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Ростовский Государственный Медицинский Университет
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RESULTS

HALcolectomyhasbeencomparedtobothtraditionalopencolectomy andlaparoscopiccolectomy.Studieshaveshownthatpatients undergoingHALcolectomyretainthebenefitsofstraightlaparoscopic surgery,butallowtheintraoperativeuseofthesurgeon’shand.Theuseof HALtechniquescanhelpovercomesomeofthetechnicalchallengesof laparoscopiccolectomywhilestillconferringthebenefitsofsmaller incisions,lesspostoperativepain,earlierreturnofbowelfunctionand earlierreturntoactivity.ManystudiesinvestigatingHALcolectomyhave focusedonleftortotalcolectomies,butseveralstudieshavecompared laparoscopicrightcolectomytoHALrightcolectomyandhaveshown similarshorttermoutcomes.

CONCLUSIONS

Hand-assistedrightcolectomyisasafeandfeasiblealternativetoboth openandlaparoscopicrighthemicolectomy.Itofferstheadvantagesof laparoscopicsurgery,butallowsthesurgeontousethehandtohelp retract,mobilize,palpateanddissect.AlthoughtraditionallyHAL colectomyhasbeenusedforleftandtotalcolectomies,itmayplayarole inrightcolectomyforamorenovicesurgeonoramoredifficultpatient conditionorpathology.
RECOMMENDEDREADINGSAND REFERENCES
ChangYJ,MarcelloPW,RusinLC,RobertsPL,SchoetzDJ.Hand-assistedlaparoscopicsigmoid
colectomy:helpinghandorhindrance?SurgEndosc2005;19:656–61. ChungCC,KeiNgDC,ChiengTsangWW,etal.Hand-assistedlaparoscopicversusopenright
colectomy:arandomizedcontrolledtrial.AnnSurg2007;246:728–33. DelaneyCP,MarcelloPW,SonodaT,etal.Gastrointestinalrecoveryafterlaparoscopiccolectomy:
resultsofaprospective,observational,multicenterstudy.SurgEndosc2010;24:653–61. HALSStudyGroup.Hand-assistedlaparoscopicsurgeryvsstandardlaparoscopicsurgeryfor
colorectaldisease.SurgEndosc2000;14:896–901. KangJC,ChungMH,ChaoPC,etal.Hand-assistedlaparoscopiccolectomyvsopencolectomy:a
prospectiverandomizedtrial.SurgEndosc2004;18:577–81. MarcelloPW.Hand-assistedlaparoscopiccolectomy:ahelpinghand?ClinColonandRectalSurg
2004;17:125–9. MarcelloPW,Young-FadokT.Laparoscopy.In:WolffBG,FleshmanJW,BeckDE,Pemberton
JH,WexnerSD,eds.TheASCRSTextbookofColonandRectalSurgery.NewYork,NY:
Springer,2007:693–712. PendlimariR,NelsonH.Laparoscopiccolorectalprocedures.In:ZinnerMJ,AshleySW,eds.
Maingot’sAbdominalOperations.12thed.NewYork,NY:McGraw-Hill,2013. TargaronaEM,GraciaE,GarrigaJ,etal.Prospectiverandomizedtrialcomparingconventional
laparoscopiccolectomywithhand-assistedlaparoscopiccolectomy:applicability,immediate
clinicaloutcome,inflammatoryresponse,andcost.SurgEndosc2002;16:234–9. VogelJD,LianL,KaladyMF,deCampos-LobatoLF,Alves-FerreiraPC,RemziFH.Hand-assisted
laparoscopicrightcolectomy:howdoesitcomparetoconventionallaparoscopy?JAmColl
Surg2011;212:367–72.
PARTII
LEFTCOLON
Chapter7
OpenMedial-to-Lateral(Left Colon)
MahmoudAbu-GazalaandAlonJ.Pikarsky

INDICATIONS/CONTRAINDICATIONS

Leftcolectomymaybeperformedasastandaloneprocedureoraspartof amoreextendedcolectomy.Theextentofdissectionandresectionis dependentonthespecificetiology.Althoughbenigndiseasesmaydictate amoreconservativeresection,mostleftcolectomiesareperformedfor malignancies.Oncologicresectionofmalignanttumorsoftheleftcolon dictatescompletemesocolicresection,wheretheentirenodalbasinofthe tumorisdissectedandremoved.Thus,tumorlocationdictatesthe anatomicmarginsoftheresection.Thebloodsupplytotheleftcolon arisesmainlyfromtheinferiormesentericartery(IMA)andfromthe arcadesoriginatingfromthemiddlecolicpediclethroughthemarginal arteryofDrummond.Inrecentyears,theminimallyinvasiveapproach forcolonresectionhasbeenprovedtobeanadequateandsafe alternativetotheopenapproachbothforbenignandmalignant etiologies.Inourdepartment,thepercentageoflaparoscopiccolectomies performedeitherformalignantdiseaseorbenignetiologieshas dramaticallyrisenduringthepastfewyears.However,openleft colectomyisstillindicatedforcomplexcasessuchaslocallyadvanced coloncancer.
Theapproachforleftcolectomyisusuallyperformedusingthelateral­to-medialapproach,inwhichthecolonisfirstmobilizedandthen devascularizationandresectionareperformed.However,medial-to­lateraldissectionissometimesindicatedwhenmobilizationofthecolon fromthelateralattachmentscouldbedifficult,forinstance,whenthe abdominalwallisinvolvedbythecolonicpathology,duetomalignant invasionorinflammatoryresponse.Thisapproachallowsearlycontrolof thevascularpedicleandearlyidentificationandpreservationofvital
structuresthatmightbedamagedifthelateral-to-medialapproachis chosen.Inthosecaseswherelateralmobilizationofthecolonmightbe difficult,accesstothelateralvitalstructures(iliacvessels,ureter,renal pelvis,inferiormesentericvein(IMV),ligamentofTreitz,andsplenic pedicle)throughthemesentericwindowmayallowearlyidentification andpreservation.
Themedial-to-lateralapproachhasprimarilybeendescribedasapart ofthe“no-touchisolationtechnique”developedbyBarnesandTurnbull inthe1950s.TheirrationalewasbasedontheworkbyTyzzerin1913and Colein1954,whosuggestedthatcolonmobilizationandtumor manipulationmayseedcancerouscellsintothevenousdrainageand worsenprognosis.Usingthemedial-to-lateralapproach,thetumorisleft insitu,whereasthevascularpedicleisligated,thuspreventingvascular tumorcellseeding.Turnbulloperatedon460patientswithcarcinomaof thecolonusingthe“no-touchtechnique,”achievinganoutstandingresult ofdoublingthe5-yearsurvivalrateinthosepatients.Contraindications tothemedial-to-lateralapproachmayincludemassivelymphadenopathy alongthevascularpedicle,orsignificantfibrosis,thickening,or inflammatoryconditionsinvolvingthemesentericbed.Insuchcases, addressingthevascularpediclefirstmightbeverycomplicatedand potentiallydangerous.
PREOPERATIVEPLANNING
Completehistoryandphysicalexaminationaremandatory.Special attentionshouldbepaidtocardiopulmonarydiseases,withpreoperative anestheticevaluationorderedasrequired,andcontrolandstabilization ofpatients’comorbiditiesbeforesurgery.Knowledgeofanyprior abdominalsurgeryisofoutmostimportance.
Thoroughevaluationofthecolonicpathologyshouldincludeadditional studiesasneeded.Endoscopicstudyofthecolonismandatoryinthe evaluationofmostpatients,especiallythosesufferingfrommalignancies. Evaluationoftheentirecolonisnecessaryforproperoperativeplanning. Thesurgeonshouldexcludeanysynchronousmalignancyoranyother concomitantpathology.
Computedtomographyisofgreatimportanceintheassessmentofthe locoregionalsignificanceofthecolonicdisease,thusaidingthe preoperativeplanning.Inmalignantdisease,evaluationofdistant metastasesisstandardforpatientmanagement.Otherimaging modalitiessuchasmagneticresonanceimagingorpositronemission tomography-computedtomographymayalsobeindicatedinthe preoperativeworkupinsomecases.

SURGERY

PatientPreparation
Useofmechanicalbowelpreparationbeforesurgeryhasbeenthesubject ofgreatcontroversyandfocusofseveralrandomizedprospectivetrials. Resultsoftrialsrangebetweenbeneficialeffectsforuseofmechanical bowelpreparationandincreaseintherateofcomplications.Severaltrials haveshownasignificantdecreaseinsurgicalsiteinfectionsinthe mechanicalbowelpreparationgroup,whencombinedwithbothoraland systemicantibiotics,whereasothertrialshaveshownahigherrateof woundinfectioninpatientsreceivingabowelpreparation.Mosttrials, however,haveshownnodifferenceincomplicationrateswithorwithout bowelpreparation,includinganastomoticleakrateandwoundinfections.
Intheauthors’department,thepracticeofmostsurgeonsisto administerpreoperativeoralandparenteralantibioticsinadditionto mechanicalbowelpreparationbeforeanycolonresection.Apoorbowel preparation,wherethebowelisfullofwaterystoolthatmightreadily spill,greatlyincreasestheriskforpostoperativesurgicalsiteinfection.
Specialsituationsthatmaydeembowelpreparationnecessaryinclude laparoscopicresectionsforsmallnon-readilypalpabletumorsorunder conditionsthatmaynecessitateintraoperativecolonoscopy.Itisalso beneficialtoclearatleastthedistalbowelfromfecalmaterialbefore surgery,bymeansofanenema,whenuseofacircularstaplerisexpected.
Itisthepracticeinmostcasestoadministerasingledoseoflow­molecular-weightheparinsubcutaneouslyontheeveningbeforethe operationday.
Itisourroutinetouseapneumaticcompressiondeviceduringall abdominaloperations.Placementofanepiduralcathetercombinedwith anesthesiaisrecommendedforallourpatientswhennospecific contraindicationispresent.Anasogastrictube(NGT)isplacedafter anesthesiainductionforallpatients.Aurinarycatheterisroutinely placedforallpatientsundergoingacolonresection.Uretericstentsare placedincasesofabulkytumorinvadingtheretroperitoneumor adjacenttotheuretersasmightbesuspectedduringpreoperative evaluation.Prophylacticparenteralantibioticsareadministered,bythe anesthesiologist,halfanhourbeforeskinincision.
Positioning
Thepatientisplacedandsecuredinthemodifiedlithotomyposition usingtheYellofin(r)Allenstirrups(Allen,Acton,MA).Thepatient’s
perineumispositionedafewcentimetersbelowthetipoftheoperating tabletoallowforeasyaccessduringoperation.Asiliconepadisplaced underthesacrumtoreducetheriskofpressuresores.Bothhandsare usuallypositionedtightlyagainstthebody,andprotectivepaddingis usedtopreventpressuresoresandnervedamage.Thepatientisthen preppedusingsoapandalcohol-basedchlorhexidinesolutionforthe abdomen.Iodine-basedsolutionisusedfortheperineum.Thepatientis thendrapedsuperiorlyoverthechest,laterallyovertheanteriorsuperior iliacspine,andinferiorlyoverthepubis.
Technique
Accesstotheabdominalcavityisgainedviaamidlineincision.Inthe caseofpriorabdominaloperations,alladhesionsarelysedusingsharp dissectionwithelectrocauteryorscissors.Thefalciformligamentisthen ligatedanddivided,andtheabdominalcavityisthoroughlyexploredand assessedforthepresenceofanymetastaticdiseaseorotherpathologies. ThecorrectplacementoftheNGTisconfirmed.Itisourpreferencetouse theBookwalter(r)retractor(SymmetrySurgical,Antioch,TN),which allowsforadequateretractionandexposureofallthepartsofthe abdominalcavity.Fourright-angleabdominalwallretractorsareplaced inallfourquadrants,takingcarenottoinjuretheintra-abdominal structures.Thesmallbowelisthenencircledusingtwolargepadsand retractedtotheright,toexposethebaseoftheleftcolicmesenteryand pelvicinlet.
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p.53
Atthisstageitisveryimportanttoevaluatetheprimarycolonic pathology,theconditionandqualityofthecolon,andassesstheextentof resectionandamountofsplenicflexuremobilizationneeded.Malignant pathologiesdictatecompletemesocolicexcisionwithdivisionofthe vascularpediclesattheirbase,dependentontheexactlocationofthe lesion.Thebordersofresectionarethenselectedonthebasisofthelimits ofdevascularizationnecessaryforanadequateoncologicresection. Diverticulardiseasemaynotnecessitatehighligationofthevascular pedicle,butthedistalresectionmarginshouldlieatorbelowtheupper rectum,whereastheproximalmargindependsonthequalityofthe remainingcolon.Splenicflexuremobilizationisusuallyundertaken. Intraoperativeplanningatthisstageisofparamountimportanceto minimizeintraoperativeandpostoperativecomplications.
TheIMVislocatedjustlateraltotheligamentofTreitzatthebaseof theleftcolonmesentery.TheIMVpassesposteriortothetailofthe
pancreastodrainintothesplenicvein.TheIMAarisesfromtheanterior surfaceoftheaortajustsuperiortoitsbifurcation.TheIMAandIMVcan befurtheridentifiedbyliftingthemesenteryoftheleftcolonanteriorly, whichtentstheperitoneumoverlyingthosevessels.IMAcanbefurther identifiedaidedbysensationofitspulse.Thereisanavascularplane lyingatthebaseofthemesenterybetweentheIMAandIMV,andalso fromtheIMAinferiorlytowardthesacralpromontory,justanteriorto theaortaandiliacvessels.Theperitoneumisscoredusingelectrocautery, alongsidethebaseoftheleftcolonmesentery,startingfromthesacral promontorysuperiorlytowardtheIMV.Thisstageusuallyincludes mobilizationofthefourthpartoftheduodenum.Gentletractionshould beappliedtothecolonandmesenterytoallowforeasierentrytothe areolarplaneatthebaseofthemesentery.Thisstepiscrucialforthe correctdissectionandidentificationofthelateralstructures.Bluntand sharpdissectionshouldcommenceintheareolarplane,atthelevelofthe sacralpromontory,whereitiseasiesttoidentifytheureterandthe gonadalandtheiliacvessels(Fig.7-1).Iftheureterisnotreadily identified,itispossiblethattheureterhasbeenliftedfromthe retroperitoneumandisstillattachedtotheposterioraspectofthe mesocolon.Theureterandgonadalvesselsshouldbetracedupward towardthekidney,mobilizingthemesocolonfromtheretroperitoneum andGerota’sfascia,keepingtheuretersafeattheretroperitoneum.The avascularwindowatthebaseofthemesocolonsuperiortotheIMA shouldalsobedissected,thusallowingforclearidentificationoftheIMV andIMA.Furtherdissectionandisolationofthevascularpediclesis carriedonusingelectrocautery,uptotheoriginoftheIMA.Thevessels arethendividedusingdoubleties.
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