Right Colectomy

Peter Mark Neary

Sherief Shawki

Conor P. Delaney

Perioperative Considerations

An oral polyethylene-based bowel preparation is given the day prior to surgery. Patients with concern for bowel obstruction do not receive oral bowel preparation.
Patients receive three doses of 1 g neomycin and 500 mg metronidazole orally the day before surgery.
Tumors are generally visualized endoscopically by the operating surgeon and tattooed (unless already visible on preoperative imaging).
Preoperative subcutaneous heparin is administered within 2 hours of surgery, and sequential compression devices are used to help prevent deep venous thrombosis prophylaxis.
Imaging is reviewed to look for relative anatomical landmarks and to exclude involvement/invasion (eg, tumor, fistula) into adjacent organs (ie, pancreas, duodenum, retroperitoneum) that may dramatically alter surgery.
Right-sided stents are infrequently, but selectively used (eg, phlegmon, radiation, tumor involvement).

Equipment

Bean bag (if desired)
2% chlorhexidine gluconate in 70% isopropyl alcohol skin disinfectant
Carbon dioxide insufflator
Bipolar energy device
Wound protector
Laparoscopic instrument set (Fig. 22-1)
Suction
10-mm 0-degree laparoscope with high definition
Camera lead
Gas tubing
12-mm balloon port
20-mm syringe
5-mm blunt-tip trocar port ×3
Laparoscopic electrocautery lead
Monopolar food switch (if desired)
Open electrocautery device
Laparoscopic towers
16Fr rubber catheter
Fluid warmer
Sterile water
Scope warmer (Fig. 22-2)
Blue-loaded linear gastrointestinal anastomosis (GIA) 80-mm stapler
TA 60- or 90-mm stapler with blue cartridge

FIGURE 22-1 ▪ Laparoscopic equipment.

FIGURE 22-2 ▪ Scope warmer with laparoscopic lens.
60 mL 0.25% bupivacaine with epinephrine 1:100 000
Minilaparotomy set
Closing instrument tray
4/0 absorbable monofilament suture
3/0 polyglactin
1 Maxon
- A 10-mm 0-degree laparoscope with high definition is preferred by the senior author.
- The authors find a 30-degree lens usually compromises the view often provided by inexperienced camera holders and rarely improves visualization.
- A 30-degree lens is on standby if necessary for a very obese male with a high hepatic flexure. A typical tray is shown in Figure 22-3.
- This varies by individual surgeon preference.

FIGURE 22-3 ▪ Full equipment set.

Anesthesia

General anesthesia is typically utilized. Laparoscopic right hemicolectomy via a medial-to-lateral method is the preferred approach.
Complete muscle relaxation is necessary for effective insufflation and laparoscopic visualization.
Epidural anesthesia is unnecessary. Pain is generally well controlled using multimodal analgesia with transversus abdominis plain block, oral and intravenous analgesia.

Patient Positioning

The patient is placed in modified lithotomy. Legs are held in Yellowfins stirrups (Fig. 22-4). Both arms are tucked, and the patient is secured on a bean bag. Edges of the bean bag are flattened when being stiffened to prevent interference with the instruments (Fig. 22-5). In patients who are too obese to safely strap both arms, the right arm is kept out. Lithotomy position gives the option to the surgeon to stand between the legs when distal transverse colon mobilization is necessary.

FIGURE 22-4 ▪ Patient positioned in modified lithotomy. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

FIGURE 22-5 ▪ Patient positioning.
An orogastric tube is inserted, as well as a Foley catheter that comes out under the patient’s right leg.
The operative technician is typically positioned between the legs.
The primary working monitor is on the patient’s right side.

Approach and Equipment

A medial-to-lateral laparoscopic right hemicolectomy is our preferred approach, as we have not found single port, hand-assist, robotics or open surgery to add value; though each may be indicated in select conditions, patients and institution protocols.
If progress is not being made utilizing the described technique, an open approach is considered.

Technique

Port Insertion

The procedure begins with a surgical huddle and time-out to confirm patient identity, procedure, allergies, history, and imaging and medication required.
The surgeon stands on the patients left, with the assistant opposite.
A vertical 10-mm incision is made immediately below the umbilicus.
A 10-mm port is inserted using Hasson technique. Two small Kocher clamps grasp and lift the exposed fascia. The fascia and underlying peritoneum are carefully opened.
A 2/0 polyglactin suture is placed with a U needle around the fascia.
The 10-mm port is inserted, and a Rommel tourniquet is used to facilitate securing adequate seal, and carbon dioxide is insufflated to a pressure of 15 mm Hg.
A 5-mm port is inserted two fingerbreadths distance medial and superior to the left anterior superior iliac spine under direct vision, taking care not to damage the inferior epigastric arteries (Fig. 22-6).
A second 5-mm port is inserted similarly a handbreadth superior to this (Fig. 22-7).

FIGURE 22-6 ▪ Inferior epigastric vessels.

FIGURE 22-7 ▪ Port insertion.
A third 5-mm port is similarly inserted into the right flank (Fig. 22-8).
Left-sided ports are placed more medially and more superiorly for taller more obese patients to avoid difficulties with reach to the hepatic flexure (Fig. 22-9).

FIGURE 22-8 ▪ Port site positioning.

FIGURE 22-9 ▪ High left lateral port placement in obese patient.

Laparoscopic Assessment of Resectability

Right hemicolectomy is mainly performed for cancer, endoscopically unresectable polyps, or terminal ileal Crohn disease.
The abdomen is inspected for tumor spread, including the liver, peritoneum, ovaries, uterus, adhesions, tattoo, fixity to retroperitoneum, and/or tethering to other organs (Figs. 22-10 and 22-11).

FIGURE 22-10 ▪ Liver.

FIGURE 22-11 ▪ Tattoo on right colon.
The extent of adhesions, inflammatory phlegmon, and the tumor size and fixation are important considerations to help decide if the operation should be done laparoscopically.
Patients with malignancy or Crohn’s disease have the entire abdomen, including the intestine, inspected at this stage, and any suspicious areas are palpated after exteriorizing the specimen.
The patient is then tilted into approximately 10 degrees Trendelenburg and maximum right side up.
The assistant moves to the patient’s left side below the surgeon to hold the camera (Fig. 22-12).
The surgeon positions the small intestine with two atraumatic bowel graspers to allow the distal ileum to stay in the pelvis with the remainder in the left flank and left upper quadrant.
The omentum is laid superior to the transverse colon (Fig. 22-13).
Tattoo and tumor characteristics can often be examined more thoroughly at this point.