Operating room setup
Steep position changes are often necessary to facilitate exposure and move small bowel out of the operative field, and it is imperative to prevent slipping. The patient is usually placed in the supine position, on egg crate foam secured to the OR table, or other mechanism to prevent the patient moving during steep position changes. A draw sheet is placed beneath the patient, and behind the foam to maximize patient contact with the foam, to then allow the sheet to be wrapped around the patient’s arms to align them alongside the patient after padding of the hands. Alternatively, a combined synchronous position with the patient in low stirrups can be considered to allow for the surgeon to be positioned between the legs to facilitate access during mobilization of the hepatic flexure. This is helpful when mobilization of the hepatic flexure is more complex than usual (phlegmon/large mass at the hepatic flexure, obesity) or if intraoperative endoscopy is anticipated. In this case, the patient’s thighs should be flat and aligned with the patient’s abdomen to prevent interference of the patient’s knees during the use of lower abdominal trocars. During the main portion of the case, both surgeon and assistant will need to be on the left side of the patient, facing the right colon. Preferably, both arms are tucked at the patient’s sides, or at least the left arm should be tucked alongside the patient.
Operative Technique: Surgical Steps
There are, quite simply, two approaches to the right colon. One either chooses lateral-to-medial  or medial-to-lateral. Multiple other approaches have been described including inferior upwards and top-down from the hepatic flexure. This does not change the fact that there are basically two approaches. The lateral-to-medial approach uses the right lateral peritoneal reflection as a marker for entering the correct retroperitoneal plane. The medial-to-lateral approach starts by isolating the base of the ileocolic pedicle and using this as an entry into the retroperitoneal plane.
This chapter will focus on the technique of extracorporeal creation of the anastomosis following resection. The techniques for intracorporeal anastomosis are covered in a separate chapter.
Insertion of trocars should be adapted to the case.
In the most simple cases, i.e., limited ileocolic resection in the patient with BMI <30, it is possible to fully mobilize the right colon and exteriorize it through a periumbilical incision, without needing to divide either the mesentery or the bowel intracorporeally. A triangular configuration, facing the right colon, uses umbilical, suprapubic, and left lower quadrant port sites.
Mobilization of the Right Colon
Lateral-to-Medial Dissection (Table 2.1)
Steps for lateral-to-medial right colectomy
Survey of peritoneal cavity
Mobilize cecum and ascending colon
1. Identify RLQ landmarks: Cecum, right ureter
2. Incise peritoneum around base of cecum and mobilize cecum medially
3. Incise right lateral peritoneal reflection, mobilize ascending colon medially
4. Confirm identification of right ureter, IVC, inferior portion of duodenum
Trendelenburg, right side inclined up
Mobilize hepatic flexure
1. Elevate hepatocolic attachments and identify duodenum
2. Divide hepatocolic attachments
3. Join dissection with the lateral dissection already performed
4. Divide right branch of middle colic vessels if required
Reverse Trendelenburg, right side inclined up
Transection of mesentery
1. Place mobilized right colon back in anatomic position and elevate to expose base of ileocolic pedicle
2. Open mesenteric windows cephalad and caudad
3. Identified duodenum via cephalad window
4. Divide vascular pedicle
5. Divide remaining mesentery
6. Divide R branch of middle colic vessels if not already done and required
Neutral horizontal position, right side inclined up
Exteriorization and anastomosis
1. Deflate pneumoperitoneum via trocars
2. Extract colon via chosen extraction site using wound protector
3. Resect and create anastomosis per preferred technique
4. Return anastomosis to abdominal cavity
5. Remove ports and check for hemostasis