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FIGURE3-1Theportplacementforamedial-to-
laterallaparoscopicrighthemicolectomy.
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OperativeSteps
Thefollowingarethegeneraloperativestepsinamedial-to-lateral laparoscopicrighthemicolectomy:
Isolationanddivisionoftheileocolicpedicle Isolationanddivisionoftherightbranchofthemiddlecolicvessels Separationoftherightcolonandmesenteryfromtheretroperitoneal
fasciainamedial-to-lateraldirection Dissectionofthegastrocolicligament,takedownofthehepaticflexure
andlateralligament Mobilizationoftheileumandmesenteryoffoftheretroperitoneum
Divisionofthebowelproximallyanddistally Anastomosis
IleocolicPedicle
ThepatientisplacedinaslightTrendelenburgposition.Theomentumis liftedabovethetransversecolon,andthedistalileumismovedintothe pelvis.Thepatientistiltedsteeplywiththerightsideup,andthemore proximalsmallbowelloopsareswepttotheleftofthemidline.
Theoperationstartswiththeisolationoftheileocolicpedicle.The ileocolicarteryisaproximalbranchoffofthesuperiormesentericartery thatcoursesjustinferiortothethirdportionoftheduodenum.Therefore, theidentificationoftheduodenalsweepthroughthemesenteryisan importantinitialstepinidentifyingtheileocolicpedicleasthetransverse colonisretractedinacephaladdirection.Ampletensiononthisvesselis criticalindistinguishingitfromthesuperiormesentericvessels.With tractionontheileocecalregioninananterolateraldirection,theileocolic arterywillbeseen“bowstringing”throughthemesentery(Fig.3-2).The rightcolicarteryarisesfromtheileocolicarterytosupplythehepatic flexurein90%ofpatients.Sincethevascularligationwillbeperformed proximaltothetakeoffoftherightcolicartery,itdoesnotneedtobe separatelyligatedinmostcases.In10%ofpatients,however,theright colicarterybranchesoffofthesuperiormesentericarterycephaladtothe ileocolicpedicle,andinthesecasestherightcolicarterywillneed separateligation.Distalinitscourse,neartheileocecaljunction,the ileocolicarteryformsanarcadewiththedistalsuperiormesenteric artery;theilealbranchandaccessoryilealbranch,whichcanbleedif injured.Therefore,thedissectionoftheileocolicarteryshouldstartinthe avascularplanebetweenthesuperiormesentericvesselsandtheileal branch.
FIGURE3-2Theileocolicpedicleidentified
throughtherightcolonmesentery.Theduodenum(D) shouldbeidentified,andthepedicleshouldtravel clearlytotheileocecaljunction.
Awidewindowismadeintheperitoneumcaudaltotheileocolic pedicleastheretroperitonealstructuresaregentlysweptawayina posteriordirection(Fig.3-3).Amesentericwindowisthenmadeonthe cephaladaspectoftheileocolicpedicle,andthepedicleisadequately isolatedtoallowforeasyvesseldivision.Thesurgeonshouldclearly identifytheduodenumtoavoidinjury(Fig.3-4).
FIGURE3-3Beginningthedissectionofthe
ileocolicpedicleintheavascularplane.
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FIGURE3-4Thedissectionoftheileocolicpedicle
withtheduodenumpreserved.D,duodenum.
Thedivisionoftheileocolicpediclecanbeperformedusingavessel­sealingenergydevice,alaparoscopicstapler,orclips.Thelevelofdivision ofthisvesselwilldependontheindicationforsurgery.Formalignancy, thispedicleshouldbeproximallydividedsoastomaximizelymphnode harvest(Fig.3-5).However,inpatientswithCrohn’sdiseasewherethe mesenterymaybethickened,thevesselisdividedwhereitissoft,usually moreproximalthandistal.
FIGURE3-5Proximallymphadenectomyofthe
ileocolicpedicle.Theileocolicvein(ICV)isseen branchingfromthesuperiormesentericvein(SMV), withtheenlargedlymphnodesattherootofthe ileocolicvesselclearedtowardthespecimen.
RightBranchoftheMiddleColicVessels
Thenextseriesofmaneuverswillassistintheidentificationofthemiddle colicvessels.First,thepreviouslycutleafofperitoneumoverlyingthe duodenumisliftedandtheduodenumandheadofpancreasarethen sweptposteriorlyandseparatedfromtherightsideofthemiddlecolic vessels(Fig.3-6).Thisstepmustbecarefullyandgentlyperformed becauseexcessiveforcewillcausetraumatothepancreaticoduodenalor gastroepiploicvein,resultinginsignificanthemorrhage.Thisdissectionis takendeeperinacephaladdirection,untilthetransversecolonis separatedfromtheduodenum.
FIGURE3-6Theduodenum(D)andheadof
pancreas(P)aresweptawayfromthetransverse mesocolon.Gentlebluntdissectioniscriticaltoavoid avulsionofveinsattheheadofthepancreas.
Oncethereisadequatespacemadetotherightofthemiddlecolic vessels,themiddlecolicpedicleisanteriorlyliftedusingtwopointsof retraction,onetotherightandonetotheleftofthepedicle(Fig.3-7A,B). Thismaneuveriscriticalintheidentificationoftherightandleft branchesofthemiddlecolicvessels.Thegoaloftheprocedureistodivide therightbranchofthemiddlecolicvesselsinordertoharvestthelymph nodesdrainingthehepaticflexureandproximaltransversecolon.The middlecolicarterysuppliesthetransversecolonandarisesfromthe superiormesentericarteryattheinferiorbaseofthepancreas.Theremay beone,two,orthreebranchesoffofthesuperiormesentericartery,and theclassicY-shapedsingletrunkoccursinlessthan50%ofcases.An imaginarylineiscreatedfromthebaseofthemiddlecolicvesselstoward theanticipatedtransactionpointofthetransversecolon(Fig.3-8).The peritoneumofthetransversemesocolonisthendividedalongthisline. Thetakeoffoftherightbranchisthenidentifiedanddividedatitsorigin (Fig.3-9).Inadditiontothemiddlecolicvessels,onewillencounterthe
rightcolicvein,locatedjusttotherightofthemiddlecolicvesselsfrom theheadofthepancreastothehepaticflexure.Therightcolicveinis isolatedanddivided,takingcarenottoinjuretherightgastroepiploic vein,whichisitsadjacentbranchrunningonthesurfaceofthepancreas towardthestomach(Fig.3-10).
FIGURE3-7A,B.Twoexamplesofthetransverse
mesocolonexposed.Identifytheright(R)andleft(L) branchesofthemiddlecolicvesselswithadequate two-pointretraction.D,duodenum.
FIGURE3-8Thedissectionlinetoidentifythe
originoftherightbranchofthemiddlecolicvessels (R).L,leftbranch.
FIGURE3-9Divisionoftherightbranchofthe
middlecolicarteryatitsorigin.R,rightbranch,L,left branch.
FIGURE3-10Ahighligationofthemiddlecolic
vesselsinlocallyadvancedcancer.Thisanatomic variantshowsanabsentrightcolicvein,witha prominentrightmiddlecolicvein(V)thatbranches fromthesuperiormesentericvein(SMV).Running togetheristherightbranchofthemiddlecolicartery (A).Bothwillbeligatedwherevisible.Theright gastroepiploicvein(GEV)alongthesurfaceofthe pancreasmustbepreserved.P,headofpancreas.
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RetromesentericDissection
Therightcolonmesenteryisthenseparatedfromtheretroperitoneumin amedial-to-lateraldirection.Withthecutedgeoftherightcolon mesenteryanteriorlyretracted,theretroperitonealfascia,orwhitelineof Toldt,isidentifiedatitsmedialaspect,andbluntlyseparatedfromthe mesentery.Thisplaneisavascular,allowingretromesentericdissectionto bedoneunderneaththehepaticflexureandascendingcolontothelateral abdominalwall(Fig.3-11).Thisdissectionshouldnotbecarriedtoo dorsally,intoorunderneathGerota’sfascia.Thetrueretroperitoneal planeismosteasilydetectedneartheduodenum,whichshouldbethe startingpointfortheretromesentericdissection.Thismedial-to-lateral dissectionleavesthehepaticflexureandathinlateralligamentofthe ascendingcolonasanaturalretractor,keepingthefloppyrightcolonin place.
FIGURE3-11Medial-to-lateralretromesenteric
dissection.ThewhitelineofToldtisseenfromthe medialaspect,asthisisbluntlyseparatedfromthe rightcolonmesentery.Atattoostainstheregionof dissection.D,duodenum.
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SuperiorandLateralDissection
Atthelevelofthefalciformligament,thegastrocolicligamentisopened. Asthetransversecolonisinteriorlyretracted,thelessersacisdissected, andthecongenitaladhesionsoftheposterioromentalleafandthe transversemesocolonareundone.Adequatetractionandtissue
triangulationarenecessarytoidentifythecorrectplaneofdissection. Avoidinginjurytotherightgastroepiploicvessels,thepreviously dissectedretromesentericplanefromthemedialapproachisthen identified.Withthetransversecoloninferiorlyretracted,fromleftto right,thehepaticflexureisliberated(Fig.3-12).Thelateralligamentof theascendingcolonisdividedsuperiorlytoinferiorly,asthedissected colonisretractedintothepelvis,untiltherightpsoasmuscleandright iliacvesselsareidentified(Fig.3-13).Theretroperitonealfasciais preserved,asthemesenteryoftheileocecalregioniswidelydissectedoff oftheretroperitoneum.Itisoftenpossibletoidentifytherightureter duringthisdissection,andthisstructureshouldbemaintained underneathanintactretroperitonealfasciaifthedissectionisproperly performed.
FIGURE3-12Takedownofthehepaticflexure
fromsuperiorly.Thetransversecolonisretracted inferiorly.
FIGURE3-13Thelateralligamentoftheright
colonisdissecteduntiltherightcolonismobilized pasttherightpsoasmuscle.
InferiorDissection
Thefinalelementsofthedissectionaretheilealattachmentstothe retroperitoneum.ThepatientisthenplacedinasteepTrendelenburg position,asthedissectedrightcolonisplacedbackintoitsoriginal position.Thesmallbowelloopsinthepelvisarecompletelyretractedina cephaladdirection(Fig.3-14).Withthedistalileumanteriorlyand superiorlyretracted,theilealattachmentstotheretroperitoneumare released.Strongbutgentletractionisneededtoretractthetissuesaway fromtherightiliacvesselsandtoavoidinjurytotherightureter.This dissectionproceedslaterallyaroundtheappendixandcecum,meeting theprevioussuperiordissection(Fig.3-15).Themedialextentofthisileal mobilizationistherightiliacvessel;thislevelwillassureadequatereach ofthesmallboweltothetransversecolonforanastomosis.
FIGURE3-14Theileumisretractedstronglyina
superiordirectiontoexposethemesenteric attachmentstotheretroperitoneum.Therightureter isvisualized.Retractthesmallboweloutofthepelvis asmuchaspossible.
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