The patient should be placed in a supine position on the operating room table. Unlike laparoscopy, the patient’s upper extremities may be left out on arm boards instead of being tucked to the sides.

A bladder catheter should be inserted prior to prepping and draping the patient. A periumbilical midline incision should be made. Upon entrance into the peritoneal cavity, an inspection of all quadrants should be performed and solid organs such as the liver palpated, paying close attention to evidence of metastases. If there are any concerns for metastatic disease, a frozen specimen should be obtained if it will change the indication for operation.

The key maneuver to beginning this operation is obtaining adequate visualization. The small bowel should be retracted to the left side of the abdomen, allowing for clear exposure of the terminal ileum and ascending colon mesentery. As well, the omentum and transverse colon should be retracted cephalad to the upper abdomen in order to provide full, unobstructed visualization.

The medial-to-lateral dissection begins with identification of the ileocolic vascular pedicle. This maneuver can be accomplished with anterior and lateral retraction of the cecum (Fig. 1-1). The ileocolic artery should be clearly identifiable as it tents within the mesentery. A peritoneal opening should be made alongside the vascular pedicle. Lifting the mesentery and pedicle toward the anterior abdominal wall and gently sweeping the retroperitoneum down allows for development of an avascular plane between these two structures. This avascular dissection is continued laterally toward the abdominal wall beneath the colon. Care must be taken during this portion of the dissection, to avoid injury to the duodenum, which should be swept down with the retroperitoneum (Fig. 1-2). After sufficient dissection to the bulb of the duodenum, attention is turned to cephalad dissection toward the hepatic flexure. The dissection continues in the avascular plane, sweeping retroperitoneum down until we are limited in exposure due to our intact vascular pedicle. Once this limit has been reached, the vascular pedicle is skeletonized and ligated. In an effort to perform an appropriate oncologic resection with complete lymphadenectomy in cases of malignancy, a high ligation of the ileocolic artery, between 1 and 2 cm from its origin at the superior mesenteric artery, is performed (Fig. 1-3). At our institution, the vascular pedicle is generally ligated with a bipolar electrosurgical energy device, but others may opt for a clamp and tie technique or use of a vascular stapler.