CHAPTER 20 Hand-assisted right colectomy
♦ Familiarity with the vascular anatomy of the right colon is essential to the safe conduct of a minimally invasive right colectomy (Figure 20-1). Vascular anatomy also significantly determines resection of colonic malignancies. Several key points guide the laparoscopic surgeon:
♦ The embryologic fusion plane originates laterally at the white line of Toldt, which occurs where the parietal peritoneum fuses with the visceral peritoneal reflection around the colon and its lateral extension (Figure 20-2). The correct dissection plane is the bloodless embryologic fusion plane. When properly mobilized in this plane, the colon reflects medially on its mesentery to become a nearly midline structure. When the dissection is carried posteriorly past the white line of Toldt, violating the parietal peritoneum as it extends across the retroperitoneal structures, the ureter and gonadal vessels are put at risk and mobilization of the colon is limited.
♦ Awareness of the relationships between the cecum, ascending colon, hepatic flexure, and proximal transverse colon to neighboring structures helps to maintain orientation during surgery and prevents injury:
♦ Lesions must be appropriately localized preoperatively. Although all of the patient’s physicians are concerned about making the correct diagnosis, only the surgeon has to perform a resection and must manage the technical details of this procedure: