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COMPLICATIONS

Potentialpostoperativecomplicationsfollowingopenlateral-to-medial rightcolectomyincludebleeding,surgicalsiteinfection,anastomotic leak,prolongedileus,bowelobstruction,venousthrombosis,urinary tractinfection,andpneumonia.Accordingtodataavailablefromthe AmericanCollegeofSurgeonsNationalSurgicalQualityImprovement Program(ACSNSQIP),anaverageriskpatientundergoingasegmental colectomywithprimaryanastomosishasa13.2%incidenceofsurgical siteinfection(superficial8.0%,deep1.4%,organspace3.8%).Abundled approachtothepreventionofsurgicalsiteinfectionscontaining evidence-basedriskmitigationmeasuresmaydecreasetheserates.The incidenceofanastomoticleakisapproximately2%andmaymanifestasa localizedintraperitonealabscess,colocutaneousfistula,orfrank peritonitis.Managementmayrequireplacementofaradiologically guideddrainorreoperation.Thirty-daymortalityislessthan1%,with emergentoperationscarryinganincreasedrisk.

RESULTS

Theopenoperativetechniqueisemployedinapproximately40–50%of electivecolectomiesintheUnitedStates.Thisnumberisundoubtedly higherforemergencyoperations.Inthelateral-to-medialapproach,the colonisfirstmobilized,permittingtheaccurateidentificationofcritical structures—duodenum,rightureter,rootofmesentery—beforevessel ligation.Thealternativeopenmedial-to-lateralmobilization(“no-touch technique”)hasbeenespousedtohavetheoreticaladvantageswhen resectingcoloncancer,butscientificdatahavenotbornethisout. Medial-to-lateralmobilizationmaybeadvantageousinlaparoscopicright colectomybecausethelateralcolonattachmentsserveasnaturalcounter tractionasthesurgeondissectsoutthevascularpedicles.Asidefromthe surgeon’spreferenceastotheoperativeapproach,whenperformingright colectomyforanoncologicindication,thelymphnodeharvestisakey qualitybenchmark.Aminimumof12lymphnodesarerequiredfor adequatenodal(N)staging.ThiswasestablishedintheIntergroup0089 trialforadjuvantchemotherapyinstagesIIandIIIcoloncancer,in whichsurvivalincreasedasmorelymphnodeswereanalyzedwhile controllingforthenumberoflymphnodesinvolved.

CONCLUSIONS

Inthischapter,wehaveoutlinedtheopensurgicaltechniquewitha lateral-to-medialapproach.Locationofthepathologyisthemajor determinantofthetypeandextentofcolonresection,influencingthe degreeofresectionbasedonthearterial,venous,andlymphaticdrainage oftheaffectedcolonsegment.Furthermore,thereisincreasingreliance, bymedicalsocietiesandhealthcarepayers,onqualityindicatorssuchas theadequacyoflymphnoderesectioninresectionsformalignancy.
RECOMMENDEDREFERENCESAND READINGS
BergDF,BahadursinghAM,KaminskiDL,LongoWE.Acutesurgicalemergenciesin
inflammatoryboweldisease.AmJSurg2002;184:45–51. Garcia-RuizA,MilsomJW,LudwigKA,MarchesaP.Rightcolonicarterialanatomy.Implications
forlaparoscopicsurgery.DisColonRectum1996;39:906–11. GoldenbergEA,KhaitanL,HuangIP,SmithCD,LinE.Surgeon-initiatedscreeningcolonoscopy
programbasedonSAGESandASCRSrecommendationsinageneralsurgerypractice.Surg
Endosc2006;20(6):964–6. GoldsteinNS.Lymphnoderecoveriesfrom2427pT3colorectalresectionspecimensspanning45
years:recommendationsforaminimumnumberofrecoveredlymphnodesbasedonpredictive
probabilities.AmJSurgPathol2002;26:179–89. KahokehrA,SammourT,Zargar-ShoshtariK,SrinivasaS,HillAG.Recoveryafteropenand
laparoscopicrighthemicolectomy:acomparison.JSurgRes2010;162(1):11–6. KellerDS,PedrazaR,Flores-GonzalezJR,LeFaveJP,MahmoodA,HaasEM.Thecurrentstatus
ofemergentlaparoscopiccolectomy:apopulation-basedstudyofclinicalandfinancial
outcomes.SurgEndosc2016;30:3321–26. LeVoyerTE,SigurdsonER,HanlonAL,etal.Coloncancersurvivalisassociatedwithincreasing
numberoflymphnodesanalyzed:asecondarysurveyofintergrouptrialINT-0089.JClin
Oncol2003;21:2912–9. MarcelloPW,RobertsPL,RusinLC,HolubkovR,SchoetzDJ.Vascularpedicleligationtechnique
duringlaparoscopiccolectomy.Aprospectiverandomizedtrial.SurgEndosc2006;20:263–9. NeutzlingCB,LustosaSA,ProencaIM,daSilvaEM,MatosD.Stapledversushandsewnmethods
forcolorectalanastomosissurgery.CochraneDatabaseSystRev2012;(2):CD003144. TheClinicalOutcomesofSurgicalTherapyStudyGroup.Acomparisonoflaparoscopically
assistedandopencolectomyforcoloncancer.NEnglJMed2004;350:2050–9.
Chapter3
LaparoscopicMedial-to­LateralRightColectomy
ToyookiSonoda
INDICATIONSANDCONTRAINDICATIONS
Ingeneral,alaparoscopicdissectionoftherightcolonismore straightforwardthanthatofthetransversecolon,leftcolon,orthe rectum.Therightcoloncanbemobilizedfromthemedial,lateral, superior,orinferioraspect,andanycompetentsurgeonmustbeableto performthecolonicmobilizationfromallfourdirections,asdictatedby anatomicvariations.Themainadvantagesofthemedial-to-lateral approachtomobilizationofthecolonincludethefollowing:
Earlyligationofthevascularpediclesincancermaypreventthe liberationoftumorcellsintothemesentericcirculationduring
mobilization(theTurnbullno-touchtechnique). Preservationofthelateralcolonicligamentuntiltheendofthe
mobilizationkeepstherightcolonfixedinplaceandutilizesthelateral ligamentasanaturalretractor,asopposedtoalateral-to-medial mobilizationwhichthenrequiresonetoretractandmanipulateafloppy colon.
Indications
Themostcommonindicationsforalaparoscopicrightcolectomyinclude malignantneoplasm,benignpolypnotamenabletocolonoscopic removal,andCrohn’sdisease.Uncommon,yetpossible,indicationsare right-sideddiverticulitis,chronicvolvulus,hemorrhage,andischemia.
Contraindications
Therearebothabsoluteandrelativecontraindicationstothelaparoscopic approachtocolectomy.Absolutecontraindicationsincludethefollowing:
Hemodynamicinstability Knownhistoryofhostileadhesionsfrompriorsurgery
Relativecontraindicationstolaparoscopydependoneachclinical circumstance,aswellasthecomfortlevelofthesurgeon.Theseinclude thefollowing:
Largetumorsize(>8cm) Tumorinvadingotherstructures Boweldilationfromobstructionorileus Emergencysurgery Historyofpriorsurgery
Apatientmayhavehadmanyoperationsinthepast,butthepresence ofadhesionsmaynotprecludeasubsequentlaparoscopiccolectomy.For example,evenpatientswhohaveundergoneoneormoreopenileocolic resectionsforCrohn’sdiseasemaystillbecandidatesforlaparoscopic ileocolectomy.Itisworthwhileplanninganinitialdiagnosticlaparoscopy toassessthisfeasibility.However,whenextensiveadhesionsarepresent necessitatingconversiontoopensurgery,thedecisiontoconvertshould bemadeearlyintheoperation.Extensiveomentaladhesionstothe abdominalwallcanbefavorableforthelaparoscopicapproach,whereas significantintraloopboweladhesionsmaybemorechallenging.
PREOPERATIVEPLANNING
Thepatientshouldbepreparedforsurgery,withattentionpaidtothe optimizationofpreoperativecomorbidities.Neoplasmsshouldbe evaluatedwithpreoperativecomputedtomography(CT)scanand colonoscopy,withadditionalimagingbymagneticresonanceimagingor positronemissiontomographyscanwhenappropriate.Patientswith Crohn’sdiseaseshouldundergocolonoscopyandcompleteimagingofthe smallintestinewithamagneticresonanceorCTenterographyorcapsule endoscopy.InilealCrohn’sdisease,itisimportanttoexaminetheimages foranileosigmoidfistula,becausethisfindingmayaffectthemagnitude oftheoperationortheplanningofanincision.
Wheneveraneoplasticlesionispresent,especiallyonethatmaynotbe visibleontheserosalsurface,anendoscopictattoomustbeplacedusing permanentink.Tattooingallowsforlaparoscopicidentificationofthe tumor-bearingsegment,andeliminatestheriskofeitherremovingan incorrectsegmentoftheintestineorresectingatumorwithinadequate lateralmargins.Thetattooshouldbeplacedinauniformmanner,in3–4 quadrantstoensurethatthetattooisvisibleontheserosalsurfaceand nothiddenbythemesentery.Itisrecommendedthatthetattoois injectedatthedistalaspectofatumor,ratherthanplacingbothproximal anddistaltattoos.Thismethodlimitsconfusionincaseonlyonetattooed areaisvisible,andishelpfulinplanningthedistallineofresection.
Theuseofmechanicalbowelpreparationbeforeelectivecolorectal surgeryiscontroversial.Severalrandomizedprospectivetrialshavenot demonstratedanadvantagetomechanicalbowelpreparationinreducing ratesofanastomoticleakandsuperficialsurgicalsiteinfection(SSI) comparedwithnomechanicalpreparation.Asaresult,manysurgeonsno longerutilizeroutinemechanicalbowelpreparationbeforeelectivecolon resection.However,arecentevaluationof4,999patientsusingthe2012 Colectomy-TargetedAmericanCollegeofSurgeonsNationalSurgical QualityImprovementProgram(ACSNSQIP)databaserevealedthatrates ofanastomoticleak(2.8%vs.5.7%,P=0.001),incisionalSSI(3.2%vs.
9.0%,P<0.001),andprocedure-relatedhospitalreadmission(5.5%vs.
8.0%,P=0.03)werelowerwiththecombinationofmechanicalandoral antibioticpreparationbeforesurgeryascomparedwithnopreparation. Patientswhoreceivedeithermechanicalororalantibioticpreparationdid notfarebetterthandidpatientswhodidnotreceivepreparation.
Anotherargumentinfavorofmechanicalbowelpreparationisthat withthelaparoscopicapproach,theabilitytopalpateanintraluminal lesionislimited.Ifthelocationofatumororpolypcannotbeascertained duringlaparoscopicsurgery,anintraoperativecolonoscopyshouldbe
performedratherthanablindresection.Colonoscopycanbedifficultin thesettingofanunpreparedcolon.Intraoperativecolonoscopyshouldbe performedwithCO2insufflationratherthanairwheneverpossible,
becauseCO2insufflationlimitsboweldistensionduetotherapid absorptionofintraluminalCO2comparedwithair.Withtheuseofair insufflation,theterminalileummustbeoccludedwithalaparoscopic
bowelgraspertoavoidbothersomesmallboweldistension;withCO
2
insufflation,however,thisprecautionisnotnecessary.
Inaddition,thereareelementsofenhancedrecoveryaftersurgery (ERAS)pathwaysthatapplytopreoperativecare.ERASpathwaysare evidence-basedprotocolsthatstandardizepre-,intra-,andpostoperative caretoimproveoutcomes,enhancerecovery,andultimatelydecrease healthcarecosts.Topreventpreoperativedehydrationresultingin hemodynamicinstabilityuponinductionofanesthesiaandthusrequiring anincreasedvolumeofintravenousfluidsthatmaythendelayrecovery aftersurgery,patientsareencouragedtodrinkclearliquidsupto2hours ofsurgery.Theyarealsoaskedtoconsumea12-oz.helpingofa carbohydrate-richdrink2hoursbeforesurgery.Aggressivemultimodal narcotic-sparinganalgesiastartspreoperativelyaswell.Patientsreceivea combinationofacetaminophen,gabapentin,andanonsteroidalanti­inflammatorydrug(NSAID)suchascelecoxibinthepreoperativeholding area,whichwillthenbepostoperativelycontinued.

SURGERY

Patientsundergoinglaparoscopicbowelresectionshouldreceive appropriateintravenousantibioticswithin1hourofskinincision.Fora lengthyoperation,theantibioticsmustbeintraoperativelyredosedonthe basisoftheirpharmacokinetics.Prophylaxisagainstdeepvein thrombosisshouldbegivenpreoperatively.
Positioning
Agelpadisplacedontheoperatingtabletoavoidpatientslippageduring extremepositioning.Formostcases,alaparoscopicrightcolectomyis performedwiththepatientinthesupineposition,withbotharmstucked atthesides.However,incasesofCrohn’sdisease,patientsareplacedin themodifiedlithotomyposition,becausestandingbetweenthelegs facilitatestheexaminationoftheproximalsmallbowel(“runningthe bowel”).Furthermore,themodifiedlithotomypositionhelpswhenan occultileosigmoidfistulaisfound.Otherindicationsofamodified lithotomypositionincludethefollowing:
p.14
p.15
Inadifficultrightcolectomy,anadditionalassistantcanstandbetween thelegsandhelpwithretractionandexposurethroughadditionalports.
Whenalesionoratattooisdifficulttoidentify,anintraoperative colonoscopycanreadilybeperformed.
Whenapatientisplacedinamodifiedlithotomyposition,thedegreeof hipflexionmustbekepttoaminimumtopreventthethighsfrom becominganimpedimentastheycollidewiththehandlesofthe laparoscopicinstrumentsduringupperabdominalwork.
Technique
PortPlacement
Thecameraportisplacedinaperiumbilicalposition.Whetheritis placedsuperiororinferiortotheumbilicusisbasedonthebodyhabitus andlocationoftheumbilicus.Thecameraportisbestplacedatthe“top
ofthedome”whentheabdomenisinsufflated;inmostpatients,this positionwillbeinfraumbilical.However,whentheumbilicusislocated lowintheabdomen(inobesityandinsomemales),thecameraportis bestplacedinthesupraumbilicalposition.Inthemajorityofcases,this periumbilicalportwoundisthenextendedaroundtheumbilicusasa mini-laparotomyforexteriorizationofthecolon,resection,and anastomosis.
AtypicalportplacementisillustratedinFigure3-1.Wefavortheblunt Hassontechnique(10or12mm)forthecameraport.Thesurgeonbegins theoperationfromtheleftsideofthepatientusingtheleftlower quadrantandsuprapubicports.Theassistantstandstotherightofthe surgeon,holdingthecameraandusingtheleftupperport.Amonitor placedneartherightshoulderofthepatientisusedbybothoperators. Aftervascularligationandmedial-to-lateralretromesentericdissection, thesurgeonmovestotherightoftheassistant,usingthetwoleft-sided ports,forhepaticflexuretakedownandlateralligamentmobilization. Theassistanthelpsthroughthesuprapubicport.
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