Laparoscopic Medial-to-Lateral Right Colectomy

Toyooki Sonoda

INDICATIONS AND CONTRAINDICATIONS

In general, a laparoscopic dissection of the right colon is more straightforward than that of the transverse colon, left colon, or the rectum. The right colon can be mobilized from the medial, lateral, superior, or inferior aspect, and any competent surgeon must be able to perform the colonic mobilization from all four directions, as dictated by anatomic variations. The main advantages of the medial-to-lateral approach to mobilization of the colon include the following:

Early ligation of the vascular pedicles in cancer may prevent the liberation of tumor cells into the mesenteric circulation during mobilization (the Turnbull no-touch technique).
Preservation of the lateral colonic ligament until the end of the mobilization keeps the right colon fixed in place and utilizes the lateral ligament as a natural retractor, as opposed to a lateral-to-medial mobilization which then requires one to retract and manipulate a floppy colon.

Contraindications

There are both absolute and relative contraindications to the laparoscopic approach to colectomy. Absolute contraindications include the following:

Hemodynamic instability
Known history of hostile adhesions from prior surgery

Relative contraindications to laparoscopy depend on each clinical circumstance, as well as the comfort level of the surgeon. These include the following:

Large tumor size (>8 cm)
Tumor invading other structures
Bowel dilation from obstruction or ileus
Emergency surgery
History of prior surgery

A patient may have had many operations in the past, but the presence of adhesions may not preclude a subsequent laparoscopic colectomy. For example, even patients who have undergone one or more open ileocolic resections for Crohn’s disease may still be candidates for laparoscopic ileocolectomy. It is worthwhile planning an initial diagnostic laparoscopy to assess this feasibility. However, when extensive adhesions are present necessitating conversion to open surgery, the decision to convert should be made early in the operation. Extensive omental adhesions to the abdominal wall can be favorable for the laparoscopic approach, whereas significant intraloop bowel adhesions may be more challenging.

PREOPERATIVE PLANNING

The patient should be prepared for surgery, with attention paid to the optimization of preoperative comorbidities. Neoplasms should be evaluated with preoperative computed tomography (CT) scan and colonoscopy, with additional imaging by magnetic resonance imaging or positron emission tomography scan when appropriate. Patients with Crohn’s disease should undergo colonoscopy and complete imaging of the small intestine with a magnetic resonance or CT enterography or capsule endoscopy. In ileal Crohn’s disease, it is important to examine the images for an ileosigmoid fistula, because this finding may affect the magnitude of the operation or the planning of an incision.

Whenever a neoplastic lesion is present, especially one that may not be visible on the serosal surface, an endoscopic tattoo must be placed using permanent ink. Tattooing allows for laparoscopic identification of the tumor-bearing segment, and eliminates the risk of either removing an incorrect segment of the intestine or resecting a tumor with inadequate lateral margins. The tattoo should be placed in a uniform manner, in 3-4 quadrants to ensure that the tattoo is visible on the serosal surface and not hidden by the mesentery. It is recommended that the tattoo is injected at the distal aspect of a tumor, rather than placing both proximal and distal tattoos. This method limits confusion in case only one tattooed area is visible, and is helpful in planning the distal line of resection.

The use of mechanical bowel preparation before elective colorectal surgery is controversial. Several randomized prospective trials have not demonstrated an advantage to mechanical bowel preparation in reducing rates of anastomotic leak and superficial surgical site infection (SSI) compared with no mechanical preparation. As a result, many surgeons no longer utilize routine mechanical bowel preparation before elective colon resection. However, a recent evaluation of 4,999 patients using the 2012 Colectomy-Targeted American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database revealed that rates of anastomotic leak (2.8% vs. 5.7%, P = 0.001), incisional SSI (3.2% vs. 9.0%, P < 0.001), and procedure-related hospital readmission (5.5% vs. 8.0%, P = 0.03) were lower with the combination of mechanical and oral antibiotic preparation before surgery as compared with no preparation. Patients who received either mechanical or oral antibiotic preparation did not fare better than did patients who did not receive preparation.

Another argument in favor of mechanical bowel preparation is that with the laparoscopic approach, the ability to palpate an intraluminal lesion is limited. If the location of a tumor or polyp cannot be ascertained during laparoscopic surgery, an intraoperative colonoscopy should be performed rather than a blind resection. Colonoscopy can be difficult in the setting of an unprepared colon. Intraoperative colonoscopy should be performed with CO₂ insufflation rather than air whenever possible, because CO₂ insufflation limits bowel distension due to the rapid absorption of intraluminal CO₂ compared with air. With the use of air insufflation, the terminal ileum must be occluded with a laparoscopic bowel grasper to avoid bothersome small bowel distension; with CO₂ insufflation, however, this precaution is not necessary.

In addition, there are elements of enhanced recovery after surgery (ERAS) pathways that apply to preoperative care. ERAS pathways are evidence-based protocols that standardize pre-, intra-, and postoperative care to improve outcomes, enhance recovery, and ultimately decrease health care costs. To prevent preoperative dehydration resulting in hemodynamic instability upon induction of anesthesia and thus requiring an increased volume of intravenous fluids that may then delay recovery after surgery, patients are encouraged to drink clear liquids up to 2 hours of surgery. They are also asked to consume a 12-oz. helping of a carbohydrate-rich drink 2 hours before surgery. Aggressive multimodal narcotic-sparing analgesia starts preoperatively as well. Patients receive a combination of acetaminophen, gabapentin, and a nonsteroidal anti-inflammatory drug (NSAID) such as celecoxib in the preoperative holding area, which will then be postoperatively continued.

SURGERY

Patients undergoing laparoscopic bowel resection should receive appropriate intravenous antibiotics within 1 hour of skin incision. For a lengthy operation, the antibiotics must be intraoperatively redosed on the basis of their pharmacokinetics. Prophylaxis against deep vein thrombosis should be given preoperatively.

Positioning

A gel pad is placed on the operating table to avoid patient slippage during extreme positioning. For most cases, a laparoscopic right colectomy is performed with the patient in the supine position, with
both arms tucked at the sides. However, in cases of Crohn’s disease, patients are placed in the modified lithotomy position, because standing between the legs facilitates the examination of the proximal small bowel (“running the bowel”). Furthermore, the modified lithotomy position helps when an occult ileosigmoid fistula is found. Other indications of a modified lithotomy position include the following:

In a difficult right colectomy, an additional assistant can stand between the legs and help with retraction and exposure through additional ports.
When a lesion or a tattoo is difficult to identify, an intraoperative colonoscopy can readily be performed.

When a patient is placed in a modified lithotomy position, the degree of hip flexion must be kept to a minimum to prevent the thighs from becoming an impediment as they collide with the handles of the laparoscopic instruments during upper abdominal work.

Technique

Port Placement

The camera port is placed in a periumbilical position. Whether it is placed superior or inferior to the umbilicus is based on the body habitus and location of the umbilicus. The camera port is best placed at the “top of the dome” when the abdomen is insufflated; in most patients, this position will be infraumbilical. However, when the umbilicus is located low in the abdomen (in obesity and in some males), the camera port is best placed in the supraumbilical position. In the majority of cases, this periumbilical port wound is then extended around the umbilicus as a mini-laparotomy for exteriorization of the colon, resection, and anastomosis.

A typical port placement is illustrated in Figure 3-1. We favor the blunt Hasson technique (10 or 12 mm) for the camera port. The surgeon begins the operation from the left side of the patient using
the left lower quadrant and suprapubic ports. The assistant stands to the right of the surgeon, holding the camera and using the left upper port. A monitor placed near the right shoulder of the patient is used by both operators. After vascular ligation and medial-to-lateral retromesenteric dissection, the surgeon moves to the right of the assistant, using the two left-sided ports, for hepatic flexure takedown and lateral ligament mobilization. The assistant helps through the suprapubic port.

FIGURE 3-1 The port placement for a medial-to-lateral laparoscopic right hemicolectomy.

Operative Steps

The following are the general operative steps in a medial-to-lateral laparoscopic right hemicolectomy:

Isolation and division of the ileocolic pedicle
Isolation and division of the right branch of the middle colic vessels
Separation of the right colon and mesentery from the retroperitoneal fascia in a medial-to-lateral direction
Dissection of the gastrocolic ligament, takedown of the hepatic flexure and lateral ligament
Mobilization of the ileum and mesentery off of the retroperitoneum
Division of the bowel proximally and distally
Anastomosis

Ileocolic Pedicle

The patient is placed in a slight Trendelenburg position. The omentum is lifted above the transverse colon, and the distal ileum is moved into the pelvis. The patient is tilted steeply with the right side up, and the more proximal small bowel loops are swept to the left of the midline.

The operation starts with the isolation of the ileocolic pedicle. The ileocolic artery is a proximal branch off of the superior mesenteric artery that courses just inferior to the third portion of the duodenum. Therefore, the identification of the duodenal sweep through the mesentery is an important initial step in identifying the ileocolic pedicle as the transverse colon is retracted in a cephalad direction. Ample tension on this vessel is critical in distinguishing it from the superior mesenteric vessels. With traction on the ileocecal region in an anterolateral direction, the ileocolic artery will be seen “bowstringing” through the mesentery (Fig. 3-2). The right colic artery arises from the ileocolic artery to supply the hepatic flexure in 90% of patients. Since the vascular ligation will be performed proximal to the takeoff of the right colic artery, it does not need to be separately ligated in most cases. In 10% of patients, however, the right colic artery branches off of the superior mesenteric artery cephalad to the ileocolic pedicle, and in these cases the right colic artery will need separate ligation. Distal in its course, near the ileocecal junction, the ileocolic artery forms an arcade with the distal superior mesenteric artery; the ileal branch and accessory ileal branch, which can bleed if injured. Therefore, the dissection of the ileocolic artery should start in the avascular plane between the superior mesenteric vessels and the ileal branch.

A wide window is made in the peritoneum caudal to the ileocolic pedicle as the retroperitoneal structures are gently swept away in a posterior direction (Fig. 3-3). A mesenteric window is then
made on the cephalad aspect of the ileocolic pedicle, and the pedicle is adequately isolated to allow for easy vessel division. The surgeon should clearly identify the duodenum to avoid injury (Fig. 3-4).

FIGURE 3-2 The ileocolic pedicle identified through the right colon mesentery. The duodenum (D) should be identified, and the pedicle should travel clearly to the ileocecal junction.