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FIGURE6-1Operatingroomandpatient
positioningforhand-assistedlaparoscopic(HAL)right colectomy.
PortPlacement
Portplacementandlocationofthehand-assistportvarybasedonpatient anatomy,surgeonpreference,andsurgeonconfidenceinbeingableto completetheoperationlaparoscopically.Twooptionsexisttoinitiatethe operation—placementofatraditionallaparoscopicportusuallyinthe periumbilicallocationandthenevaluationandplacementofthehand­assistportorinitialplacementofthehand-assistportwithsubsequent laparoscopicportplacement.Theapproachisoftenrelatedtosurgeon experienceandcertaintyofthediagnosis.
Figure6-2demonstratessomeofthemorecommonportsandhand-
assistdevicelayouts.PartsA,B,andCdemonstratea10-or12-mm supraumbilicalHasson-typeportwiththehand-assistdeviceintheright lowerquadrant,verticalsuprapubiclocation,andlowtransverse suprapubiclocation.Anadditional5-mmportisplacedintheleftlower quadrantwiththeoptiontoplaceanadditional5-mmportinthe midepigastrumifrequiredtoassistwithdissectionorretraction.Figure
6-2Dillustratesthehand-assistdeviceintheperiumbilicallocationwith
twoadditionalportsontheleftsideoftheabdomen,oneforthecamera
andoneforaworkingport.Theplacementofthehandinthe midline/periumbilicallocationallowsthemostsurgicalversatility,but thehandcanobscurevisualization.Currenthand-assistdevicesallow easyinsertionandremovalofthehandintoandoutoftheperitoneal cavitywhilemaintainingpneumoperitoneum.Thesizeoftheincision requiredforthehand-assistdeviceistypicallythesameastheglovesize ofthesurgeonincentimeters.Oncethelocationischosenandthe incisionismade,thewoundretractor/protectorisplacedandsecured. Thehand-assistportisthensecuredtothebase.Theuseofsurgical lubricantonthebackofthesurgeon’sglovedhandfacilitateshand exchangesthroughthehand-assistport.
FIGURE6-2Handportoptionsforhand-assisted
laparoscopic(HAL)rightcolectomy.A.Rightlower quadrant.B.Suprapubicmidline.C.Suprapubic transverse.D.Periumbilicalmidline.
p.44
p.45
Pneumoperitoneumisachievedusingstandardcarbondioxide insufflationandistypicallymaintainedat15mmofmercurythroughout theprocedure.A10-mm30-degreelaparoscopeisutilizedandplaced throughtheperiumbilicalport.Initialgrossexplorationoftheperitoneal cavityiscarriedouttoconfirmtheanatomy,confirmthediagnosis, ensuretherearenoseveredenseadhesions,andtoexaminethesurfaces oftheliverandperitoneum.Aftercompletinginitialevaluationofthe abdominalcavityandcontents,theprocedureisinitiated.Inadditionto thelaparoscopeandthehand-assistport,anenergydevicefordissecting andvascularpediclecontrolisalsotypicallyutilized.Five-millimeter versionsofcurrentenergydevicetechnologiescanbeutilizedonthebasis ofsurgeonorhospitalpreference,orstandardelectrocauterycanbeused fordissectionwiththeuseofclips,ties,orstaplesforcontrolofvascular pedicles.
MobilizationoftheRightColon
Thestepsoftheoperationarethesameaswithanopenright hemicolectomy.Therearetwoapproaches,thelateral-to-medial approach,whichisthesameoperationthatistaughtanddoneusingthe openapproach,andthemedial-to-lateralapproach.Themedial-to-lateral approachfirstgainscontrolofthevascularpedicleandusesthecolon’s attachmentstoaidinthedissection.
Medial-to-Lateral
ThepatientispositionedinitiallyheaddownorinTrendelenburg positionwithrightsideup.Thececumisgraspedandretractedanteriorly intotherightlowerquadrant,whichplacestheileocolicpedicleonstretch andallowsforitsidentification(Fig.6-3).Theileocolicpedicleisthen isolatedbyscoringtheperitoneumoverlyingitatitsbaseand skeletonizingitfromsurroundingstructures(Fig.6-4).Theduodenum canbeidentifiedjustcephaladtothisandissweptposteriorlyoutof harm’sway.Theileocolicpedicleisthencontrolledanddividedatits takeoffusinganenergydevice,clips,ties,oralaparoscopicstapler— whicheverthesurgeonprefers.Oncethepedicleisdivided,themesentery oftherightcoloniselevatedoffoftheretroperitoneumintheavascular planeutilizinggentlebluntdissection(Fig.6-5).Thedissectioniscarried outlateraltotherightsidewall,medialtowardthemidline,andcephalad totheinferioredgeoftheliver.Duringthisdissection,theduodenumis sweptposteriorlyandprotected.Therightcolicvesselscanbesacrificed duringthisportionofthedissection.Next,attentionisturnedtothe remaininglateralattachmentsoftherightcolon.Theterminalileumis elevatedoffoftherightpelvicbrimbyincisingtheperitoneumand
raisingitofftherightiliacvesselsandrightureter.Mobilizationofthe terminalileumiscarriedtotheleveloftheduodenum.Thedissectionis continuedalongthececumandrightcolonbydividingalongthewhite lineofToldtusingthesurgeon’sfingerasnecessarytodissectthecorrect planeandtofullymobilizethecolonbycompletingthedissectionthat wascarriedfromthemedialside.Thisdissectioniscarriedtothehepatic flexure.ThepatientisthenpositionedinreverseTrendelenburgandthe omentumiselevatedanteriorlyandfreedfromthehepaticflexure, dissectingtowardthemidtransversecolon.Thehepatocolicand gastrocolicligamentsaredividedsharplyuntilreachingthemid transversecolon.Caremustbetakenduringthisdissectiontoprotectthe duodenum.Thisdissectioncanbecarriedoutwithelectrocauteryoran energydevice.Thisdissectionshouldallowforadequatemobilizationof thecolontobeabletoexteriorizeit,ortoallowintracorporealdivisionof therightbranchofthemiddlecolicvessels.
FIGURE6-3Ileocolicpedicleonstretch.
FIGURE6-4Relationshipofduodenumtoileocolic
pedicle.
FIGURE6-5Dissectingrightcolonmesenteryaway
fromretroperitoneum.
p.46
p.47
Lateral-to-Medial
Thelateral-to-medialapproachfollowsthestepsthatmostsurgeonsare typicallytaughtduringopenrighthemicolectomyandthereforefamiliar tomostsurgeons,includingtrainees.Thepatientisplacedin Trendelenburgpositionwiththerightsideup.Theoperationbeginswith mobilizationoftheterminalileumandcecumbyincisingtheperitoneum andretractingthececumtowardtheleftupperquadrant.Theterminal ileumiselevatedfromtherightpelvicbrim,protectingtheiliacvessels andrightureterduringthedissection.Thececumandappendixarefreed fromretroperitonealattachments.Thedissectioniscontinuedalongthe ascendingcolonworkingtowardthehepaticflexurebydividingalongthe whitelineofToldt.Thecorrectplaneraisestherightcolonoutofthe retroperitoneumwithoutdisturbingretroperitonealstructuresortissue. Theduodenumneedstobepositivelyidentifiedandsweptposteriorlyto avoidmobilizingitalongwiththecolon.Theterminalileumandcecum arefullymobilizedtotheleveloftheduodenum.Furtherdissectionis carriedfromthehepaticflexuretowardthemidtransversecolonby freeingtheattachmentsoftheomentum,gallbladder,andstomach, stayingclosetothecolon,andworkingintheavascularplane.The transversecolonisfurthermobilizedontoitsmesenterysothattheentire rightcolonisnowmobilizedontoitsmesenteryoffofthe retroperitoneum.Thevascularpediclesandmesenterycanbe intracorporeallyorextracorporeallydivided.Inobesepatients,
intracorporealdivisionisofteneasierasthemesenterycanbefore shortenedanddifficulttoexteriorize.Intracorporealdivisionispreferred formalignantdiseasestoensurehighligationofthepedicles.
ExtracorporealAnastomosis
Oncethecolonisfullymobilizedutilizingeitherthemedial-to-lateralor lateral-to-medialapproach,itcanbeexteriorizedthroughthehand-assist portforthedivisionofthebowelandtheanastomosis(Figures6-6and6-
7).Thepatientcanbereturnedtoneutralposition.Thebowelcanbe
dividedutilizingtechniquesfamiliartotheparticularsurgeon.Typically, ifalaparoscopicstaplerwasusedtocontrolthevascularpedicles,thiscan beusedtoperformboweldivisionandanastomosis.Ifalaparoscopic staplerwasnotutilized,anopenstaplercanbeusedtodividethebowel andperformtheanastomosis.Anyremainingmesenteryorvascular pediclescanbeligatedanddivided.Aside-to-side,functionalend-to-end anastomosisisfashionedandtheenterotomycreatedcanbeclosedusing astaplerorcanbehand-sewnclosed.Alternatively,ahand-sewn anastomosiscanbeperformedifthatisthesurgeon’spractice.The mesentericdefectcanbeleftopenorcloseddependingonthesurgeon’s preference.Theanastomosisisthenreturnedintracorporeallytothe abdominalcavityandirrigationoftheabdomencanbeperformed.The remaininglaparoscopicportscanberemoved.Anyfascialdefectlarger than8mmshouldbere-approximated.Thefasciaatthehand-assistport isre-approximatedineitheraninterruptedorrunningmanner.Skin incisionsareallirrigatedwithwarnedsalinesolution.Skinisclosed utilizinganabsorbablesubcuticulartechniqueoranalternativeofthe surgeon’spreference.
FIGURE6-6Handportwoundprotectorinthe
incision.
FIGURE6-7Terminalileum,rightcolonand
transversecolonexteriorizedthroughincisionfor extracorporealresectionandanastomosis.
POSTOPERATIVEMANAGEMENT
PatientsundergoingHALrighthemicolectomycanenjoybenefitssimilar tothoseappreciatedbypatientsundergoinglaparoscopicsurgery includingquickerreturnofbowelfunction,lesspostoperativepain, earlierdischargefromthehospital,andsoonerreturntoactivities. Patientsshouldbeoutofbedambulatingthesamedayassurgery, typicallywithin6hoursoftheoperationcompletion.Clearliquiddietis permittedwhenthepatientisfullyawakeanddietadvancedastolerated. Non-opiatepaincontrolisencouraged,whereasnarcoticsarereservedfor painnotcontrolledbyothermodalities.Urinarycatheterisremovedon thefirstpostoperativeday.Dischargecriteriavarybysurgeonand institution,buttypicallyincludetoleranceofdiet,paincontrol,and passageofflatus.Activitycanbeastoleratedwiththeexceptionofheavy liftingorstraining,whichshouldbelimitedforthefirstseveralweeks accordingtothesurgeon’spractice.

COMPLICATIONS

ComplicationsofHALrighthemicolectomyaresimilartocomplications ofopenorlaparoscopicrighthemicolectomyandcanbedividedinto intraoperativeandpostoperativecomplications.Themainintraoperative complicationsincludebleedingandinjurytootherintra-abdominal structures.Bleedingcanresultfromlackofcompleteligationofvascular pedicles,tearingofmesentery,oraggressivebluntdissectionthatisnot carriedoutinanavascularplane.Immediaterecognitionandcontrolof bleedingismandatory,andthereshouldbenoevidenceofongoing bleedingbeforecompletingtheoperation.Injurytootherstructuressuch asenterotomiesorcolotomiescanoccurmorefrequentlyifadhesionsare present.Thermalinjurytobowelnotbeingresectedneedstobe recognizedintraoperatively,becausedelayedperforationcanoccurifnot detectedandrepaired.Otherintraoperativecomplicationsspecifically relatedtolaparoscopictechniquesincludehypercarbia,injurytobowelor vesselsduringportplacement,andtearingortractioninjuriesfrom laparoscopicinstruments.Ureteralorurinarytractinjuriescanoccur duringmobilizationoftherightcolonascanduodenalinjuries.Caremust betakentoprotectretroperitonealstructures.
Postoperativecomplicationsmirrorthoseofopencolectomies. Anastomoticleaksarethemostseriouscomplications,andoptimal surgicaltechniquesincludingensuringappropriatebloodsupply, avoidingtension,goodalignmentofthebowel,andgentleatraumatic tissuehandlingmustbeadheredto.Woundinfectionsorsurgicalsite infectionsarearelativelycommonpostoperativecomplicationfromcolon resections.Preventativemeasuressuchasmechanicalandantibiotic bowelpreparation,perioperativeprophylacticantibiotics,and intraoperativenormothermiacanhelpminimizetheincidenceofwound infection.Inaddition,HALcolectomyusesawoundprotectoraspartof thehand-assistdevice,protectingtheskinandsubcutaneoustissuesfrom contamination.
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Venousthromboembolismandpulmonaryembolismcanandshould beprophylaxedagainsttypicallyutilizingchemicalandmechanical methods.Earlymobilizationcanalsohelppreventdeepveinthrombosis andisencouraged.Incentivespirometryandearlymobilizationalsohelp preventpulmonarycomplications.Complicationssuchaspostoperative ileusandearlypostoperativebowelobstructioncanprolonghospitalstay.
Minimizingnarcotics,ambulating,gumchewing,andtargeted,goal­directedfluidmanagementcanhelpminimizethechanceofdeveloping anileus.
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