Program Colorectal Pathway: Laparoscopic Right Colectomy for Benign Disease

Fig. 2.1

Operating room setup

Patient Positioning

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 [5] 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.

Trocar Placement

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.

In the event that the case is not simple, requiring an additional port either to divide the mesentery or to mobilize a phlegmon, an additional fourth trocar is placed (Fig. 2.2). This can be positioned in the right lower quadrant or the left upper quadrant, where an instrument through this port is generally deployed by the camera holder.

../images/465809_1_En_2_Chapter/465809_1_En_2_Fig2_HTML.jpg — Fig. 2.2

Trocar placement

Mobilization of the Right Colon

Lateral-to-Medial Dissection (Table 2.1)

The main aim of this approach is full mobilization of the right colon to the midline. This makes the right colon a midline structure and allows choices regarding ligation of the vasculature and transection of the mesentery [6].

Table 2.1

Steps for lateral-to-medial right colectomy

Step	Patient position
Survey of peritoneal cavity	Neutral
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	Neutral

Classically in this approach, the patient is first placed in Trendelenburg position with the right side inclined up. The right lateral peritoneal reflection alongside the cecum and ascending colon is identified and scored. My preference is for an electrocautery device rather than a bipolar device which when used inappropriately can enter a nonanatomic plane. Once the correct retroperitoneal plane is identified, the cecum is gently swept medially, and the ureter is identified and protected (Fig. 2.3a, b). With the cecum under tension, which means retracting it medially and cephalad, the medial peritoneal reflection alongside the distal terminal ileum can be entered, and the terminal ileal mesentery can be mobilized off of the retroperitoneum.

../images/465809_1_En_2_Chapter/465809_1_En_2_Fig3_HTML.png — Fig. 2.3

(a) Cecum, and right ureter covered by peritoneum. (b) Cecum, and right ureter exposed after peritoneum incised

The right lateral peritoneum alongside the ascending colon is exposed by retracting the ascending colon towards the midline. The anterior surface of Gerota’s fascia should remain intact (Figs. 2.4 and 2.5). The dissection can be continued towards the liver (Fig. 2.6). In a patient with a BMI <30, the ascending colon can be mobilized to the midline, releasing its attachments from the duodenum and allowing visualization of the mesenteric window cephalad to the ileocolic pedicle (Fig. 2.7). In patients of higher BMI, this particular view may not be visible until the mobilization of the hepatic flexure is completed.

../images/465809_1_En_2_Chapter/465809_1_En_2_Fig4_HTML.jpg — Fig. 2.4

Gerota’s fascia inferior portion

../images/465809_1_En_2_Chapter/465809_1_En_2_Fig5_HTML.jpg — Fig. 2.5

Gerota’s fascia mid portion

../images/465809_1_En_2_Chapter/465809_1_En_2_Fig6_HTML.jpg — Fig. 2.6

Right lateral peritoneal reflection at hepatic flexure

../images/465809_1_En_2_Chapter/465809_1_En_2_Fig7_HTML.jpg — Fig. 2.7

Mesenteric window cephalad to the ileocolic pedicle

The operative table should then be placed in reverse Trendelenburg still with the OR table inclined right side up. The hepatocolic attachments at the hepatic flexure should be identified. These can be better delineated by gently lifting them up noting the movement of the superficial tissues over the underlying retroperitoneal plane. This will help to identify the plane of transection which can be developed between the retroperitoneal plane and the hepatocolic attachments (Fig. 2.8). These attachments often have small blood vessels, and here a vessel sealing device can be helpful (Fig. 2.9).