Ileocolic Artery Ligation
KEY STEPS
1. Insertion of ports: 10-mm umbilical Hasson technique; 5-mm left iliac fossa; 5-mm left upper quadrant; 5-mm right iliac fossa (selectively).
2. Ileocolic pedicle defined and mobilized, carefully protecting fascia around vessel, preserving Toldt fascia, thereby protecting ureter and duodenum.
ADDITIONAL ADVICE
1. When performing medial mobilization of the ileocolic artery for cancer, make your initial peritoneal incision close to the SMA to ensure a complete mesocolic excision.
2. Once the vessel has been divided, perform as much as possible of the medial to lateral dissection, working laterally, then inferiorly behind the cecum, and finally up behind the hepatic flexure.
3. When the right branch of the middle colic artery is taken in more obese patients, it is often easier to do this after the superior aspect of the hepatic flexure has been mobilized, and the right branch can be placed under traction.
The patient is rotated with the right side up and left side down, to approximately 15 to 20 degrees tilt, and often as far as the table can go. This helps move the small bowel over to the left side of the abdomen. The patient may be placed into slight Trendelenburg position, although this is not always necessary for this step. The surgeon then inserts two atraumatic bowel clamps through the two left-sided abdominal ports. The greater omentum is reflected over the transverse colon so that it comes to lie on the stomach. If there is no space in the upper part of the abdomen, one must confirm that the orogastric tube is adequately decompressing the stomach of gas. The small bowel is moved to the patient’s left side, some remaining in the pelvis and upper abdomen, allowing visualization of the ileocolic pedicle. This may necessitate the use of the assistant’s 5-mm atraumatic bowel clamp through the right lower quadrant in order to tent the ileal mesentery medially and cephalad.
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