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PARTI
RIGHTCOLON
Chapter1
OpenMedial-to-LateralRight Colectomy
ValerieS.EmuakhagbonandJaimeE.
Sanchez

INDICATIONS/CONTRAINDICATIONS

Thereareseveralapproachesthatcanbeutilizedinperformingaright colectomy,eitheropenorlaparoscopic,whichincludemedial-to-lateral
andlateral-tomedialdissections.Thischapterfocusesontheopen medial-to-lateraltechnique.
Indicationsforrightcolectomyincludemalignancy,inflammatorybowel disease,bleeding,obstruction,andischemia.Indicationsspecificfor
performingamedial-to-lateralmobilizationincludeappropriatebenign lesionsthatareunabletoberemovedendoscopically,aswellaslocally advancedmalignancywithinvasionintosurroundingstructures.The medial-to-lateralapproachforarightcolectomyhasseveraladvantages, includingearlyligationofthevascularpedicle,whichintheorycanallow formoreaggressivemanipulationofthespecimen.Thismethodis knownasthe“no-touch”technique.Thisconceptwasintroducedinthe early20thcenturywherevigorousmanipulationofmalignanttumors wasfoundtoresultinthedevelopmentofextensivelivermetastasesin micemodels.Thetechniquewasthendescribedandfurtherpopularized byTurnbullandBarneswhereinearlylymphovascularcontrolpriorto tumormanipulationshowedanimprovementof5-yearsurvivalrates whencomparedwithpatientsundergoingconventionalcolectomy.By firstelevatingthemesentery,thisdissectionalsoallowsthesurgeonto betterdefineretroperitonealstructuresthatmaybevitalincasesof locallyadvancedcancer.
PREOPERATIVEPLANNING
Asinallcasesofcoloncancer,patientsshouldundergoapreoperative stagingevaluation.Thisassessmentincludesacarcinoembryonicantigen
levelaswellascomputedtomographyscanofthechest,abdomen,and pelvis,whichwillhelpdetermineifthereislocallyadvanceddisease, invasionintosurroundingstructures,ordistantmetastasis.Ifneeded,a magneticresonanceimagingormagneticresonanceangiogrammaybe obtainedforfurtherevaluation.Also,appropriatemedicaloptimization andcardiopulmonaryriskassessmentareessential.
Atourinstitution,mechanicalbowelpreparationisnotroutinely performedforpatientsundergoingarightcolectomy.Thistopicremains controversialbuthasnotbeenshowntodefinitivelychangesurgicalsite infectionoranastomoticleakrates,basedonaCochranereviewby Guenagaetal.,inpatientsundergoingsegmentalcolectomy.However, manysurgeonsfeelthatamechanicalbowelpreparation,whichshould includeoralantibiotics,willdecreasestoolburdenandpostoperative morbidity.

SURGERY

Positioning
Thepatientshouldbeplacedinasupinepositionontheoperatingroom table.Unlikelaparoscopy,thepatient’supperextremitiesmaybeleftout
onarmboardsinsteadofbeingtuckedtothesides.
p.1
p.2
Technique
Abladdercathetershouldbeinsertedpriortopreppinganddrapingthe patient.Aperiumbilicalmidlineincisionshouldbemade.Uponentrance
intotheperitonealcavity,aninspectionofallquadrantsshouldbe performedandsolidorganssuchastheliverpalpated,payingclose attentiontoevidenceofmetastases.Ifthereareanyconcernsfor metastaticdisease,afrozenspecimenshouldbeobtainedifitwillchange theindicationforoperation.
Thekeymaneuvertobeginningthisoperationisobtainingadequate visualization.Thesmallbowelshouldberetractedtotheleftsideofthe abdomen,allowingforclearexposureoftheterminalileumand ascendingcolonmesentery.Aswell,theomentumandtransversecolon shouldberetractedcephaladtotheupperabdomeninordertoprovide full,unobstructedvisualization.
Themedial-to-lateraldissectionbeginswithidentificationoftheileocolic vascularpedicle.Thismaneuvercanbeaccomplishedwithanteriorand
lateralretractionofthececum(Fig.1-1).Theileocolicarteryshouldbe clearlyidentifiableasittentswithinthemesentery.Aperitonealopening shouldbemadealongsidethevascularpedicle.Liftingthemesentery andpedicletowardtheanteriorabdominalwallandgentlysweepingthe retroperitoneumdownallowsfordevelopmentofanavascularplane betweenthesetwostructures.Thisavasculardissectioniscontinued laterallytowardtheabdominalwallbeneaththecolon.Caremustbe takenduringthisportionofthedissection,toavoidinjurytothe duodenum,whichshouldbesweptdownwiththeretroperitoneum(Fig.
1-2).Aftersufficientdissectiontothebulboftheduodenum,attentionis
turnedtocephaladdissectiontowardthehepaticflexure.Thedissection continuesintheavascularplane,sweepingretroperitoneumdownuntil
wearelimitedinexposureduetoourintactvascularpedicle.Oncethis limithasbeenreached,thevascularpedicleisskeletonizedandligated. Inanefforttoperformanappropriateoncologicresectionwithcomplete lymphadenectomyincasesofmalignancy,ahighligationoftheileocolic artery,between1and2cmfromitsoriginatthesuperiormesenteric artery,isperformed(Fig.1-3).Atourinstitution,thevascularpedicleis generallyligatedwithabipolarelectrosurgicalenergydevice,butothers mayoptforaclampandtietechniqueoruseofavascularstapler.
FIGURE1-1Retractionofthececumallowsfor
identificationoftheileocolicvascularpediclewithin thecolonicmesentery(identifiedbyforceps).
FIGURE1-2Dissectionwithintheavascularplane
createsawindowbetweenthecolonicmesentery (tentedattheileocolicarterybyforceps)andthe underlyingretroperitonealstructuresincludingthe duodenum(blackarrow).
FIGURE1-3Highligationoftheileocolicartery1–
2cmfromitsoriginatthesuperiormesentericartery (SMA).
Aftervascularpedicleligation,thedissectioncontinuescephalad towardthetransversecolonbytransectingthetransversemesocolon, includingligationoftherightcolicarteryandrightbranchofthemiddle colicartery.Atthispoint,attentionisfocusedoncompletingthemedial dissection,bytransectingthemesenteryoftheterminalileumtothesite wherethebowelistobedivided(Fig.1-4).Thisstepcompletesthe medialdissection.
FIGURE1-4Completedmedialdissectionwith
ligatedvascularpedicleandmesentery.
Entranceintothelessersacbeginsthelateraldissection.After entranceintothelessersacandwithcaudalandmedialretractionofthe transversecolon,oneshouldbeabletoeasilyligatethegastrocolicand hepatocolicligamentsasthemobilizationcontinueslaterally.Ligationof theseattachmentsshouldallowforcompletemobilizationofthehepatic flexure(Fig.1-5).Withcontinuedmedializationofthehepaticflexure andascendingcolon,thewhitelineofToldtandlateralwallattachments areincised(Fig.1-6).Onemustensurethatasthecolonismedially retractedandthatthekidneyandureterremaindownwithinthe retroperitoneum.Theureterisnotroutinelyidentifiedduringright colectomyifthedissectionproceedswithintheavascularplanedescribed earlier.
FIGURE1-5Mobilizationofthehepaticflexureby
transectionofhepatocolicligaments(rightkidney identifiedbygrayarrow;duodenumidentifiedby blackarrow;liveridentifiedbywhitearrow).
FIGURE1-6Transectionofremaininglateral
peritonealattachmentsatthewhitelineofToldt.
p.2
p.3
Incasesoflocallyinvasivedisease,surroundingstructuresshouldbe resectedenblocwiththecolon.Totheextentpossible,oneshouldhave
thisinformationbasedonpreoperativeimaginganddiscusswith consultants,suchasvascularsurgeryorurology,ifnecessary.
Oncethecolonhasbeenfullymobilized,theterminalileumand transversecolonshouldbetransectedusingabowelstaplertoavoid contaminationoftheperitonealcavity.Anileocolicanastomosisis createdbasedonsurgeonpreference.Althoughwepreferastapled anastomosis,bothhand-sewnandstapledtechniquesprovideequivalent patientoutcomes.
Forastapledanastomosis,theantimesentericcornersofthestapled linesforbothileumandcolonareremoved.Eachlimbofa gastrointestinalstaplerisinsertedintothelumensandfiredtocreatea side-to-sideileocolicanastomosis.Theresultingcommonenterotomyis thenclosedwithuseofanotherstapleload.However,itcanalsobe closedusingahand-sewntechnique.
Theanastomosisshouldbeinspectedforcompleteness,patency,and hemostasis.Oncesatisfied,anyavailableomentummaybeusedtocover theanastomosisandattentionshouldbeturnedtoclosureofthe peritonealcavity,basedonsurgeonpreference.
POSTOPERATIVEMANAGEMENT
Postoperatively,patientsfollowanenhancedgastrointestinalrecovery protocol.Onthenightofsurgery,patientsareassistedoutofbed,
allowedaclearliquiddiet,andstronglyencouragedtoambulate. Nasogastrictubesarenotroutinelyused.Theamountofnarcoticpain medicationsislimitedinthepostoperativeperiodinaneffortto decreasepostoperativeileusandlengthofstay.Paincontrolcanbe achievedwithmultipleadjuncts,suchastheuseofanepidural,long­actinglocalanesthetics,aswellasnon-narcoticmedications.
Workingtogetherwiththeanesthesiateam,welimitpre-and intraoperativefluidsbyusingagoal-directedapproachwithatarget urineoutputofabout0.3–0.5ml/kg/hrasageneralrule.Postoperative fluidadministrationislimitedthroughouttheperioperativeperiod. AccordingtoNoblettetal.,theuseofprotocol-basedintraoperativefluid administrationwasshowntoleadtoshorterhospitalstaysanddecreased morbidityinpatientsundergoingelectivecolorectalresection.
Thebladdercatheterisremovedonthefirstpostoperativedayand prophylacticperioperativeantibioticsarediscontinuedwithinthefirst 24hoursaftersurgery,asperprevioussurgicalcareimprovement project(SCIP)guidelines.Forthisreason,weroutinelyuseertapenemas ourantibioticofchoiceasitprovides24-hourcoveragewithasingle dose.
Patientsareofferedaregulardietonthemorningaftertheoperation aslongastheytoleratewithoutnauseaoremesis.Hospitaldischarge occurswhenthepatientistoleratingoraldiet,painisadequately controlled,andthepatientisambulatingwithoutmajordifficulty. Dischargeisnotconditionaluponhavingbowelfunctionifthepatient’s postoperativerecoveryisotherwisesatisfactory.
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