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COMPLICATIONS

Afteranopenmedial-to-lateralrightcolectomy,complicationscan include,butarenotlimitedto,surgicalsiteinfection,prolongedileus,
anastomoticleak,andintra-abdominalabscess.Theincidenceof ileocolicanastomoticleakoccursinlessthan2%ofpatientsandthatof surgicalsiteinfectionhasbeenreportedtovarybutshouldbelessthan approximately10%.The30-daymortalityratefollowingaright colectomyisrareandifitdoesoccur,itisusuallyduetocardiovascular orthromboembolicevents.

RESULTS

Althoughpaststudieshaveshownasurvivaladvantagewhenusingthe “no-touch”technique,theseoutcomeshavenotbeenreproduciblein
modernstudies.Inarandomizedprospectivetrial,Wiggersetal.showed therewasnodifferenceinmorbidityormortalitycomparingthe“no­touch”techniquetoconventionalresections.

CONCLUSION

Anysurgeonperformingrightcolectomiesshouldbefamiliarwiththe medial-to-lateralapproach.Althoughnooncologicadvantagehasbeen
provenascomparedtothelateral-to-medialtechnique,itmayoffer superiorvisualizationinsomesituations.
RECOMMENDEDREFERENCESAND READINGS
AnwarS,HughesS,EadieAJ,ScottNA.Anastomotictechniqueandsurvivalafterright
hemicolectomyforcolorectalcancer.SurgJRCollSurgEdinbIrel2004;2:277–80. BarnesJ.Physiologicresectionoftherightcolon.SurgGynecolObstet1952;94:722–6. GuenagaKK,MatosD,Wille-JorgensenP.Mechanicalbowelpreparationforelectivecolorectal
surgery.CochraneDatabaseSystRev2009:CD001544. KonishiT,WatanabeT,KishimotoJ,NagawaH.Electivecolonandrectalsurgerydifferinrisk
factorsforwoundinfection.AnnSurg2006;244:758–63. MoghadamyeghanehZ,HannaMH,CarmichaelJC,etal.Nationwideanalysisofoutcomesof
bowelpreparationincolonsurgery.JAmCollSurg2015;220:912–20. NoblettSE,SnowdenCP,ShentonBK,HorganAF.Randomizedclinicaltrialassessingtheeffect
ofDoppler-optimizedfluidmanagementonoutcomeafterelectivecolorectalresection.BrJ
Surg2006;93:1069–76. TurnbullRB,KyleK,WatsonFR,SprattJ.Cancerofthecolon:theinfluenceoftheno-touch
isolationtechniconsurvivalrates.AnnSurg1967;166:420–5. TyzzerEE.Factorsintheproductionandgrowthoftumormetastases.JMedRes1913;28:309. WiggersT,JeekelJ,ArendsJW,etal.No-touchisolationtechniqueincoloncancer:acontrolled
prospecttrial.BrJSurg1988;45:409–15.
Chapter2
OpenLateral-to-Medial Colectomy
BenjaminM.Martin,FarahA.Husain,and
EdwardLin

INDICATIONS/CONTRAINDICATIONS

Indications
Surgicalresectionoftherightcolonmaybeindicatedformalignant, premalignant,andbenignetiologies.Thelocationandunderlying pathologydeterminetheextentofresection.Anextendedright hemicolectomymaybeneededforlesionsspanningthehepaticflexureto mid-transversecolon,multipleadenomas,orsynchronouslesions.
Malignant—coloncancer,appendicealcancer Premalignant—polypsnotamenabletoendoscopicremoval Benign—ischemia,inflammatoryboweldisease,right-sided
diverticulitis,infection,cecalvolvulus,bleedingfromarteriovenous malformation,trauma
Evenintheeraofminimallyinvasivecolonresections,9–21%of laparoscopiccolectomiesrequireopenconversionbecauseofthepatient’s inabilitytotolerateCO2insufflationorbecauseofdenseintra-abdominal
adhesionsfromprevioussurgery.
Contraindications
Therearenoabsolutecontraindicationstoanopenrightcolectomy.
Difficultcircumstancessuchasapatientwithseverecardiopulmonary diseaseandalargeright-sidedpolypthatisnotamenabletoendoscopic removalpresentdistinctchallenges.Eachpatientshouldbereviewedona case-by-casebasisforappropriateness.
PREOPERATIVEPLANNING
Beforeelectivecolonresection,medicalcomorbiditiesshouldbe identifiedandoptimized.Thismayincludecorrectionofanemia, electrolyteandacid–basedisorders,fluiddeficits,andmalnutrition.Most patientswillhaveundergoneacontrast-enhancedcomputedtomography (CT)scanoftheabdomenandpelvisduringthediagnosticworkup, providingaroadmaptothemesentericvasculature.ChestCTisalso indicatedforthosewithstageIIorgreatercoloncancertoruleout metastaticdisease,aswellasacompletecolonoscopytoidentifypotential synchronouslesions.Asidefromthececumandrectum,theaccuracyof exacttumorlocationcannotalwaysbeascertainedbycolonoscopy.When feasible,endoscopicinktattooingorclipmarkingshouldbeperformed becauseintraoperativecolonoscopytolocalizethetumoristime consumingandmayunnecessarilyinduceboweldistension.
Traditionally,preoperativebowelpreparationhasbeenperformed beforeelectivecolonresection.Thispointhasbeendebatedwithoutclear resolution.Iftimepermits,amechanicalbowelpreparationwitha polyethyleneglycolsolutionfollowedbytheoralantibioticsneomycin anderythromycin,theeponymousNichol’sprep,canbeused.Otherwise, anyorallavagesolutionisacceptable.Itisimportanttonotethatthe surgeonisnotalwaysaffordedtheluxuryoftimeinpreoperative planningandbowelcleansing.Fortunately,bowelpreparationmaynotbe ascriticalforrightcolonresectionswhencomparedtoleftcolonand rectosigmoidresections.
SURGICALANATOMY
Topography
Oncologiccolonresectionandlymphnodeharvestarebasedonthe vascularsupplyoftheirsubsegments.Thecolonandrectumarederived fromtheembryologicmidgutandhindgut,withthebloodsupply followingthesuperiormesentericarteryandinferiormesentericartery, respectively.Derivativesofthemidgutincludethececumandtheright halftotwo-thirdsofthetransversecolon.Thederivativesofthehindgut aretheleftone-thirdtoone-halfofthetransversecolon,thedescending colon,sigmoidcolon,rectum,andthesuperiorportionoftheanalcanal.
Cecum
Thececumislocatedintherightiliacfossaandisapproximately10cm long,withthewidesttransversediameterofallthecolonsegments averaging7.5cm.Itiscompletelyenvelopedinvisceralperitoneumandis usuallymobile.Thegonadalvesselsandtherighturetertypicallycourse posteriortothemedialborderofthececum.Theterminalileumempties fromamedial-to-lateraldirectionintothececumthroughathickened invaginationcalledtheileocecalvalve.Thevalvepreventsretrogradeflow fromthecolonintothesmallbowel,butinapproximately25–30%of individualstheileocecalvalveisincompetent.Theincompetentvalveis mostevidentduringcolonoscopywhencolonicairreadilypassesintothe smallintestine,resultinginmarkedabdominaldistensionandpatient discomfort.Patientswithdistalcolonicobstructionandafunctional ileocecalvalvetypicallyhavecolonicdilatationonradiographythat mimicsaclosed-loopobstruction.Althoughthececumisquite distensible,adiametergreaterthan12cmcanresultinischemicnecrosis andperforation.
AscendingColon
Fromthececum,theascendingcolonisthe12–20cmsegmentthat coursessuperiortowardtheliverontherightside.Withtheexceptionof itsposteriorsurface,whichisfixedtotheretroperitoneum,theascending coloniscoveredlaterallyandanteriorlybyvisceralperitoneum.The psoasmuscle,secondportionoftheduodenum,rightureter,andthe inferiorpoleoftherightkidneyhaveimportantanatomicrelationshipsto theposterioraspectoftheascendingcolon.Laterally,theascendingcolon isattachedtotheparietalperitoneumviaanembryonicfusionplane
betweenthevisceralandparietalperitoneum.Thissubtleanatomic landmark,sometimescalledthe“whitelineofToldt,”isrelatively avascularandservesastheclassiclandmarkforsurgicalmobilizationof theascendingcolonawayfromitsretroperitonealattachments.The hepaticflexureoftheascendingcolonrestsundertherightliverand turnsmediallyandanteriorlyintothetransversecolon.Thehepatic flexurecanoftenbeidentifiedduringcolonoscopybythepurplish impressionoftheliveronthesuperioraspectofthecolonwallwhenthe scopereachestherightside.
TransverseColon
Thetransversecolonissuspendedbetweenthehepaticflexureandthe splenicflexureonitsmesenteryandspans40–50cm,sharingimportant anatomicrelationshipswiththestomach,tailofthepancreas,spleen,and theleftkidney.Itiscompletelyinvestedwithperitoneumandhasalong mesenteryknownasthetransversemesocolon,whichmayberedundant enoughtoreachintothepelvis.Anatomically,thetransversecolonis attachedtothegreatercurvatureofthestomachbythegastrocolic ligamentoromentum.Thegreateromentumisattachedbyathin, relativelyavascularmembranetotheantimesentericsurfaceofthe transversecolon.Locallyadvancedtumorsofthetransversecolonmay involvethestomach,pancreas,and/orduodenumposteriorly,aswellas thespleenandomentum.
BloodSupply
Arteries
Therightcolonanduptotwo-thirdsoftheproximaltransversecolonare derivedfromthemidgut,aregionsuppliedbythesuperiormesenteric artery.Thedistaltransversecolonandleftcolonarederivedfromthe hindgut,suppliedbytheinferiormesentericartery(Fig.2-1).Allthe terminalvesselsthatvascularizealimitedareaofthebowelwallare suppliedbythesearteries.Collateralizationisexcellentalongmarginal arteriesatthemesentericborder,servingasanimportantsourceofa segment’sbloodsupplywhenamajorvesselisoccluded.Thepresenceof thesemarginalarteriesalsoallowsthesacrificeofmajorvessels, facilitatingthecolon’smobilizationforanastomosis.Anextremeexample ofsuchamobilizationwouldbeacolonicinterpositionforesophageal replacement.Thelymphaticsandinnervationofthecolonfollowthe vascularsupply.
FIGURE2-1Arterialsupplytothecolonand
rectum.
p.6
p.7
Thesuperiormesentericartery(SMA)suppliestheentiresmallbowel with12–18jejunalandilealbranchestotheleftandthreemajorcolonic branchestotheright.Theileocolicvesselisthemostconstantofthese branchesandsuppliestheterminalileum,appendix,andcecum.The rightcolicarteryisthemostvariablebloodsupplyofthecolonandmay beabsentinupto20%ofpatients.Whenpresent,therightcolicartery canoriginatefromtheSMAasabranchoftheileocolicarteryormiddle colicartery.Therightcolicarterycommunicateswiththemiddlecolic arterythroughthemarginalarteries.
Themiddlecolicarteryisamajorsourceofbloodsupplytothecolon andisanimportantsurgicallandmarkwhenplanningacolonresection becauseitisademarcationpointfortheclinicaldefinitionofarightor lefthemicolectomy.ThisarteryarisesproximallyastheSMAentersthe smallbowelmesenteryattheinferiorborderofthepancreas.Themiddle colicarterythenascendsintothetransversemesocolonandclassically splitsintotherightandleftcolonicbloodsupplythroughthemarginal arteries.Themiddlecolicarterymaybeabsentinsomepatients,andthe
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