We will be illustrating the hand-assisted approach to a lapa­roscopic right hemicolectomy and ileocecectomy. As in the previous chapter, the seven basic steps are described, fol­lowed by the various approaches including the lateral, medial, inferior, and superior approaches. The advantages and tips of utilizing the hand-assisted approach to diffi cult scenarios and complications will be reviewed.

With the widespread adoption of laparoscopy by most sur­gical specialties, colon and rectal surgery has incorporated laparoscopic techniques into many of its common abdominal procedures. Right hemicolectomy and ileocecectomy are two such procedures where the laparoscopic approach is becom­ing more commonplace and in some cases the standard of care. It is clear that laparoscopy has many benefi ts, and its benefi cial role for right hemicolectomy is no exception. It is safe, cost-effective, and allows for high-quality oncologic outcomes [ 1 – 5 ]. Patients undergoing laparoscopic colecto- mies have shorter lengths of hospital stay, less usage of pain medication, and quicker recovery and return to activity at

may be inserted in the lower midline (LM), upper midline (UM), or right upper quadrant (RUQ) to facilitate retraction of the colon or small bowel by the surgeon’s assistant. This additional port is typically 5 mm in size to permit the use of a bowel grasper by the assistant.

Upon initial establishment of pneumoperitoneum and inser­tion of the laparoscope, general inspection of the abdomen ensues (Box 6.5 ). Adequate visualization may fi rst require the insertion of additional working ports for retraction. This includes insertion of a hand port in the most appropriate loca­tion based on body habitus, location of diseased bowel, and chosen approach. Changes in patient position may also be useful at this time. Exploratory laparoscopy should include the peritoneal surface and omentum for possible tumor seed­ing. The liver must be evaluated for visible metastases, and placing the patient in reverse Trendelenburg position and using a 30° laparoscope will facilitate its inspection. In a female, the pelvis should be inspected for ovarian metas­tases. The primary tumor should be identifi ed, either with palpation with a grasper, anatomic landmarks such as the

The timing of division of the ileocolic pedicle during the pro­cedure varies depending on which approach is used for lapa­roscopic right hemicolectomy. Although many divide intracorporeally and as one of the initial steps, extracorpo­real division is acceptable, and no data support any improved oncologic outcome using one technique over another as long as a high ligation can be achieved safely through the extrac­tion site to yield adequate number of lymph nodes in the pathologic specimen for malignant disease (Box 6.6 ). The extracorporeal vessel ligation may be preferentially utilized for patients with friable mesentery in Crohn’s disease.

The duodenum must always be identifi ed during laparo­scopic right hemicolectomy (Box 6.8 ). With the use of elec- trocautery and advanced energy devices during colon mobilization and division of the mesentery and its vessels, the duodenum is at risk of injury at many stages of the proce­dure. With the creation of a window in the right colon mes­entery during the medial to lateral approach, blunt dissection mainly with a grasper or occasionally the surgeon’s fi ngers is used to identify and isolate the duodenum along its inferior border at the level of its sweep. Again, by retracting the right colon anteriorly with the surgeon’s right hand in the abdo­men, adequate visualization is achieved. Once a window is made in the right colon mesentery, the surgeon’s fi ngers are placed within the defect to tent up the right colon. A grasper is then used to bluntly sweep down the duodenum and sweep up the superior edge of the mesenteric defect. This should be an avascular plane and the loose areolar tissue should easily separate with blunt dissection. There is no need to grasp the duodenum at all during its identifi cation and isolation (see Video 6.3 ). Once this is done, the duodenum is used as a landmark during dissection of the hepatic fl exure.

right plane. Slow and meticulous dissection is usually ade­quate to fi nd the correct plane. The transverse colon and hepatic fl exure will progressively move into an inferior posi­tion as dissection proceeds (see Video 6.7 ).

In addition to the division of the ileocolic vessels, the right branch of the middle colic artery may be divided if the patient’s anatomy allows, but is not an essential step in an ileocecectomy. Placing the patient in reverse Trendelenburg position will allow the small bowel to move inferiorly into the pelvis and the transverse colon mesentery to be better visualized. There are two approaches to the transverse meso­colon: inframesocolic and supramesocolic from laterally or medially.

Alternatively, an intracorporeal bowel resection and anas­tomosis may be performed. This will still require extraction of the specimen but allows for the hand port to be placed in a number of cosmetically advantageous locations, such as the Pfannenstiel location. The totally intracorporeal anastomosis requires additional time and laparoscopic skills but is feasi­ble in the hands of an experienced surgeon.

The lateral to medial approach to hand-assisted laparoscopic right hemicolectomy follows the previously described surgi­cal steps in the order of 1, 4, 3, 5, 2, 6, and 7. In this approach, following insuffl ation and exploration of the abdomen, the line of Toldt is incised laterally and the cecum, ascending colon, and ileum are mobilized early in the procedure. The right ureter is identifi ed at this point in the procedure. The duodenum is identifi ed from the lateral position, and the ascending colon is carefully mobilized, ensuring that the dis­section remains anterior to Gerota’s fascia. The duodenum may appear quickly in the situation of a short ascending colon, and extreme caution must be used during lateral dis­section. This placement allows for medial retraction of the colon with the surgeon’s hand while proceeding with lateral mobilization of the cecum and ascending colon. The patient is placed in left tilt regardless of port placement to visualize the lateral edge of the ascending colon. Next, the transverse colon and hepatic fl exure can be mobilized from a lateral or a medial approach, so as to join up with the previously dis­section line along the right colon. These two maneuvers allow the colon to be brought medially and the hepatic fl ex­ure brought inferiorly. The duodenum is again visualized. Once the colon is mobilized, the ileocolic pedicle is identi­fi ed and ligated, and the mesentery of the right colon is divided to the right branch of the middle colic artery. The right branch of the middle colic artery may then be divided. Exteriorization and bowel resection are then performed.