including the lymphadenectomy,
anastomosis can be performed extracorporeally
. Fig.32.12). Whether the gastrointestinal tract is
(
reconstructed by end-to-end anastomosis, side-toside anastomosis, hand suture, or stapler depends
on the preference of the surgeon. Aer removal of
the wound protector, the minilaparotomy is closed
and the operative eld is checked again by laparoscopic view. e technique of lateral to medial dissection with extracorporeal anastomosis is
probably the adequate approach for surgeons with
small experience in laparoscopic surgery, since this