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24
T. M. Young-Fadok
the duodenum can be visualized through the cephalad mesenteric window, and a
transverse line of dissection can be estimated across the base of the ileocolic pedicle, in line with the lateral margin of the duodenum (Fig.2.15). In the heavier patient
(BMI >30), the anatomy is often difcult to discern. After a transverse scoring incision is made across the medial peritoneum of the right colon, over the estimated
base of the ileocolic pedicle; careful dissection is employed to achieve two aims:
isolation of the base of the ileocolic pedicle and identication of the retroperitoneal
plane by using gentle sweeping actions to elevate the posterior aspect of the mesentery off the retroperitoneum. Once the base of the ileocolic pedicle is identied, the
vein and artery can be dissected separately and divided using an electrocautery
device (Fig.2.16). For benign disease, the artery and vein can often be divided
together using an advanced energy or stapling device. Many surgeons also prefer the
addition of an endoloop to conrm control of the vascular supply.
Dissection then continues in the correct retroperitoneal plane, sweeping the right
ureter, IVC, gonadal vessel, and duodenum posteriorly while elevating the right
colon and extending the plane of dissection to the right lateral peritoneal reection.
The mesenteric transection is carried towards the chosen proximal margin in the
distal ileum and also towards the chosen distal resection margin in the colon. Full
mobilization is extended laterally to the right lateral peritoneal reection which is
then also divided. As entry into this plane is somewhat by trial and error, without the
landmark provided by the right lateral peritoneal reection, videos of this approach
tend to have a more bloody exposure, other than in expert hands.In patients with
Fig. 2.15 Duodenum seen
after opening mesenteric
window cephalad to the
base of the ileocolic
pedicle
Fig. 2.16 Division of
ileocolic artery
2 Masters Program Colorectal Pathway: Laparoscopic Right Colectomy forBenign…
25
Crohn’s disease, division of the mesentery can be challenging due to marked thickening and also friability if steroids have been used. Transection of the mesentery
may be safer near the base of the ileocolic pedicle where mesenteric thickening is
less prominent, or the mesentery may be more safely approached extracorporeally
after exteriorization of the mobilized right colon.
Proponents of this approach indicate early vascular control as an important fea-
ture. The lymph node harvest may be greater [7] although the oncologic signicance of more than 12 lymph nodes is as yet unclear.
Top-Down Approach
This approach is a variant of the lateral-to-medial approach described above except
that it starts at the hepatic exure rather than at the cecum. This is slightly more
technically challenging than starting at the cecum, as there is no peritoneal reection. This is an attractive option when inammation from ileocolic Crohn’s disease
or a desmoplastic reaction from a cecal cancer obscures the retrocecal plane.
Transection andAnastomosis oftheRight Colon
Decisions regarding transection margins, and intra- versus extracorporeal anastomosis, are often decided ahead of time based on the patient’s underlying diagnosis
and pathology. It is important, however, to be able to adjust the operative approach
as indicated by intraoperative ndings. In the case of ileocolic Crohn’s disease, the
distal transection margin is generally somewhere in the ascending colon, as determined by the extent of disease. Mobilization of the hepatic exure is still helpful,
not to obtain margins but in order to obtain adequate length to perform a long sideto-side anastomosis if that is the preferred method.
For the novice and intermediate surgeon, laparoscopic mobilization is the mini-
mum necessary to make the distal ileum, right colon, and proximal transverse colon a
mobile section of bowel that, in a patient of BMI <25–30, can be exteriorized through
a periumbilical incision with the resection and anastomosis performed extracorporeally. Patients with a higher BMI should have the vascular pedicle and mesentery
divided intracorporeally, and this allows the anastomosis to be performed extra- or
intracorporeally without tension and pulling on the middle colic vessels. Intracorporeal
anastomosis, addressed in a separate chapter, requires more advanced skills [8–10].
With regard to extraction incisions, the easiest incision to use is a periumbilical
incision. This requires only mobilization of the right colon to the midline, at which
point it is now a midline structure and can be easily exteriorized. However, this incision is associated with a higher subsequent incisional hernia rate [11]. Transection
of the mesentery and vasculature intracorporeally allow additional choices in terms
of an extraction incision, and a right lower quadrant or even a Pfannenstiel incision
can be employed. Use of a wound protector may reduce the risk of surgical site
infection. Transrectal extraction has been described for specic distal colonic and
rectal procedures, but is not advocated for right-sided procedures and requires intracorporeal anastomosis.
26
T. M. Young-Fadok
Pitfalls andTroubleshooting
Troubleshooting is the forethought given to avoiding pitfalls! Difculties can potentially be anticipated in certain settings: uncertain location of lesion, obesity, and
inammation.
A common error with both lateral and medial approaches is straying from the
correct retroperitoneal plane, which can disrupt either the complete mesenteric
excision plane by being too supercial or dissect too deeply into the retroperitoneum risking injury to the right ureter, inferior vena cava, or duodenum. With the
lateral approach, being both too lateral and too deep can incur the risk of undermining the right kidney.
A bulky mass or extensive inammation should prompt a very close look on CT
scan at the relationship to the ureter, and consideration should be given to placement
of ureteral stents to assist intraoperative identication of the ureter.
While T4 malignancies and large Crohn’s phlegmons can be approached laparo-
scopically by an experienced surgeon, these are not cases for the novice laparoscopic surgeon and should prompt conversion if they were not anticipated
preoperatively. Other indications for conversion are inability to nd the correct tissue planes, concern regarding injury to the ureter, IVC or duodenum, and uncontrolled bleeding. Failure to make progress with the procedure is also an indication
to convert.
Learning curves are a popular way of conveying the potential difculty of learn-
ing a procedure. For a straightforward right colectomy, in the absence of complex
anatomy or pathology, a trainee who is capable of performing a laparoscopic cholecystectomy should be able to develop the skills for right colectomy, as described
here with extracorporeal anastomosis, within 5–10 cases. More complex techniques,
such as single-incision right colectomy [12], intracorporeal anastomosis, and complete mesorectal excision, have longer learning curves which are yet to be dened.
Outcomes
Most level 1 evidence for the role of laparoscopy in colorectal surgery has focused
on randomized controlled trials (RCTs) for colon cancer and subsequently for rectal
cancer. There is less evidence for benign disease. For example, a Cochrane review
found only two RCTs for ileocolic Crohn’s disease, involving 120 patients, and
concluded that there was no signicant difference in perioperative outcomes and
long-term reoperation rates for disease-related or non-disease-related complications
of Crohn’s disease. Multiple cohort studies exist, however, that cumulatively support the benets of a laparoscopic approach, to the point where RCTs became
untenable from the perspective of assuming equipoise. In other words, repeated,
consistent, believable evidence from reliable experts led to the situation whereby it
would not be possible to devise a RCT where the investigator truly believed that it
was unknown whether either arm of a laparoscopic vs open RCT would show
improved outcomes.
2 Masters Program Colorectal Pathway: Laparoscopic Right Colectomy forBenign…
Table 2.3 Short and long term advantages of laparoscopy
Short-term advantages Long-term advantages
Reduced time to bowel function
Reduced pain
Less opioid use
Shorter length of hospital stay
Less pulmonary impact
Decreased costs
Fewer/smaller incisional hernias
Reduced incidence of small bowel obstruction
27
Laparoscopic approaches gained acceptance with reported advantages of faster
return to normal activity and diet, reduced hospital stay, reduced postoperative pain,
and better cosmesis. Longer-term, laparoscopic surgery has shown smaller abdominal fascial wounds, lower incidence of hernias, and decreased rates of small bowel
obstruction from adhesions (Table2.3).
Although evidence accumulated re. potential improved outcomes from laparos-
copy, there also came concerns related to the loss of tactile evaluation of the bowel,
i.e., missing occult segments of Crohn’s disease and inability to palpate a polyp
which would not have visible serosal manifestations. These issues are usually
addressed by the exhortation to dene anatomy preoperatively, e.g., CT enterography to elicit evidence of proximal small bowel disease in Crohn’s, and use of tattooing, CT colonography, and intraoperative endoscopy to localize polyps.
Conclusions
Laparoscopic right colectomy for benign disease is a good starting point for those
learning the skills necessary for minimally invasive colorectal surgery, including
not just trainees but also surgeons already experienced in open colorectal procedures but wishing to develop laparoscopic skills. Operative planning, OR setup,
patient positioning, and trocar placement are important components of a successful
operation that also recognizes correct tissue planes, resection margins, anastomotic
technique, and specimen retrieval.
References
1. Champagne BJ, Steele SR, Hendren SK, Bakaki PM, Roberts PL, Delaney CP, et al. The
American Society of Colon and Rectal Surgeons Assessment Tool for performance of laparoscopic colectomy. Dis Colon Rectum. 2017;60(7):738–44.
2. Homma S, Kawamata F, Yoshida T, Ohno Y, Ichikawa N, Shibasaki S, et al. The balance
between surgical resident education and patient safety in laparoscopic colorectal surgery: surgical resident’s performance has no negative impact. Surg Laparosc Endosc Percutan Tech.
2017;27(4):295–300.
3. Dasari BVM, McKay D, Gardiner K. Laparoscopic versus open surgery for small bowel
Crohn’s disease. Cochrane Database Syst Rev. 2011;(1):CD006956.
4. Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, etal. Guidelines for
perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®)
Society Recommendations. World J Surg. 2019;43(3):659–95.
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5. Young-Fadok TM.Video podium presentation, SAGES Annual Meeting 2018. Session: masters colorectal: MIS approaches to the right colon. Laparoscopic lateral-to-medial dissection– a
safer approach? [Internet]. Available from: https://www.youtube.com/watch?v=zAz_XdSceh8
6. Lee SJ, Park SC, Kim MJ, Sohn DK, Oh JH.Vascular anatomy in laparoscopic colectomy for
right colon cancer. Dis Colon Rectum. 2016;59(8):718–24.
7. Honaker M, Scouten S, Sacksner J, Ziegler M, Wasvary H.A medial to lateral approach offers
a superior lymph node harvest for laparoscopic right colectomy. Int J Colorectal Disease.
2016;31(3):631–4.
8. Biondi A, Santocchi P, Pennestri F, Santullo F, D’Ugo D, Persiani R.Totally laparoscopic right
colectomy versus laparoscopically assisted right colectomy: a propensity score analysis. Surg
Endosc. 2017;31(12):5275–82.
9. Martinek L, You K, Giuratrabocchetta S, Gachabayov M, Lee K, Bergamaschi R.Does laparoscopic intracorporeal ileocolic anastomosis decreases surgical site infection rate? A propensity
score-matched cohort study. Intl J Colorectal Dis. 2018;33(3):291–8.
10. Milone M, Elmore U, Di Salvo E, Delrio P, Bucci L, Ferulano GP, etal. Intracorporeal versus
extracorporeal anastomosis. Results from a multicentre comparative study on 512 right-sided
colorectal cancers. Surg Endosc. 2015;29(8):2314–20.
11. Pares D, Shamali A, Stefan S, Flashman K, O’Leary D, Conti J, et al. Predictive factors for extraction site hernia after laparoscopic right colectomy. Int J Colorectal Disease.
2016;31(7):1323–8.
12. Haas EM, Nieto J, Ragupathi M, Aminian A, Patel CB.Critical appraisal of learning curve for
single incision laparoscopic right colectomy. Surg Endosc. 2013;27(12):4499–503.
T. M. Young-Fadok
Masters Program Colorectal Pathway:
Laparoscopic Left andSigmoid
Colectomy forBenign Disease
JuliaT.Saraidaridis andPeterW.Marcello
Introduction andRationale
Laparoscopic colectomy was rst described in the early 1990s. The rst randomized
trials evaluating laparoscopic colectomy versus open surgery were in patients with
malignant disease. These trials demonstrated less blood loss, earlier recovery of
bowel function, less need for narcotics, and a shorter length of stay for patients who
had procedures performed laparoscopically [1–5]. Because of the inammatory
nature of most benign conditions prompting colectomy, there was some hesitation
regarding the feasibility of a laparoscopic approach for these indications. Slowly,
data evaluating laparoscopic sigmoid colectomy in patients with diverticulitis accumulated [6–10]. These studies demonstrated that laparoscopic left or sigmoid colectomy is possible in patients with diverticular disease with an increased operative
time compared to open surgery, a decreased length of stay, and a decreased complication prole. They also demonstrated that conversion is less for surgeons who utilized a hand-assisted laparoscopic approach. Using these two approaches, straight
laparoscopy and hand-assisted laparoscopy, most patients with diverticular disease
requiring sigmoid colectomy can undergo surgery in a minimally invasive fashion.
This chapter details the indications, operative technique, and outcomes of studies
evaluating laparoscopic and hand-assisted laparoscopic (HAL) sigmoid and left colectomy for benign disease.
3
J. T. Saraidaridis (*) · P. W. Marcello
Lahey Hospital and Medical Center, Division of Colon and Rectal Surgery,
Burlington, MA, USA
e-mail: julia.t.saraidaridis@lahey.org; peter.w.marcello@lahey.org
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020
P. Sylla et al. (eds.), The SAGES Manual of Colorectal Surgery,
https://doi.org/10.1007/978-3-030-24812-3_3
29
30
J. T. Saraidaridis and P. W. Marcello
Indications andContraindications
The most common benign condition that prompts left or sigmoid colectomy is the
many manifestations of diverticulitis including recurrent disease, smoldering disease, colovesical/colovaginal stula, or stricture. Other benign conditions prompting an elective left or sigmoid colectomy include Crohn’s colitis, ischemic colitis,
endometriosis, or diverticular bleeding. As diverticulitis is the most commonly seen
disorder requiring left or sigmoid colectomy in benign disease, this chapter will
focus on this indication.
In the past, the inammation and scarring associated with the chronic
manifestations of diverticular disease prompted many surgeons to shy away from
minimally invasive approaches. However, increasing experience with both handassisted laparoscopy and straight laparoscopy has prompted minimally invasive
techniques to be the mainstay of treating this condition. In our practice, for repeated
attacks of uncomplicated diverticulitis, we proceed with a straight laparoscopic
approach with a planned extraction through a small Pfannenstiel incision. For
patients with a body mass index greater than 30kg/m
for a straight laparoscopic case is relatively similar to a hand-assisted incision. So,
for this reason, for morbidly obese patients, we utilize a hand-assisted approach.
Additionally, for any patient with a history of complicated diverticulitis including
abscess, phlegmon, or stula, a hand-assisted laparoscopic approach can be
particularly helpful to facilitate blunt dissection and identify the correct surgical
planes.
There are very few contraindications to approaching benign conditions of the left
and sigmoid colon using a laparoscopic approach. Contraindications include
patients who are unable to tolerate laparoscopy or steep changes in operating room
table positioning. A relative contraindication is the presence of dense or extensive
adhesions associated with a prior history of open laparotomy in the past. With experience, however, most laparoscopic surgeons will attempt a laparoscopic approach,
even in the setting of previous open surgery. Extreme caution should be taken when
entering the reoperative abdomen in order to avoid an injury, especially in the setting of prior peritonitis, prior intraabdominal bleeding, or previous mesh placement,
which may result in formation of dense adhesions. If the abdomen proves to be
hostile, conversion to an open procedure should quickly be decided.
2
, the size of the extraction site
Principles andQuality Benchmarks oftheApproach/Technique
The principles of resection for diverticular disease are the same in laparoscopic
approaches as they are in open approaches: isolation and ligation of the sigmoid
pedicle, mobilization of the left and sigmoid colon including takedown of the splenic
exure, proximal transection, distal transection at the proximal rectum, and anastomosis. For diverticular disease, there are additional parameters including the performance of an adequate colon resection to minimize recurrence of disease and an
attempt to decrease the risk of common complications of sigmoid resection. In our
ab
3 Masters Program Colorectal Pathway: Laparoscopic Left andSigmoid Colectomy…
Fig. 3.1 (a, b) Splaying of the taeniae
31
practice, to assist in reducing the risk of recurrence of diverticular disease, all prior
CT scans are evaluated to assess the proximal extent of disease. Any portion of the
bowel that has been involved in previous inammation/diverticulitis attacks is
included in the planned resection. Once in the operating room, prior to initiating the
mobilization of the bowel, the bowel is palpated to assess for chronic thickening or
acute inammation. The proximal transection margin does not need to be so proximal so as to include all diverticula, it just needs to be proximal enough to include all
areas of previous inammation. It should also be on soft, pliable bowel with soft
pliable mesentery. The planned proximal colon transection can be marked (using an
ink pen tip, clip, or cautery) at the start of the operation. This will ensure that the
appropriate proximal margin is achieved which can be more challenging to determine once the colon and its mesentery are fully mobilized. The distal transection
margin should be on the proximal rectum. This is identied by the splaying of the
taeniae (Fig.3.1a, b). A colorectal rather than a colosigmoid anastomosis is believed
to be the single most important factor in decreasing the chance of recurrent diverticular disease [11, 12].
In addition to providing an adequate resection, a principle of left/sigmoid
resection for benign disease is to avoid a high ligation of the sigmoid pedicle. The
avoidance of a high ligation decreases the risk of ureteral injury and hypogastric
nerve injury. Some studies have indicated that avoiding a high ligation of the pedicle
decreases the chance of anastomotic leak [13]. Other studies have not conrmed this
association [14]. However, in our practice for benign disease, we preserve the sigmoid pedicle given this concern.
Preoperative Planning, Patient Work-Up, andOptimization
In the planning of a minimally invasive approach to surgical resection for
diverticulitis, a number of factors must be considered preoperatively. For those
patients whom have not had a colonoscopy in the 2years prior to resection, repeat
endoscopic evaluation is warranted. Some of our surgeons will perform an on-table
colonoscopy on the day of surgery in order to avoid repeating a bowel preparation.
32
J. T. Saraidaridis and P. W. Marcello
For patients with complicated diverticulitis, additional factors must be taken into
account preoperatively. Patients with residual diverticular abscess and/or stula will
keep their percutaneous drain up until the time of surgery. The drain will be prepped
into the eld and then removed once the abdomen has been entered. For those
patients with suspected colovesical stula, cystoscopy and ureteral stent placement
are usually performed just prior to surgery. If the stula takedown results in a bladder defect, it should be repaired with sutures. In regard to ureteral stent usage in the
absence of colovesical stula, the decision to place stents prophylactically is up to
the individual surgeon. In general, when signicant inammation and/or residual
phlegmon, abscess, or stula is anticipated, left-sided stents are usually placed prophylactically to minimize the risk of an unrecognized ureteral injury.
All prior abdominal scars should be evaluated as potential extraction sites.
Patients are educated about enhanced recovery pathways including non-opioid pain
relief alternatives, early ambulation, and early resumption of diet. All of our patients
undergoing elective colon surgery undergo mechanical and antibiotic bowel preparation the day before surgery. Please refer to the chapters on enhanced recovery
protocol in colorectal surgery for more details on this topic (Chaps. 7 and 8).
Operative Setup
Patients are placed on a bean bag in a modied lithotomy position on a split-leg
table. The arms are tucked at the sides and surrounded by foam padding and an
inated bean bag. The chest is wrapped circumferentially three times with threeinch silk tape afxing them to the table. The legs are split with the buttock at the
bottom of the table to allow for trans-anal access, and then the legs are secured in
place with Velcro straps. Patients are given subcutaneous heparin, and sequential
compression devices are applied for deep venous thrombosis prophylaxis.
Antibiotics are administered less than 1hour prior to surgical incision. We use both
monopolar cautery and the bipolar vessel sealer as our energy sources. Both of these
instruments are placed on the eld at the initiation of the case. A CO
is available as needed for the procedure. Most cases are initiated with a colonoscopic evaluation of the colon. The Foley catheter is placed after colonoscopy in
women to avoid risk of urinary tract infection as our group found that there was
contamination of the catheter from colonoscopy if it had been placed pre-procedure.
The catheter is draped over the leg to reduce contamination from the passage of
staplers and endoscopes trans-anally.
colonoscope
2
Operative Technique
Port Placement
For straight laparoscopic procedures, a 12mm Hassan port is placed in the umbilicus.
5mm ports are placed in the right upper quadrant, the right lower quadrant, and the
3 Masters Program Colorectal Pathway: Laparoscopic Left andSigmoid Colectomy…
Fig. 3.2 Room setup
for laparoscopic sigmoid
colectomy. (Used with
permission of
Springer Nature from
Leroy etal. [26])
33
left lower quadrant (Fig.3.2). Extraction is most often performed through a small
Pfannenstiel incision or via an extension of the Hassan port site.
For a hand-assisted approach, the operation begins with the creation of an
incision for the hand-port. Early along the learning curve of hand-assisted, an 8cm
lower midline incision is recommended in the case that conversion is required. Once
the surgeon is comfortable with a hand-assisted approach, a Pfannenstiel incision
2 cm above the pubis is the preferred approach. The incision is cosmetically
pleasing, has an extremely low risk of incisional hernia, and is an excellent incision
to work in the pelvis where further dissection or an anastomosis can be completed.
The hand device is placed into the incision, and then three 5mm trocars are placed