There is essentially no difference in surgical outcomes between the two approaches, as is reviewed in a later section of this chapter. Hence, the surgeon should choose the most familiar and comfortable approach based on prior training and experience. There are, however, some inherent advantages and disadvantages of each method. The advantages of the lateral approach (LA) are (1) early identification of key structures such as the right ureter and duodenum and (2) use of the same dissection as in the open technique. The advantages of the medial approach (MA) are (1) early ligation of the vascular ileocolic pedicle, theoretically preventing liberation of tumor cells into mesenteric circulation and (2) the preservation of the lateral colonic ligament until the end of the mobilization, which helps with right colon retraction and exposure. MA may not be feasible under conditions in which the right colon mesentery is fixed to the retroperitoneum, for example, in cases with significant malignant adenopathy involving the ileocolic pedicle or extremely thickened mesentery due to Crohn’s disease or morbid obesity.

The role of mechanical bowel preparation (MBP) with oral antibiotics remains controversial. Some authors have shown no advantage, whereas others have shown that MBP with oral antibiotics reduces the rates of anastomotic leak, surgical site infection, and postoperative ileus. The authors advocate for routine use of MBP with oral antibiotics not only for the reasons mentioned but also for other technical reasons. The ability to “palpate” the bowel with laparoscopic instruments is limited without preparation. Furthermore, it is practically impossible to perform an intraoperative colonoscopy, if need be, without preparation. Lastly, if proximal diversion is unexpectedly required, MBP ensures that the remnant colon will be evacuated and clean rather than full of stool.

Secure patient positioning is essential for a successful laparoscopic right colectomy, which requires rotation of the surgical bed to several extreme angles. Foam padding must be carefully placed to avoid pressure injury, especially in obese patients. Appropriate time and focus should be dedicated to this portion of the case and the participating staff, including nursing and anesthesiology staff, should be oriented in advance. Before the patient enters the room, a gel pad/beanbag is placed on the operating table to avoid patient slippage during extreme tilt. The patient is placed on the pad and induced/intubated by anesthesiology. Lines and tubes are inserted, including any necessary arterial or venous catheters, an orogastric tube, a Foley catheter and, when relevant (as discussed earlier), ureteral stents. The legs are wrapped with knee-length sequential compression device sleeves and placed in Allen stirrups for modified lithotomy positioning, with extra padding inserted behind the leg. Both arms are secured at the sides by placing the beanbag to suction, and gauze padding is used to protect the skin from any lines or tubing. Foam and tape are placed across the chest to secure the upper body to the bed and shoulder rests are placed on a padded support that is secured to the table.