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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_917_Библиотеки_им_академика_М_И_Перельмана.pdf
14 Laparoscopic Right Colectomy: Options forIleocolonic Reconstruction
203
Fig. 14.2 Position B. Trocars positioning with the surgical team between the patient’s legs.
(Copyright © Giovanni Dapri. Illustration by M.Crespi)
Trocars Placement
There are several options for trocar positioning for laparoscopic right hemicolectomy with planned ECA or ICA.Over time, the surgeon will eventually identify
their preferred conguration and alternatives when required based on body habitus,
adhesions from prior surgery, and need for additional assist trocars. Most surgeons
will place their 12mm stapler port where they plan to extract the specimen, so that
there are fewer incisions at risk for subsequent hernia formation. It is important to
mark potential extraction sites at the start of the procedure as after insufation; the
abdominal wall will become distorted.
Position A(Fig. 14.1)
With the patient supine, a 5/12mm trocar is placed just at the umbilicus for the
5/10mm scope or endoscopic linear stapler. This trocar site can later be enlarged
204
G. Dapri and M. Montorsi
for specimen extraction via the umbilical incision when ECA is performed. A
5/12mm trocar is placed in the suprapubic region, slightly to the left of the midline for the surgeon’s left-hand instruments like the grasping forceps, or the
scope or the endoscopic linear stapler if introduced through this port. This latter
trocar will be enlarged for specimen’s extraction via a Pfannenstiel incision after
completion of ICA. A 5 mm trocar is placed in the epigastrium, slightly to the left
of the midline for the surgeon’s right-hand instrument, like an energy device and
the needle holder for suturing. If needed for added retraction, a 5mm trocar can
be placed along the right mid-clavicular line in the right upper quadrant for the
assist grasping forceps. Additional assist trocars can be placed in any number of
locations as needed. This is particularly useful in obese patients and in patients
with extensive adhesions. When suturing is found to be challenging due to the
suboptimal port placement, an existing assist port is rstly recommended. If this is
still suboptimal, one or more additional trocars can be placed, so that the surgeon’s
right and left hands are properly triangulated with the camera targeted on the
relevant anatomy.
Position B (Fig.14.2)
With the patient supine with split-leg or in low lithotomy position, a 12mm trocar
is placed in the suprapubic location for the 10mm scope and for the endoscopic
linear stapler. This trocar will be enlarged for specimen removal via a Pfannenstiel
incision, after completion of intracorporeal anastomosis. A 5mm trocar is placed on
the left mid-clavicular line in the left iliac fossa for the surgeon’s right-hand instruments like the needle holder for suturing or for the introduction of 5mm scope at
the time of endoscopic stapling. A 5mm trocar is placed on the right mid-clavicular
line in the right iliac fossa for the surgeon’s left-hand instruments, like the grasping
forceps. If needed for retraction, a 5mm trocar is placed in the epigastrium, slightly
to the left of the midline for the assist grasping forceps.
Options forIleocolonic Reconstruction
When an ECA is performed, the specimen is extracted through the enlarged
trocar site (e.g., 12 mm umbilical trocar). Both the ileum and trasnverse colon
are transected extracorporeally using a standard linear stapler, and the specimen is handed off the field. The anastomosis is then created.
When an ICA is performed, following vascular dissection and mobilization
of the ileum, right and transverse colon, the distal ileum and the proximal transverse colon are transected intracorporeally using an endoscopic linear stapler.
The specimen is then placed above the liver or in the low pelvis and the ICA is
created. The specimen will be later extracted through the incision of the surgeon’s choice.
14 Laparoscopic Right Colectomy: Options forIleocolonic Reconstruction
205
Techniques ofIntracorporeal andExtracorporeal Ileocolonic
Anastomoses
Side-to-Side Stapled Anastomosis
The ileal loop is placed alongside the transverse colon ensuring no twisting of the
mesentery. The limbs can be aligned in an isoperistaltic or antiperistaltic conguration, depending on the natural way the bowel lays and surgeon’s preference.
In the isoperistaltic anastomotic conguration, an enterotomy is created along
the antimesenteric aspect of the ileum 1–2cm proximal to the stapled end using
monopolar cautery or any energy device. The transverse colon is opened as well
along its antimesenteric aspect, keeping a 5–8 cm distance from its stapled end
(Fig.14.3). Each arm of a standard or endoscopic linear stapler (with a 45mm or
60mm load of the appropriate staple height) is inserted in each limb, and the stapler
is closed and red (Fig.14.4). The staple line can be visualized through the enterotomy and checked for hemostasis. The enterocolotomy can then be closed by
another ring of the stapler or by suturing. With the stapled closure, care must be
taken not to narrow the anastomosis or staple across the mesentery to the anastomosis. Authors’ preference for sutured closure of the enterocolotomy is a single layer
anastomosis by two converging running sutures, using absorbable material (e.g.,
polydioxanone/PDS 2/0), started at both corners of the anastomosis (Fig. 14.5).
There are several options for suture closure of the enterocolotomy based on the
surgeon’s preference.
Fig. 14.3 Side-to-side
stapled isoperistaltic
anastomosis: opening of
the viscera. (Copyright ©
Giovanni Dapri.
Illustration by M.Crespi)
206
Fig. 14.4 Side-to-side
stapled isoperistaltic
anastomosis: insertion of
the linear stapler.
(Copyright © Giovanni
Dapri. Illustration by
M.Crespi)
Fig. 14.5 Side-to-side
stapled isoperistaltic
anastomosis: closure of
the enterocolotomy by
two running sutures.
(Copyright © Giovanni
Dapri. Illustration by
M.Crespi)
G. Dapri and M. Montorsi
In the antiperistaltic anastomotic conguration, an enterocolotomy is created
along the ileum 1–2cm proximal to its stapled end. The transverse colon is opened
close to its stapled end as well (Fig.14.6). Each arm of a standard or endoscopic
linear stapler is inserted in each limb, and the stapler is closed and red (Fig.14.7).
The enterocolotomy is then closed using two converging running sutures of
14 Laparoscopic Right Colectomy: Options forIleocolonic Reconstruction
Fig. 14.6 Side-to-side
stapled antiperistaltic
anastomosis: opening of
the bowel. (Copyright ©
Giovanni Dapri.
Illustration by M.Crespi)
Fig. 14.7 Side-to-side
stapled antiperistaltic
anastomosis: insertion of
the linear stapler.
(Copyright © Giovanni
Dapri. Illustration by
M.Crespi)
207
absorbable material (e.g., PDS 2/0), started at both corners (Fig.14.8) or using the
other options described above.
An alternative technique during right colectomy with ECA consists in exteriorizing the specimen en bloc with the distal ileum and proximal transverse colon
208
Fig. 14.8 Side-to-side
stapled antiperistaltic
anastomosis: closure of
the enterocolotomy with
running sutures.
(Copyright © Giovanni
Dapri. Illustration by
M.Crespi)
G. Dapri and M. Montorsi
without transecting the bowel rst. Upon exteriorization, rather than transecting the
bowel, the enterotomy and colotomy are made with insertion of the linear stapler
and creation of the anastomosis. The enterocolotomy is transected along with the
attached ileum and transverse colon using a second load of linear stapler. This
approach only requires a total of two stapler loads rather than three to four loads,
when the bowel is transected prior to creation of the anastomosis.
Side-to-Side Handsewn Anastomosis
The ileal loop is placed alongside the transverse colon, in either an isoperistaltic or
antiperistaltic conguration. A continuous running suture is placed aligning the
ileum to the colon using absorbable material (e.g., PDS 2/0) (Fig.14.9). After completing this rst running suture (typically ~5cm in length), which constitutes the
posterior anastomotic layer, a second running suture for the anterior layer is started
at the planned apex of the anastomosis. After taking the rst bite with the suture, a
transverse colotomy and ileal enterotomy are created using monopolar cautery or
any energy device (Fig.14.10). The second running suture is used to construct the
anterior layer of the anastomosis. At the opposite corner of the anastomosis, the
posterior running suture is continued onto the anterior layer for a few bites in order
to oversew the corner of the anastomosis (Fig.14.11). The two running sutures are
then tied together.
Side-to-End Stapled Anastomosis
For this type of anastomosis, the bowel is aligned in an isoperistaltic conguration
with the terminal ileum oriented at 90 degrees relative to the transverse colon. The
14 Laparoscopic Right Colectomy: Options forIleocolonic Reconstruction
Fig. 14.9 Side-to-side
handsewn anastomosis:
posterior anastomotic
layer completed with the
rst running suture.
(Copyright © Giovanni
Dapri. Illustration by
M.Crespi)
Fig. 14.10 Side-to-side
handsewn anastomosis:
creation of the
enterotomy and colotomy
after having started the
second running suture for
the anterior anastomotic
layer. (Copyright ©
Giovanni Dapri.
Illustration by M.Crespi)
209
ileal loop is placed with its lateral (antimesenteric) side against the stapled end of
the transverse colon. The ileum is opened by making an enterotomy close to its
stapled end. The transverse colon is also opened close to its stapled end (Fig.14.12).
A standard or endoscopic linear stapler is inserted in each limb and red (Fig.14.13).
The enterocolotomy is closed by any method previously described (Fig.14.14).
210
Fig. 14.11 Side-to-side
handsewn anastomosis:
transition of the posterior
running suture to
anteriorly, for a few bites,
to oversew the corner of
the anastomosis.
(Copyright © Giovanni
Dapri. Illustration by
M.Crespi)
Fig. 14.12 Side-to-end
stapled anastomosis:
opening of the viscera.
(Copyright © Giovanni
Dapri. Illustration by
M.Crespi)
G. Dapri and M. Montorsi
14 Laparoscopic Right Colectomy: Options forIleocolonic Reconstruction
Fig. 14.13 Side-to-end
stapled anastomosis:
insertion of the linear
stapler. (Copyright ©
Giovanni Dapri.
Illustration by M.Crespi)
Fig. 14.14 Side-to-end
stapled anastomosis:
closure of the
enterocolotomy by two
running sutures.
(Copyright © Giovanni
Dapri. Illustration by
M.Crespi)
211
212
G. Dapri and M. Montorsi
An alternative ECA with side-to-end stapled anastomosis, which is popular
among few surgeons, consists in the use of a circular stapler to complete a side-toend ileocolonic anastomosis. The stapled end of the terminal ileum is transected and
the anvil of an EEA stapler (of the appropriate size) is inserted in the lumen and
secured into place by tying a purse-string suture. A colotomy is made along the
transverse colon either at the stapled end or just proximal to it. The EEA stapler is
advanced retrograde, and the spike is deployed along the antimesenteric side of the
colon. The spike is connected to the anvil and the stapler is closed and red. The
colotomy is transected using a ring of linear stapler.
Side-to-End Handsewn Anastomosis
The ileal loop is placed with its lateral (antimesenteric) side against the stapled
closed colon end. A rst running suture is started on the ileum, 5–8cm from its
stapled closed end (Fig.14.15). This running suture is performed bringing the ileum
together with the transverse colon, from far to near, toward the stapled end of the
ileum. This rst running suture constitutes the posterior anastomotic layer. Then, a
new suture is started close to the starting point of the posterior layer, to initiate the
anterior layer. After the rst bite, the transverse colon and ileum are incised
(Figs. 14.16). The rest of the anastomosis is created as described previously
(Fig.14.17).
End-to-Side Handsewn Anastomosis
This type of anastomosis replaces the anatomic ileocecal junction and is constructed in an isoperistaltic conguration. The ileal loop is placed with its stapled
Fig. 14.15 Side-to-end
handsewn anastomosis:
posterior anastomotic
layer completed with the
rst running suture.
(Copyright © Giovanni
Dapri. Illustration by
M.Crespi)