Indications/Contraindications

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RECOMMENDEDREFERENCESAND READINGS

BelimoriaKY,BentremDJ,MerkowRP,etal.Laparoscopic-assistedvs.opencolectomyfor

cancer:comparisonofshort-termoutcomesfrom121hospitals.JGastrointestSurg

2008;12:2001–9. 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. ClinicalOutcomesofSurgeryTherapyStudyGroup.Acomparisonoflaparoscopicallyassistedand

opencolectomyforcoloncancer.NEnglJMed2004;350:2050–59. ColonCancerLaparoscopicorOpenResectionStudyGroup.Survivalafterlaparoscopicsurgery

versusopensurgeryforcoloncancer:longtermoutcomeofarandomizedclinicaltrial.Lancet

Oncol2009;10:44–52. DelaneyCP,MarcelloPW,SonodaT,WiseP,BauerJ,TechnerL.Gastrointestinalrecoveryafter

laparoscopiccolectomy:resultsofaprospective,observational,multicenterstudy.SurgEndosc

2010;24:653–61. GreenBL,MarshallHC,CollisonF,etal.Long-termfollowupoftheMedicalResearchCouncil

CLASICCtrialofconventionalversuslaparoscopicallyassistedresectionincolorectalcancer.

BrJSurg2013;100:75–82. KennedyGD,HeiseC,RajamanickamV,HarmsB,FoleyEF.Laparoscopydecreasespostoperative

complicationratesafterabdominalcolectomy:resultsfromtheNationalSurgicalQuality

ImprovementProgram.AnnSurg2009;249:596–601. LarsonDW,LovelyJK,CimaRR,etal.Outcomesafterimplementationofmultimodalstandard

carepathwayforlaparoscopiccolorectalsurgery.BrJSurg2014;101:1023–30. LiangJT,LaiHS,LeePH.Laparoscopicmedial-to-lateralapproachforthecurativeresectionof

right-sidedcoloncancer.AnnSurgOncol2007;14:1878–9. SlimK,VicautE,Launay-SavaryMV,ContantC,ChipponiJ.Updatedsystematicreviewand

meta-analysisofrandomizedclinicaltrialsontheroleofmechanicalbowelpreparationbefore

colorectalsurgery.AnnSurg2009;249:203–9.

Chapter4

LaparoscopicLateral-toMedialRightColectomy

JoshuaH.WolfandIdoMizrahi

INDICATIONS/CONTRAINDICATIONS

Theindicationsforperformingalaparoscopicrightcolectomycanbe dividedintothreegroups:

Neoplasia

innovationssuchasendoscopicmucosalresection(EMR)and endoscopicsubmucosaldissection(ESD),somecoloniclesionsarestill foundtobeunresectableandnecessitatecolectomy.

colon,orhepaticflexurearethemostcommonindicationsfor performingarightcolectomy.Tumorsinthetransversecolonmore commonlyrequireanextendedrightcolectomy.

terminalileum,orcecum,arightcolectomyisneeded.

Inflammation

inflammatory,fistulizing,orstricturingdisease.Theseoperationsare typicallymoretechnicallydemandingthansurgeryforcancer. Intraoperativefindingssuchasalargeinflammatorymass,interloop abscesses,andfistulastothesigmoidcolonmayposetechnicaldifficulty

andultimatelyleadtoconversiontoopensurgery.Stricturesmaybe missedbecauseoflimitedtactilesensationandthesurgeonshould considerextracorporealpalpation.

beararediseaseinWesterncountries,itisverycommoninEastAsia andspecificallyinKorea,withanincidenceof1caseperevery2.9–17 casesofappendicitis.RCDisespeciallycommonamongmalesintheir relativelyearlyyears.

OtherIndications

andlargebowelshouldbecarefullyinspected.Suchcasesaretypically addressedwithalaparotomy.

nonviablebowel,pneumatosisintestinalisrequiresimmediatesurgery withresectionoftheaffectedsectionofthecolon.

diagnosticandtherapeuticcolonoscopyrangesbetween0.07%and

0.1%.Theriskincreasesto0.2%afterEMRandisashighas5%after ESD.ItisreasonabletoscheduleanESDintheoperatingroomfollowed bysurgeryiftheESDhasfailed.

excessivemobilityofthececum.

hemorrhageisunusualbecausethebleedingsourceisdifficultto localize.However,arightcolectomycanbewarrantedifan arteriovenousmalformationorotherbleedingpathologyisdefinitively localizedtotherightcolon.

ischemia.

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Therearenoclearabsolutecontraindicationsforuseoflaparoscopyin performingrightcolectomy.Relativecontraindicationsincludethe following:

PREOPERATIVEPLANNING

Properpreoperativepatientevaluationfocusingonrelevanthistoryis crucialtohelprealizesatisfactorysurgicaloutcomes.Closeattention shouldbegiventofactorsthatmayaltersurgicalplanning.

HistoryandPhysicalExamination

andrheumatologicdisordersrequiringsteroidtreatmentasthesemay impairanastomotichealing.

clearlydocumented.Somepatientsmayneedaperioperativestress doseandadivertingloopileostomydependingontissuefragility.

doseshouldbeclearlydocumented.Itiscontroversialwhetheraperiod ofwaitingbeforeoperatingisnecessary.Ithasbeensuggestedtowait approximately4–6weeksbetweenthelastdoseofbiologictherapyand surgery.

ofcareforcoloncancer,somepatientswithmetastaticdiseasemay requireneoadjuvantchemotherapyandsurgeryshouldbedelayed approximately4weeksafterthecompletionoftreatment.

reviewed,withspecificattentiontotheremaininglengthofbowel,type ofanastomosis,andpostoperativecomplications.

cancer,andanyotherrelevantcancersthatmaysuggestgenetic predispositiontocoloncancer.

owninstitutionwithadedicatedgastrointestinalpathologistifpossible, specificallyforpatientswithinflammatoryboweldisease(IBD)or followingresectionofamalignantpolyp.

andavailableatthetimeofthesurgery.Findingsshouldbediscussed withtheperformingendoscopist.TattooingshouldbedonewithIndia inkinmultiplequadrantsdistaltothetumortoassurethatthetattoois

visibleontheserosalsurfaceandnothiddenbythemesentery.Make sureotherareashavenotbeenpreviouslyinkedtominimizeconfusion atthetimeofsurgery.WhensuspectingIBD,itisadvisedtotake multiplebiopsiesofnormal-appearingcolon.

shouldbeespeciallyattentivetopriorincisions,previousstomasites, hernias,masses,lymphnodes,andbodyhabituswithacalculatedbody massindex.

Labs/Imaging

panelareroutinelyordered.Coagulationstudiesshouldbeorderedif indicated.

takenbeforesurgery.

thepatient’snutritionalstatus.Preoperativeenteralorparenteral nutritionalsupportshouldbeconsideredinclinicallymalnourished patients.

withoralandintravenouscontrastaremandatoryforcancerpatients. Priorimagingshouldbereviewedwithaspecializedabdominal radiologistwithspecificattentiontothelocationofthelesion, involvementoflymphnodes,vascularandurinaryabnormalities,and metastasistootherorgans.PatientswithIBDarebetterevaluatedwith CTormagneticresonanceenterography.

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SelectingaSurgery:LateralApproachorMedial Approach?

Thereisessentiallynodifferenceinsurgicaloutcomesbetweenthetwo approaches,asisreviewedinalatersectionofthischapter.Hence,the surgeonshouldchoosethemostfamiliarandcomfortableapproachbased onpriortrainingandexperience.Thereare,however,someinherent advantagesanddisadvantagesofeachmethod.Theadvantagesofthe lateralapproach(LA)are(1)earlyidentificationofkeystructuressuchas therightureterandduodenumand(2)useofthesamedissectionasin

theopentechnique.Theadvantagesofthemedialapproach(MA)are(1) earlyligationofthevascularileocolicpedicle,theoreticallypreventing liberationoftumorcellsintomesentericcirculationand(2)the preservationofthelateralcolonicligamentuntiltheendofthe mobilization,whichhelpswithrightcolonretractionandexposure.MA maynotbefeasibleunderconditionsinwhichtherightcolonmesentery isfixedtotheretroperitoneum,forexample,incaseswithsignificant malignantadenopathyinvolvingtheileocolicpedicleorextremely thickenedmesenteryduetoCrohn’sdiseaseormorbidobesity.

MechanicalBowelPreparationwithOralAntibiotics

Theroleofmechanicalbowelpreparation(MBP)withoralantibiotics remainscontroversial.Someauthorshaveshownnoadvantage,whereas othershaveshownthatMBPwithoralantibioticsreducestheratesof anastomoticleak,surgicalsiteinfection,andpostoperativeileus.The authorsadvocateforroutineuseofMBPwithoralantibioticsnotonlyfor thereasonsmentionedbutalsoforothertechnicalreasons.Theabilityto “palpate”thebowelwithlaparoscopicinstrumentsislimitedwithout preparation.Furthermore,itispracticallyimpossibletoperforman intraoperativecolonoscopy,ifneedbe,withoutpreparation.Lastly,if proximaldiversionisunexpectedlyrequired,MBPensuresthatthe remnantcolonwillbeevacuatedandcleanratherthanfullofstool.

PREOPERATIVECOUNSELING

Itisimportanttosetrealisticexpectationswiththepatientregardingthe lengthoftheoperation(approximately2–3hours),lengthofhospitalstay (typically2–3days),recoverytime(veryindividual,butapproximately1– 2weeks),andfuturebowelfunction,whichshouldnotbesignificantly alteredinrightcolectomy.Theauthorscounselallpatientsregardingthe possibilityofadivertingostomy,andpracticebilateralstomamarkingfor allpatientsscheduledforanelectivecolectomy.Somemayprefertomark onlypatientsathighriskfordiversion,reducingworkloadfrom enterostomaltherapistsandanxietyfrompatients.

Forcertainpatients,prophylacticcystoscopyanduretericstentsshould bediscussedaswell.Althoughindicationsarenotclearlydefined,stents aregenerallyusedforreoperativecases,largetumors,previousradiation therapy(lessrelevantforarightcolectomy),diverticulitis,fistulas, Crohn’sdisease,andobesity.

SURGERY

Positioning

Securepatientpositioningisessentialforasuccessfullaparoscopicright colectomy,whichrequiresrotationofthesurgicalbedtoseveralextreme angles.Foampaddingmustbecarefullyplacedtoavoidpressureinjury, especiallyinobesepatients.Appropriatetimeandfocusshouldbe dedicatedtothisportionofthecaseandtheparticipatingstaff,including nursingandanesthesiologystaff,shouldbeorientedinadvance.Before thepatiententerstheroom,agelpad/beanbagisplacedontheoperating tabletoavoidpatientslippageduringextremetilt.Thepatientisplaced onthepadandinduced/intubatedbyanesthesiology.Linesandtubesare inserted,includinganynecessaryarterialorvenouscatheters,an orogastrictube,aFoleycatheterand,whenrelevant(asdiscussed earlier),ureteralstents.Thelegsarewrappedwithknee-lengthsequential compressiondevicesleevesandplacedinAllenstirrupsformodified lithotomypositioning,withextrapaddinginsertedbehindtheleg.Both armsaresecuredatthesidesbyplacingthebeanbagtosuction,and gauzepaddingisusedtoprotecttheskinfromanylinesortubing.Foam andtapeareplacedacrossthechesttosecuretheupperbodytothebed andshoulderrestsareplacedonapaddedsupportthatissecuredtothe table.

Modifiedlithotomypositioningispreferredbytheauthorsoversupine becauseofseveraldistinctadvantages.First,itallowstheoperating surgeontostandbetweenthepatient’slegs,offeringausefulvantagefor mobilizingthehepaticflexure.Second,itmaintainstheaccessibilityfor intraoperativecolonoscopy,whichmayberequiredtoclarifyunexpected findings,includingpolyps,fistulae,anddiverticulardisease. Intraoperativecolonoscopycanalsobeusedtohelpselectanappropriate resectionmargin.

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p.28

Afterpositioningandsecuringthepatient,itisimportanttotestthe bedinthevariouspositionsthatwillbeusedintheoperationtoreinforce anyobviousareasofinstability.Overheadlightingshouldbebroughtover thepatientandlaparoscopicmonitorsshouldbeplacedattheheadofthe patientandonthepatient’srightside.Thepatient’sabdomenisthen preppedwithabetadineorchlorhexidinesolutionanddrapedina standardmanner.Cordsforthelightsource,camera,suction,energy

device,andBoviecauteryarebundledandsecuredonthesideofthe patientadjacenttothelaparoscopictower.Aschematicoftheroomsetup isshowninFigure4-1.

FIGURE4-1Arrangementofequipmentand

personnel.Numberscorrespondtovarious componentsoftheroomsetup:(1)anesthesiologist; (2)operatingsurgeon;(3)assistantsurgeon;(4)scrub nurse;(5)circulatingnurse;(6)ORtable/patient;(7) instrumenttable;(8and9)videomonitors;(10) laparoscopictower.OR,operatingroom.Thepatient willbeinthelithotomypositionafterendotracheal intubation.

Technique

Theoperativetechniqueisdividedintofivestages:

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