Approaching the Transverse Colon

N. Arjun Jeganathan

Jeremy M. Lipman

Perioperative Consideration

The transverse colon runs across the abdomen from the hepatic flexure to the splenic flexure.
The transverse colon has a covering of visceral peritoneum and has an associated mesentery.
- The mesentery has a variable thickness and size—this is important when identifying the vessels.
- There may be significant redundancy of the transverse colon.
Be aware of the posterior gastric wall and the ligament of Treitz when dividing the mesentery to the transverse colon to avoid iatrogenic damage.
The transverse colon can be mobilized as a part of an operation (eg, low anterior resection) or resected (eg, total abdominal colectomy).

Anesthesia and Patient Positioning

General anesthesia with orogastric tube and Foley catheter
- Complete paralysis for appropriate relaxation.
Modified lithotomy with legs in stirrups (knees and hips slightly flexed) to permit the surgeon to stand between the patient’s legs
- Alternatively, split-leg position allows for easier maneuverability if access to the anus is not anticipated.
Both arms tucked at the patient’s side to facilitate access to the abdomen and increase surgeon comfort.
The patient must be secured to the bed with straps, pads, or tape.
- The patient should not move during the extreme positioning that can be used to facilitate exposure.
Reverse Trendelenburg with right or left lateral rotation is useful to improve visualization of the splenic and hepatic flexures, respectively.

Instruments and Equipment

Hasson port (12-mm diameter)
10-mm 30-degree laparoscope
At least two 5-mm operating ports
Two 5-mm laparoscopic bowel graspers (atraumatic)
5-mm laparoscopic curved scissors with attachment for electrocautery
5-mm vessel sealing device

Technique

Port Placement

A periumbilical camera port with at least two working ports is necessary (Fig. 23-1).
The location of the ports must be such that triangulation of the camera and working ports to the hepatic flexure, mid-transverse colon, and splenic flexure will be optimized.
Typically, a right and left lower quadrant location for working ports provides adequate needs, although upper abdominal port placement may be useful for challenging exposures.

FIGURE 23-1 ▪ Periumbilical 10-mm camera port with suggested 5-mm working port positions. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

Surgical Approaches

Approaching the transverse colon is most often performed as a component of right, left, or total colectomy (Fig. 23-2).
- The indicated procedure will usually direct the approach to transverse colon.
If access to other areas of the colon is compromised, a supramesocolic approach may be useful.

FIGURE 23-2 ▪ Range of approaches to transverse colon include lateral-to-medial from right or left, as well as supramesocolic and inframesocolic approaches via the ileocolic artery, inferior mesenteric artery, or inferior mesenteric vein. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

Right-Sided Medial-to-Lateral Dissection Approach