Книга_861_Библиотеки_им_академика_М_И_Перельмана

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Ростовский Государственный Медицинский Университет

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Entry/Exploration

OptimalportplacementisshowninFigure4-2.OpenHassontechnique isperformedthroughaninfraumbilicalincisiontoinsertablunt12-mm trocarasthecameraport.Inmid-transverselesionsorobesepatients,a supra-umbilicalincisioncanbeused.Afterinsertion,theabdomenis insufflatedtoapressureof15mmHgwithcarefulattentiontothe patient’shemodynamics.A30-degreeangledlaparoscopeisplacedand theabdominalcavityisinspectedforanysignsoftraumaticport placement.Twoadditionalleftabdominalportsareinsertedunderdirect vision.Theleftlowerquadrant(LLQ)portisplaced2cmmedialand2 cmsuperiortotheanteriorsuperioriliacspine.Forpropertriangulation, theLUQportisplacedafullhand-breathcephaladtotheLLQinsertion site.Itmaybehelpfultorotatethepatienttotherighttoallowthesmall bowelandsigmoidtofallawayfromtheareadirectlybeneaththeport insertion.Ifneeded,additionalportsmaybeplacedinthesuprapubicor epigastricpositions.Theauthorspreferauniformportsizeof12mmto allowforuseof10-mmenergydevicesandstaplers.

FIGURE4-2Portsitesandtriangulation.The

standardportsitesforlaparoscopicrightcolectomy areshown.Acameraportisinsertedthroughan infraumbilicalincisionthatwilllaterbeenlargedfor specimenextraction,andtwo12-mmworkingports areinsertedintheleftabdomen(A).Thisarrangement allowstriangulationtotherightlowerquadrant(B). Redline,portsite;blackcircle,ostomymarking.

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Oncethetwoworkingportsareinserted,boththeassistantandthe operatingsurgeonmovetothepatient’sleftside.Beforemobilizingthe colon,thepatient’sabdomeniscarefullyexploredforanyevidenceof malignantormetastaticdiseaseontheperitonealsurfaces,ontheliver, oronthesmallbowel.Suspiciouslesionsarebiopsiedandsentforfrozen pathology.

MobilizationoftheRightColon

ThetableisrepositionedinTrendelenburgandrotatedtotheleft.The assistantispositionedtotherightoftheoperatingsurgeon.Twobowel graspersareplacedthroughtheworkingportsandusedtosweepthe smallboweloutoftherightiliacfossaandexposetheileocolicangle. Withanteromedialtractiononthececum,aharmonicscalpelisusedto incisetheperitoneumlaterallyandtoadvancethedissectionplane cephaladalongthewhitelineofToldt(Fig.4-3).Therightureteris identifiedearlyatthelevelofthepelvicbrimasitcrossestheiliac bifurcation(Fig.4-4).Asthecolonismobilizedoffthelateralabdominal wall,twolandmarksmustbeproperlyidentified:First,theplanebetween thecolonicmesenteryandGerota’sfasciashouldbevisualizedandused toguidethedissectiontowardtheflexure.Failuretofindthisplanewill resultinmedialrotationoftherightkidneyandriskahighureteral injury.Second,theduodenumshouldberecognizedandexposedasthe colonisrotatedmedially.Thelateralsurfaceofthecolonicmesenteryis dissectedfromtheduodenumforcompletemobilization(Fig.4-5).

FIGURE4-3Lateraldissectionalongthewhiteline

ofToldt.Thefirststepofcolonicmobilizationrequires exposureoftheileocolicangle,retractionofthecolon anteromediallyandincisingthewhitelineofToldt lateraltothececum(A).Thisincisioniscarried cephaladtowardthehepaticflexure,asindicatedby thedashedwhiteline(B).

FIGURE4-4Identificationoftherightureter.A.

Therightureter(whitearrows)isvisualizedatthelevel oftheiliacbifurcation.B.Lateraltotheileocolicangle asthececumisretractedmedially.

FIGURE4-5Mobilizationoftheproximal

transversecolon.Thegastrocolicandhepatocolic omentumaredividedinatransversedissection (dashedwhiteline)thateventuallyjoinsthelateral mobilizationatthehepaticflexure.

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Afterlaterallyreleasingtherightcolon,thetableistiltedintoreverse Trendelenburgposition.Theassistantmovestotheleftofthesurgeonto centerthelaparoscopiccameraontherightupperquadrant(RUQ).The transversecolonisretractedcaudallyandanenergydeviceisusedto dividethegastrocolicligament,withcaretoprotectthegallbladder,liver capsule,andduodenumasthedissectioniscontinuedlaterallytothe hepatocolicligament(Fig.4-6).Oncethetransverseandright-sided dissectionplanesarejoined,theentirerightcoloncanberetracted inferomediallyoutoftheRUQandanyremainingattachmentstothe underlyingduodenumcanbelysed.

FIGURE4-6Duodenalattachments.The

duodenumisexposedwithmedialrotationofthe colonafterreleasingthelateralandomental attachments.Therightcolonicmesenteryisdissected offtheduodenumforfullmobilization.

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MesentericDissectionandVesselLigation

Withthecolonfullymobilized,theileocolicvesselsareexposedand ligated.ThepatientisplacedbackintoTrendelenburgandthecolonis displacedanterolaterallytoidentifythepedicle.Peritoneumoverlyingthe mesenteryisscoredoneithersideofthevessels,creatingawindow throughthemesenteryintothelateraldissectionspace.Theduodenum mustbevisualizedthroughthisopeningtopreventinjury.Thevesselsare clearedofsurroundingfatdowntothebaseofthecolonicmesenteryat thetakeoffoftheileocolicvesselsfromthesuperiormesentericvessels (Fig.4-7).Intracorporealligationoftheileocolicarteryandveinisthen performedusingavessel-sealingenergydevice,clips,orastaplerwitha vascularstapler.Themesenteryisdivideddistally,toor,ifindicated, includingtherightbranchofthemiddlecolicartery,andproximally, alongtheilealmesenterytoapoint10cmfromtheileocecaljunction.

FIGURE4-7Isolationanddivisionoftheileocolic

pedicle.Theileocolicvesselsareidentifiedby retractingthemobilizedcolonanterolaterally,andthe adjacentperitoneumisscored(A).Theduodenumis visualizedthroughthemesentericwindowbefore divisionoftheileocolicvessels(B).

ResectionandAnastomosis

Thecameraismovedtooneofthelateralportsandalockinggrasperis placedthroughtheumbilicalporttograspthececum.Theinfraumbilical incisionisextendedcephaladforadistanceofapproximately3–4cm, curvingtotheleftoftheumbilicus.Awoundprotectorisplacedaround thegrasper/porttoreduceratesofinfectionandaidinspecimen extraction.Thebowelisdeliveredthroughtheincisionwiththelocking grasper.Thebowelisdividedwithastapleratthevasculardemarcations causedbydivisionofthemesentery.Intheabsenceofany contraindication,a100-mmgastrointestinalstaplerisusedtoperforma stapled,functionalend-to-end,anatomicside-to-sideileocolic anastomosistorestorebowelcontinuity.Pitfallsandsolutionsrelatedto thesetechnicalstepsaredescribedinTable4-1.Indocyaninegreen fluorescenceperfusionassessmentcanbeusedtoconfirmvascularity beforeand/orafteranastomoticcreation.

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TABLE4-1 Pitfallsandsolutionsduringlateraltomedial

laparoscopicrightcolectomy

Pitfall Solution

Difficultyidentifyingvascularpedicle Placepedicleunderbettertraction

Dissectfurtherleftonthetransverse colon

Poorreachofthetransversecolonto theumbilicus

Extendincisiontoepigastrium(minilaparotomy)

Intracorporealvesselligation,ifnot alreadyperformed

Anastomotictwisting Maintainorientationbykeepingbowel

continuity

Reinsufflateifanyconcern

Mesenterichernia Theoretical

Closure

Theanastomosisisgentlyreinsertedintotheabdomenthroughthe

umbilicalincision.Theabdomenmaybereinsufflatedtoverify hemostasisandclosethetworemainingportslaparoscopicallywitha suturepasser.Themidlineincisionisirrigatedandclosedwith interruptednumberonepolydixanonesutures,andtheskinincisionsare closedwithrunning4-0absorbablesuture.Incisionsaredressedwith benzoinandadhesivestrips,andcoveredwithapaddedadhesive bandage.

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