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4 Right Colectomy: Straight Laparoscopic
Figs. 4.3 and 4.4 Two alternative port positions for a laparoscopic right colectomy. A third working port can be added in the right lower quadrant
if needed
55
right colon are avascular. Within this retroperitoneal triangle
posterior to the right colon, the right gonadal vessels are
encountered fi rst, moving from lateral to medial. The next
vertically oriented structure is the right ureter, which crosses
over the right common iliac vessels at the inferomedial border of this triangle. The vena cava is the next structure medial
to the ureter running vertically in this plane. Proceeding
cephalad in this plane, the second and third portions of the
duodenum and head of the pancreas are encountered next.
Just medial to the pancreatic head, the middle colic vessels
are encountered. Lateral to these structures, the hepatic fl exure lies over Gerota’s fascia of the right kidney.
Objectives of the Laparoscopic Procedure
Four objectives must be accomplished in order to complete a
laparoscopic right colectomy: (1) the right colon and its mesentery must be mobilized off of the retroperitoneum and
duodenum; (2) the vascular pedicles must be divided at the
appropriate level for the disease process; (3) the lateral
attachments, hepatic fl exure, and omental attachments must
all be divided; and (4) the specimen must be extracted and
the anastomosis performed.
There are four commonly used approaches for a laparoscopic right colectomy—the medial, inferior, lateral, and
superior approaches. Regardless of the method, the purpose
is to mobilize the right colon completely from the retroperitoneum and the sweep of the duodenum. This accomplishes
three purposes—it allows for safe ligation of the mesenteric
vessels; it frees the colon so that it can be delivered out
through the extraction site; and lastly, it allows for a tensionfree ileocolic anastomosis.
Medial Approach
The medial approach to the right colectomy involves an initial
incision through the ileocolic mesentery underneath the ileocolic artery (Video 4.1 ). This vascular pedicle is identifi ed by
grasping the cecal mesentery and lifting it anteriorly down
into the right lower quadrant. The vessels will form a bowstring in the mesentery. The peritoneum below the vessel is
incised, and the retroperitoneal plane is identifi ed. The initial
retroperitoneal dissection is performed bluntly through this
window. The duodenum is encountered early in the dissection
and should be gently swept down from the mesentery. Once
the duodenum has been identifi ed and is safely dissected
away from the pedicle, the ileocolic artery can be divided.
Vascular ligation allows this window to be opened widely and
greatly facilitates the remainder of the retroperitoneal dissection. Gentle blunt dissection should be carried out in this
plane laterally beyond the colon and in a cephalad direction
beyond the hepatic fl exure. The entire sweep of the duodenum
should be swept down in order to complete the mobilization.
Inferior Approach
The inferior approach begins with a peritoneal incision underneath the terminal ileal mesentery extending from the distal
mesentery up to the duodenum. As in the medial approach,
56
S.R. Hunt
the retroperitoneal dissection also proceeds superiorly and
laterally. An advantage of this approach is that the window
aperture is much wider than with the medial approach. The
duodenum is again identifi ed in the retroperitoneum and
swept out of harm’s way. This dissection should continue laterally beyond the colon and in a cephalad direction beyond
the hepatic fl exure, again including the entire sweep of the
duodenum.
Lateral Approach
The lateral approach is similar to the conventional open
approach. An advantage of this approach is that it is more
familiar for a traditional open surgeon and can ease the transition to performing laparoscopic colectomies. Additionally,
this approach may be necessary when infl ammation or adhesions preclude the medial or inferior approach. The disadvantage of this approach is that it can sometimes be diffi cult
to perform the retroperitoneal dissection toward the operator
and the camera. Again, the duodenum should be identifi ed in
the retroperitoneum and kept safe from harm.
Superior Approach
The fi nal approach is the superior-to-inferior approach. This
approach is begun by incising the gastrocolic omentum and
dissecting from medial to lateral in the plane cephalad to the
mesentery of the proximal transverse colon. Dissection then
proceeds inferiorly after the hepatic fl exure attachments have
been divided. The duodenum should be identifi ed in the retroperitoneum as the hepatic fl exure of the colon is mobilized
and pulled down toward the patient’s left hip. As with the
lateral approach, it becomes more diffi cult as the dissection
proceeds medially. The superior approach is invaluable in
situations in which there is a large cecal mass or signifi cant
infl ammation in the right lower quadrant or the ileocolic
mesentery.
Every surgeon should be familiar with all of these
approaches, as different patient habitus, anatomic variation,
and disease presentation often necessitates some combination
of these approaches in order to adequately mobilize the colon.
neoplastic disease, the liver should be closely inspected for
metastatic disease. If a suspicious lesion is identifi ed, it can
usually be biopsied laparoscopically by passing a core needle biopsy device subcostally through a stab incision. If the
resection is being performed for Crohn’s disease, the small
bowel should be visualized in its entirety.
The patient should then be placed in steep Trendelenburg
and in the left lateral decubitus position. As described above,
it is important to secure the patient to the table in order to
avoid any mishaps. The omentum should be rolled over the
top of the transverse colon and draped onto the stomach.
This maneuver exposes the serosal surface of the transverse
colon, keeps the omentum from displacing small bowel into
your fi eld of view, and allows access to the omental attachments of the transverse colon. Next, the small bowel is swept
out of the pelvis into the left upper abdomen. The terminal
ileum should then be placed alongside the ascending colon,
exposing the inferomedial aspect of the terminal ileal mesentery. These steps are greatly aided by the gravity resulting
from proper bed positioning.
Mobilization of the Colon and Mesentery from the Retroperitoneum
The terminal ileal mesentery should be lifted off of the retroperitoneum, allowing visualization of along the base of
the mesentery up to the fourth portion of the duodenum
(Fig. 4.5 ). While it is not usually necessary to identify the
right ureter during this procedure, it can often be seen at this
The Procedure
For the purposes of this textbook, the operation will be
described using the inferior approach. The other approaches
will be referenced when appropriate.
After pneumoperitoneum has been established, the
abdominal cavity should be visualized, and any abnormalities should be noted. If the resection is being performed for
Fig. 4.5 The inferior approach begins by elevating the terminal ileal
mesentery off of the retroperitoneum. In this thin patient, the right ureter and inferior vena cava can be visualized through the peritoneum.
Just offscreen to the right, behind that fold of mesentery, is the inferomedial aspect of the fourth portion of the duodenum
4 Right Colectomy: Straight Laparoscopic
57
Fig. 4.6 With the terminal ileal mesentery elevated, the peritoneum is
excised in a line along the base of the mesentery up toward the duodenum—allowing access to the retroperitoneal space
Fig. 4.7 Once the peritoneum is incised, elevation of the mesentery
and gentle blunt dissection in the retroperitoneum develops the avascular plane behind the ileocolic mesentery
point. A score should be made in the peritoneum along the
base of the terminal ileal mesentery up to the duodenum
(Fig. 4.6 ). The retroperitoneal fusion plane can then be
accessed through this peritoneal entry point (Fig. 4.7 ).
Often, the challenging part of this procedure is identifying
the appropriate retroperitoneal plane. The simplest method
by which this plane can be exposed is to place a blunt instrument behind the cecum and lift anteriorly and cephalad with
modest force. This maneuver will usually reveal the appropriate areolar plane. Dissection should then be carried out
bluntly in a lateral and cephalad direction. This is accomplished by elevating the mesentery upward with the left
hand and using the right-handed instrument to develop the
plane. It is not necessary to grasp tissue with the retracting
Fig. 4.8 As the retroperitoneal dissection proceeds, the retroperitoneal
duodenum is visualized (center). The areolar attachments of the duodenum to the right colon mesentery can then be bluntly dissected to separate the entire sweep of the duodenum from the mesentery
instrument, and it may be kept closed during this portion of
the procedure. If exposure is inadequate, a third 5 mm port
may be added to allow the surgical assistant to facilitate
exposure. Sweeping the right-handed instrument in the
shape of a backwards “C” allows the dissection to progress
in a cephalad direction. Occasionally, the dissection is better
suited to using the right hand to lift the mesentery toward
the anterior abdominal wall and developing the plane with
the left-hand instrument. If the dissection becomes diffi cult,
the surgeon should return back to a known plane, confi rm
the anatomy, and proceed with dissection from the known
plane. The duodenum is identifi ed during the cephalad portion of this dissection. Tension at the apex of the dissection
is critical to progression, and the left hand should frequently
be replaced to keep tension in this plane. The left hand can
provide optimal tension by engaging the apex of the dissected plane and lifting anteriorly and toward the camera.
The duodenum will be found at the medial and superior
aspect of this plane (Fig. 4.8 ). Once identifi ed, it should be
swept down and medially until the entire sweep of the duodenum and a portion of the pancreatic head have been freed
from the mesentery. Once this is accomplished, dissection
should be carried out laterally behind the hepatic fl exure.
Around the duodenum, it may be necessary to sharply divide
some areolar tissue; however, energy should be used sparingly, if ever, in this avascular plane. If the duodenum is dissected posteriorly from the right colon mesentery, the right
ureter is certain to be removed from harm’s way.
If the duodenum cannot be easily identifi ed using this
inferior approach, the other approaches should be considered, as it is a necessity to free the duodenum from the
colonic mesentery when mobilizing the right colon.
Frequently, all four approaches are required before the duodenum can be safely identifi ed and dissected away from the
specimen.
58
Identifi cation and Division
of the Vascular Pedicles
Once the retroperitoneal dissection has been accomplished,
the vascular pedicles may be divided next. Alternatively, the
right colon attachments can be divided at this point in the
procedure, depending on the surgeon’s preference. The ileocolic vessels are the most readily identifi ed and should be the
fi rst vascular pedicle that is isolated and divided. This pedicle can be identifi ed by grasping the cecum and pulling it
down into the right lower quadrant and elevating it. This tension exposes a bowstring where the ileocolic pedicle exists.
If an inferior approach has been used, there should be dark,
purple windows on each side of the ileocolic vessels
(Fig. 4.9 ). If there is uncertainty about its identity, the pedi-
cle can be grasped and walked out to its distal extent to avoid
confusion with the superior mesenteric artery. Once the ileocolic pedicle has been identifi ed, the window should be
opened on each side of the pedicle and the vessels ligated
(Fig. 4.10 ). This author uses a vessel-sealing device, but
Fig. 4.9 After the retroperitoneal dissection is completed, the ileocolic
pedicle can be identifi ed by pulling the cecum into the right lower quadrant and elevating it. The pedicle forms a bowstring, and the windows
on each side of the vessels appear dark
S.R. Hunt
clips and staplers offer equally effective means of vessel
ligation. If the ileocolic pedicle is the only pedicle that needs
to be divided for a specifi c disease, the operator may proceed
to the next step. If the middle colic vessels are to be divided,
it should take place at this point. The right branch of the middle colic artery can usually be identifi ed by following the cut
edge of the divided ileocolic pedicle onto the transverse
colon mesentery (Video 4.2 ). The fi rst fatty structure encountered will be the right branch of the middle colic artery. If
this is to be divided intracorporeally, it should be isolated
and divided in the same manner. Before applying an energy
source to any middle colic vessels, the gastrocolic attachments to the superior transverse colon mesentery should be
divided to avoid injury to the stomach.
Division of the Right Colon Attachments
The right colon attachments can then be divided. This is most
easily accomplished with the patient in reverse Trendelenburg
position. The simplest way to approach this is to start at the
free edge of dissection just lateral and inferior to the cecum.
The lateral attachments can then be lifted off of the retroperitoneum, as the posterior dissection should have already been
performed lateral to the colon (Fig. 4.11 ). Division of these
attachments should proceed in a cephalad direction. As this
is an avascular plane, the division may be performed with
scissors, cautery, or a vessel-sealing device. The surgeon
should intermittently look both above and below the lateral
attachments to confi rm their location. A common mistake in
dividing the lateral detachments is to continue dividing these
attachments beyond the hepatic fl exure lateral to the liver.
The surgeon should take note of the location of the colon and
divide only the colonic attachments. This will necessitate a
deliberate medial turn at the hepatic fl exure and to avoid
going posterior to the kidney.
Fig. 4.10 After the windows on each side of the ileocolic pedicle are
opened, the vessels are easily identifi ed, and the pedicle can be divided
just distal to its origin
Fig. 4.11 The lateral attachments of the right colon viewed from an
inferior vantage point. The grasper is pulling the mesoappendix medially, and the retroperitoneal dissection is seen to extend laterally beyond
the colon
4 Right Colectomy: Straight Laparoscopic
59
Fig. 4.12 The superior approach is begun by incising the attachments
between the omentum and the proximal transverse colon. This approach
can be used in combination with other approaches to assist with mobilization of the hepatic fl exure
Fig. 4.13 As the dissection proceeds proximally along the transverse
colon in the fused gastrocolic plane, the remaining hepatic fl exure attachments can be demonstrated by pulling downward and medially on the colon
Frequently, the most diffi cult part of a right colectomy is
the fi nal mobilization of the hepatic fl exure. A helpful
maneuver to better visualize the hepatic fl exure attachments
is to fl atten out the colon just medial to the attachments and
pull down toward the patient’s left lower quadrant. If this still
does not allow for continued mobilization of the hepatic fl exure, a superior approach should be attempted.
The superior approach involves incising the gastrocolic
omentum just cephalad to the proximal transverse colon
(Fig. 4.12 ). Prior to beginning this dissection, the patient
should be placed in reverse Trendelenburg position. A plane
is usually easily identifi ed just cephalad to the transverse
colon mesentery. Dissection should be carried out bluntly in
this plane laterally. As this dissection proceeds proximally
along the transverse colon, the peritoneum of the gastrocolic
attachments should be incised and the plane developed moving from medial to lateral toward the hepatic fl exure.
Eventually, the only remaining attachments will be the
hepatic fl exure attachments, and these can be visualized by
grasping the colon proximal and distal to the fl exure and
pulling down toward the left lower quadrant (Fig. 4.13 ).
After the hepatic fl exure attachments have been divided,
the duodenum should be identifi ed. There are often fi lmy
attachments of areolar tissue that must be divided sharply
before the right colon can be completely mobilized. Once the
surgeon feels that the right colon has been mobilized adequately, this must be confi rmed. Confi rmation is best accomplished by grasping the hepatic fl exure of the colon and
dragging it down to the left lower quadrant well beyond the
site of planned exteriorization. The operator should also
assure that the colon has been mobilized suffi ciently to lift it
anteriorly up to and through the abdominal wall.
It is a grave mistake to attempt to exteriorize an incompletely mobilized colon. This can lead to excessive force in
trying to deliver the colon through the extraction incision.
Such force can cause avulsion of the middle colic vessels and
rapid blood loss that can necessitate an emergent conversion
to an open procedure.
Extended Right Colectomy
If it is necessary to resect a signifi cant portion of the transverse colon as part of the right hemicolectomy, the procedure
need be modifi ed only minimally. The retroperitoneal dissection is performed in exactly the same fashion as described
above. This author prefers to divide the lateral attachments
and mobilize the hepatic fl exure prior to dividing the vessels
when performing an extended right colectomy. After the
hepatic fl exure is mobilized, the omentocolic attachments
across the transverse colon can then be divided. If the omentum is to be removed with the specimen, the gastrocolic
omentum can be divided with a vessel-sealing device. Once
the omental attachments are divided, the superior aspect of
the transverse colon mesentery should be cleared down to the
base of the mesentery by dividing the gastrocolic attachments to the posterior stomach. Only after these attachments
are divided can high ligation of the middle colic vessels be
accomplished safely.
Exteriorization and Anastomosis
Once the colon is suffi ciently mobilized, preparations should
be made for exteriorization. Prior to desuffl ating the abdomen, the retroperitoneum and vascular pedicles should be
inspected and hemostasis confi rmed. If the camera port is in
the center of the abdomen, the operator should note which
incision would most easily allow for the specimen to be
exteriorized with the least tension. Usually, this is a periumbilical incision. Infrequently, the incision is above or below
the umbilicus. The fat fold at the cecum should be grasped
and locked in a laparoscopic grasper. The periumbilical incision should then be extended to the appropriate size, usually
60
S.R. Hunt
around 3 cm. A self-expanding wound retractor facilitates
extraction and may help to prevent wound infections [
1 ].
The specimen can then be extracted by grasping it with a
Babcock clamp after it is delivered up into this incision with
the laparoscopic atraumatic grasper. The bowel should be
maintained in an anatomic orientation during this portion of
the procedure to prevent twisting prior to creating the anastomosis. The terminal ileum and colon can be divided, and
the remaining mesentery to these points should also be
ligated. After each portion of the bowel is divided, it should
be held in place by an assistant or grasped with a Babcock
clamp that is clipped to the drapes to avoid twisting the
bowel. While some prefer to perform an intracorporeal anastomosis, we perform ours in an extracorporeal fashion.
There is no proven advantage to the intracorporeal anastomosis, and the extraction incision does not need to be
extended in order to perform the anastomosis extracorporeally. The anastomosis can be performed in a side-to-side,
functional end-to-end fashion, or in an end-to-side fashion.
We do not close our mesenteric defect, as this can be diffi cult to do through a small extraction incision. This has been
shown to be a safe practice [ 2 ].
Pearls and Pitfalls
When diffi culty is encountered in a laparoscopic procedure,
it can frequently be attributed to one of two simple things—
lack of tension or a poor understanding of one’s anatomic
location. If a procedure is not proceeding according to plan,
the surgeon must stop and ask oneself: (1) “Do I have enough
tension?” and (2) “Do I know where I am?” If the answer to
either question is negative, it should be corrected immediately. If the anatomy still cannot be determined after simple
maneuvers, serious consideration should be given to converting to an open procedure.
In some cases, the anatomy may be obvious, but the pro-
cedure still is not progressing because of patient or disease
factors. As long as there is no overt danger of proceeding
laparoscopically, there are two options short of conversion to
an open procedure. Extra 5 mm ports can be placed to aid
exposure. Another option is to use a hand-assisted device.
When adding a hand port, be cautious to place it in a position
where it will be possible to extract the specimen without
undue tension—usually in the periumbilical position. Such
positioning of the hand port will necessitate moving the camera port to another location, such as the epigastrium.
Conversion to open is not a failure, and it is often the bet-
ter part of valor. Any perception by the surgeon that proceeding laparoscopically would be unsafe or unsound
oncologically demands conversion to an open procedure. It
is preferential to convert before anything untoward occurs,
rather than after. Litigation for laparoscopic mishaps is
unfortunately common, but litigation for conversion should
be nonexistent.
Conclusion
The straight laparoscopic approach to a right colectomy or
ileocolic resection is a safe, reproducible, and reliable technique that provides all the advantages of minimally invasive
surgery. While the inferior approach is preferred in most
cases by this author, surgeons should be aware of all methods
available to effectively accomplish the retroperitoneal mobilization, division of lateral and hepatic fl exure attachments,
ligation of the vascular pedicle, and resection/anastomosis.
References
1. Reid K, Pockney P, Draganic B, Smith SR. Barrier wound protection
decreases surgical site infection in open elective colorectal surgery: a
randomized clinical trial. Dis Colon Rectum. 2010;53(10):1374–80.
2. Causey MW, Oguntoye M, Steele SR. Incidence of complications
following colectomy with mesenteric closure versus no mesenteric
closure: does it really matter? J Surg Res. 2011;171(2):571–5.
Right Colectomy: Hand-Assist
Kirk A. Ludwig and Timothy Ridolfi
K e y P o i n t s
• Hand-assisted laparoscopic right colectomy, as described
here, is a top-down approach.
• The anatomy is viewed from a laparoscope placed near
the falciform ligament in a subxiphoid position.
• The operation is performed with a hand port placed in the
midline and then only two additional 5 mm ports.
• This is a single-surgeon approach with no need for a
trained assistant.
• Unlike other laparoscopic right colectomy techniques, the
dissection starts and stays in a single plane throughout the
operation, which minimizes operative time and makes for
a smooth, clean, bloodless, and anatomic dissection.
• This approach gives the surgeon an excellent view of the
middle colic vessels allowing for proximal ligation deep
in the transverse colon mesentery.
• Since, at present, the ileocolic anastomosis that follows a
right colectomy is most commonly performed extracorporeally, using the extraction site for a hand port makes
intuitive sense.
Electronic supplementary material: Supplementary material is avail-
able in the online version of this chapter at
Videos can also be accessed at
978-1-4939-1580-4
K. A. Ludwig , M.D. (*) • T. Ridolfi , M.D.
Division of Colorectal Surgery, Department of Surgery ,
Medical College of Wisconsin , 9200 W. Wisconsin Ave. ,
Milwaukee , WI 53226 , USA
kludwig@mcw.edu; tridolfi @mcw.edu
e-mail:
.
10.1007/978-1-4939-1581-1_5 .
http://www.springerimages.com/videos/
5
Introduction
Since the introduction of laparoscopic cholecystectomy in
the late 1980s, laparoscopic techniques have been rapidly
and successfully applied to multiple abdominal operations,
including colon and rectal resections. However, in large part
due to the degree of diffi culty, oncologic concerns, and the
diffi culty in demonstrating dramatic advantages compared to
the open approach, laparoscopic colon surgery was slow to
evolve. In the early years, laparoscopic colectomy was targeted towards benign conditions such as Crohn disease and
diverticulitis. As experience was gained, the technique was
applied to not only all portions of the colon and rectum but to
malignant disease as well. Initial concerns regarding oncologic outcomes, such as locoregional clearance of tumor,
recurrence rates, and long-term survival, have largely been
answered by four prospective, randomized, controlled trials
demonstrating the equivalency of laparoscopic and open procedures [ 1 – 4 ]. In addition, minimally invasive colon surgery
has been associated with a number of short-term benefi ts,
including faster recovery, less pain, shorter hospitalization,
and improved cosmetic outcome [ 5 ].
Technical diffi culty with laparoscopic colorectal surgery
is still an issue, which probably explains why the majority of
colorectal surgery is still performed using open techniques
[ 6 ]. There are a variety of techniques for performing a lapa-
roscopic right colectomy: there is the (open) standard lateral
to medial approach, there is the medial to lateral laparoscopic
approach wherein the ileocolic artery is grasped and taken
near its origin as the initial maneuver, and there is the bottom- up or retroperitoneal approach wherein the operation
starts by incising the peritoneum at the base of the small
bowel mesentery from the right lower quadrant up the duodenum and then the ileal and right colon mesentery are lifted
off of the retroperitoneum to the hepatic fl exure, while the
lateral attachments are left in place to fi x the colon in position. It is valuable for the laparoscopic surgeon to be facile
with each, since in different situations, they can each be
H.M. Ross et al. (eds.), Minimally Invasive Approaches to Colon and Rectal Disease: Technique and Best Practices,
DOI 10.1007/978-1-4939-1581-1_5, © Springer Science+Business Media New York 2015
61
62
K.A. Ludwig and T. Ridolfi
applied to advantage. However, the approach illustrated here
is the hand-assisted laparoscopic right colectomy. What follows are the concepts underlying this operative approach and
a description of the technique.
Background
The concept of using the hand to facilitate a laparoscopic
colon operation is based on a number of factors. The fi rst and
most basic concept is that as long as an incision will be made
at some point in the case, for extraction and the anastomosis,
why not make it at the beginning of the case and use the incision to facilitate the conduct of the operation? While there is
legitimate argument over whether the hand-assisted laparoscopic colectomy is associated with the same short-term
patient-related benefi ts as the standard laparoscopic operations, data from the literature suggests that it does [ 7 – 9 ].
Some fi nd troubling the fact that a “large” incision has to be
made on the abdominal wall for placement of the hand-assist
device. For the average surgeon, the incision size will be
about 7 cm. This compares favorably to the average extraction incision size in the COST trial, 6 cm, and the CLASICC
trial, 7 cm [ 10 , 11 ]. Some argue that the hand-assisted tech-
nique is not as “gentle” as the standard laparoscopic
approach. While there is probably more abdominal wall
“trauma” associated with this approach due to the stretching
of the wound with the hand placed through it, one could reasonably argue that in terms of what happens inside the abdomen, there is no more gentle instrument than the hand: surely
less “traumatic” than the 5 and 10 mm graspers that apply
signifi cant force, over small surface areas, especially on
fragile tissues. Who would ever grasp the small bowel or the
colon with clamps during open surgery?
Second, for surgeons who do not perform a high volume
of colon surgery, it can be diffi cult to learn and utilize laparoscopic colon surgery techniques. In addition, with laparoscopic colectomy, operative times tend to be long, and there
is a fairly high conversion rate, which can be frustrating. In
the COST trial [ 10 ] and the CLASSIC trial [ 11 ], the average
operative time for laparoscopic colectomy was almost an
hour more than for the open colectomy. In the COLOR trial
the open operations were 30 min faster than the laparoscopic
procedures. In each of these trials, the conversion rate was
greater than 20 %. While these conversion rates are quite a
bit higher than rates reported in more recent series [ 6 ], there
are still situations that can make laparoscopic colon surgery
long, diffi cult, and frustrating. The hand-assisted technique
may help reduce operative times signifi cantly, and in the
authors’ experience, conversion to open operation rarely
occurs. A surgeon with a good grasp of the pertinent anatomy and just a modicum of laparoscopic skill can learn and
use this technique.
Third, there are simply a number of practical issues
related to laparoscopic colon surgeries that a hand-assisted
technique can help overcome. For example, the increasing
number of obese patients is a problem. Over 60 % of adults
in the United States today are considered either overweight
or obese [
12 ]. Unfortunately, due to the diffi culty of per-
forming standard laparoscopic colon surgery on these
patients, the very patients who might benefi t the most from a
minimally invasive operation may simply be excluded due to
their size. Diffi culty will vary from patient to patient and will
vary by patient gender. For example, women tend to carry
much of their excess weight within the abdominal wall.
While a laparoscopic colon resection in an obese female may
seem a daunting task, in reality, the thicker the pannus, the
more likely that the amount of intra-abdominal fat will be
such that laparoscopic operation will be possible. With an
obese woman, the most diffi cult part of the operation may
not be the intra-abdominal dissection, but the exteriorization
of the specimen and elevation of the bowel ends for the construction of an anastomosis. In the obese male, the situation
is often exactly the opposite: the abdominal wall may be
quite thin while the omentum and the mesentery may be
extraordinarily thick, and the colon may be engulfed in its
fatty appendages. Moving the heavy omentum and thick and
heavy mesentery and bowel around with small-diameter laparoscopic instruments can be very diffi cult. The weight of
the tissue increases the likelihood of tearing tissue and
creating a tough situation with bleeding to contend with.
This type of obese patient, that is, the one with most of the
excess weight inside, as is most often the case in males, is
generally not a good candidate for standard laparoscopic
colon surgery. But they can often be managed well using a
hand- assisted technique.
Fourth, when performing a standard laparoscopic colon
operation with a large organ like the colon, where exposure
is so important, it really helps to work with the same team
on a regular basis, and this can be diffi cult to coordinate for
the average surgeon. Many of the standard laparoscopic
approaches to colon surgery require an assistant to help with
exposure. This assistant must be trained, as this person has to
provide the all-important exposure. Many surgeons do not
have ready access to a trained assistant for a routine colectomy. The technique illustrated does not require a second surgeon to assist. The camera can be held by a nurse or surgical
assistant. Many of the troubles with exposure can be overcome with this technique, and this technique makes laparoscopic colon surgery doable in obese patients. Five millimeter
graspers do not work very well to lift and expose anatomy in
obese patients, but the hand does this job very well.
Fifth, there are a number of anatomic issues that can
challenge the surgeon when performing a laparoscopic right
colectomy, and the hand-assisted approach can help overcome
these diffi culties. For example, the hand-assisted technique
5 Right Colectomy: Hand-Assist
63
overcomes the diffi culty in doing a laparoscopic right
colectomy in a patient who has had a cholecystectomy with
adhesions that fi x the hepatic fl exure into the gallbladder
fossa or approaching the mesenteric vessels in the patient
who has the omentum stuck down onto the right colon or the
ventral surface of the right colon mesentery. Especially when
operating for cancer, if the omentum is adherent to the right
colon, it should be left in place, and this makes exposure of
the vessels problematic. Patients who have had an appendectomy will also frequently have omental adhesions in the right
lower quadrant that can make the standard laparoscopic
approaches more diffi cult. The hand-assisted technique that
is illustrated minimizes these diffi culties signifi cantly.
Another problem for the standard laparoscopic approaches
to the right colon is a bulky tumor. Laparoscopic instruments
are just not very good at moving bulk around in the abdomen, while the hand works quite well.
Finally, the hand-assisted right colectomy technique
makes proper management of the middle colic vessels fairly
easy. Anyone who has performed any signifi cant number of
laparoscopic colon resections would agree that the middle
colic vessels and the transverse colon mesentery are the
hardest part of the colon anatomy to manage properly. The
reasons are that the vascular anatomy in this area is quite
variable, the arteries are surrounded by large veins that can
bleed easily, the mesentery in this area is short, exposure is
diffi cult, and bleeding in this area takes the surgeon right
down onto the pancreas and the superior mesenteric artery.
This can just simply be a diffi cult area to manage well using
standard laparoscopic right colectomy approaches. Using the
technique illustrated, the surgeon gains a very good view of
the middle colic vessels. This is a particular concern with
regard to resecting cancers up at the hepatic fl exure or the
proximal transverse colon. The primary advantage here is
that the vessels are seen from above and are approached from
the side, moving from the patient’s left to right. The middle
colic vessels can be hard to manage head on using laparoscopy. From the side, they are very straightforward. Ileocecal
resections are frequently performed for ileocecal Crohn disease, but this is a different operation. With an ileocecal resection, there is no particular need to take the middle colic
vessels. The hepatic fl exure is mobilized simply to allow
mobility for extraction of the ileum and right colon so that a
safe extracorporeal anastomosis can be conducted in the
ascending colon, not the transverse colon. When the issue is
cancer, much concern about taking the vessels near their origin will be shown.
The vast majority of right colectomies are performed to
manage neoplastic disease, either invasive cancer or large
polyps that cannot be managed using a colonoscope. As a
general rule, since the likelihood that a polyp will harbor a
cancer increases with the size of the polyp, when the indication for colectomy is a large adenoma, a formal resection
should be performed. Another, not infrequent, indication for
laparoscopic segmental colon resection is in the management of a malignant polyp that has been removed colonoscopically. If the polypectomy fails to meet one or more of
the accepted criteria for a curative polypectomy, a formal
resection is indicated. In these situations, the operation is
conducted to remove the area of bowel involved so as to
ensure that there is no cancer left within the bowel wall itself
and to do a regional lymphadenectomy to remove potentially
involved nodes. Again, a formal resection is recommended.
Other much less common indications for a laparoscopic right
colectomy might include management of right colonic bleeding from a vascular malformation or infl ammatory disease
due to right colon diverticulitis.
The formal right colectomy for neoplasia involves the usual
maneuvers that defi ne an oncologic colon resection: (1) proximal lymphovascular pedicle ligation and complete lymphadenectomy, (2) wide en bloc resection of tumor- bearing bowel
segment with adjacent soft tissue and mesentery, and (3) minimizing the possibility of tumor contamination to the abdominal
cavity, the wounds, or the bowel above or below the tumor.
The formal oncologic right colectomy, then, involves
proximal ligation of the ileocolic pedicle and the right branch
of the middle colic artery for cecal tumors or the entire middle colic pedicle for tumors in the ascending colon up to the
proximal transverse colon. The ileum is divided about
15–20 cm from the ileocecal valve which corresponds to a
point on the small bowel at which the superior mesenteric
artery ends. The transverse colon is divided at its midpoint.
Operation (Video 5.1 )
Patient Positioning
For the hand-assisted right colectomy illustrated, the patient
is placed on the operating table in the supine position.
Intermittent compression devices are placed, a general anesthetic is administered, and a urinary catheter and an orogastric tube are inserted. Both arms are tucked alongside the
body. The arms are held in position by a folded drawsheet
that the patient lays on. The ends of the drawsheet are brought
up alongside the body, the arms are placed next to the body,
the drawsheet is pulled around the arms, and it is placed
under the patient. In addition, the patient is secured to the
bed with multiple pieces of three inch tape. One or more
pieces are placed across the lower extremities and a piece is
used across the chest. Foam pads can be placed beneath the
tape. These maneuvers are used to keep the patient on the
operative table during the extremes of bed tilt that are often
required to obtain exposure (Fig. 5.1 ). Having both arms
tucked is more secure for the patient, and it also provides the
surgeon and the assistant with maximal mobility around the
64
K.A. Ludwig and T. Ridolfi
Fig. 5.2 The midpoint of the hand-assist incision is at the midpoint of
a line drawn from the anterior superior iliac spine to the costal margin.
For most patients, the incision will be centered on the umbilicus.
For obese patients, it may be well above the umbilicus
of the patient, and the entire team focuses on these monitors.
Additional monitors are really not needed for the illustrated
procedure.
Fig. 5.1 The patient is positioned on the operating table in the supine position with both arms tucked at the side. Tape is used around the chest and the
legs to ensure that the patient stays on the table in the extremes of bed tilt
operative table. The operative fi eld should be lengthened by
pushing the IV poles up towards the patient’s head and asking the anesthesia personnel to push the table away from
their equipment. Again, this simply gives the operative team
more room to maneuver around the table. The fi eld is prepped
from the nipples to the mid-thigh level and the towels are
placed wide on the abdomen. We prefer to have the towels
held in position with an Ioban™ sheet. This is used to keep
the towels in place, since when they are placed so widely on
the abdomen, they can easily fall down the sides of the
patient, exposing the un-prepped table. In addition, the
Ioban™ sheet keeps instruments, cords, and cables from falling down alongside the patient outside the sterile fi eld.
The exact routing of the camera cord, the fi beroptic light
cord, and the insuffl ation tube will vary based on the arrangement of the operating room. The energy sources are brought
onto the fi eld at the patient’s right shoulder. Typically,
no suction is set up for this operation, as it is rarely used.
If need be, it is brought on to the fi eld at the foot of the bed.
One or two video monitors will be placed along the right side
Port Placement
For the hand-assisted laparoscopic right colectomy, the ports
and the hand-assist device are placed as follows. The handassist device is placed in the midline. One should center this
midline wound based upon palpable skeletal landmarks. The
center of the hand port incision should be at the midpoint of
a line drawn from the costal margin to the anterior superior
iliac spine (Fig. 5.2 ). This will center the hand properly on
the anatomy, independent of the location of the umbilicus,
the location of which will vary based on the body habitus of
the patient. In obese patients, the entire hand port incision
may be well above the umbilicus, while in average weight
patients, the incision is generally centered on the umbilicus.
The midline wound is optimal, based upon surgeon ergonomics, consideration of extracorporeal anastomosis, and
maintenance of videoscopic perspective of the relevant anatomy for right colectomy. Generally speaking, the size of the
incision for the device will be the size of the surgeon’s glove
in centimeters. However, in practicality, one can usually
cheat this size by a centimeter or so.
The authors use the GelPort™ device. It is easy to use and
it provides the advantage of being able to place ports, instruments, or staplers right through the device even with the
hand in place. Also, the surgeon’s hand can be brought in and
out of the abdomen without losing pneumoperitoneum. This
feature helps for teaching purposes, as it is easy to go from
the surgeon’s to the assistant’s hand in the abdomen.