Right Colectomy for Malignant Disease

Fig. 13.1

Trocar positions , numbers indicate trocar sizes in mm

../images/465809_1_En_13_Chapter/465809_1_En_13_Fig2_HTML.jpg — Fig. 13.2

Opening of the peritoneum below the ileocolic vascular bundle

../images/465809_1_En_13_Chapter/465809_1_En_13_Fig3_HTML.jpg — Fig. 13.3

Medial-to-lateral dissection posterior to the right mesocolon and anterior to Gerota’s fascia

Lateral mobilization is now facilitated. This portion of the dissection starts around the cecum and the appendix (Fig. 13.4), and then gradually the lateral suspension of the ascending colon is taken down. Hepatic flexure mobilization is completed by taking down its suspension toward the fatty tissue around the right kidney and the retroperitoneum below the liver. The omentum is gradually taken down until the central transverse colon is reached.

../images/465809_1_En_13_Chapter/465809_1_En_13_Fig4_HTML.jpg — Fig. 13.4

Beginning of medial-to-lateral dissection, with opening of the peritoneum below the ileocolic vascular bundle

The ileocolic vascular bundle (Fig. 13.5) is exposed by lifting it up laterally close to the cecum. An incision is made medially below it, and a connection is created toward the previously created blind ending located posteriorly. The peritoneum is further incised below the ileocolic vessels toward their origin. The superior mesenteric vein (SMV) is identified and dissected for further central lymph node harvest (Fig. 13.6). The origin of the ileocolic vessels is identified, skeletonized, and divided with the laparoscopic energy device, a laparoscopic stapler or clips. The dissection continues cephalad along the SMV. In a minority of cases, a true right colic artery (Fig. 13.7), originating from the superior mesenteric artery (SMA), is identified and similarly divided. Further central dissection will lead toward the gastrocolic trunk of Henle (Fig. 13.8) where anatomic variations are frequent. In most cases, the right colic vein, superior right colic vein, and right gastroepiploic vein form this trunk, but they may also have separate origins from the SMV. The trunk or the individual veins are sealed and transected centrally. Next, the middle colic vein and artery (Fig. 13.9) are identified. The SMA normally runs posteriorly toward the anatomical left side of the SMV in this region. Central dissection continues along the middle colic vein and artery toward the right branches of both vessels (Fig. 13.10). They are also sealed and transected centrally. The transverse mesocolon may be further transected distally to facilitate mobilization if needed. At this point the central dissection is complete (Fig. 13.11). The bowel is grasped close to the cecum using a laparoscopic bowel grasper. The right ureter stays behind the anterior peritoneal envelope which is never injured or dissected and may be visualized in skinny patients easily.

../images/465809_1_En_13_Chapter/465809_1_En_13_Fig5_HTML.jpg — Fig. 13.5

Medial-to-lateral dissection , approaching the superior mesenteric vein

../images/465809_1_En_13_Chapter/465809_1_En_13_Fig6_HTML.jpg — Fig. 13.6

Identification and dissection of superior mesenteric vein

../images/465809_1_En_13_Chapter/465809_1_En_13_Fig7_HTML.jpg — Fig. 13.7

Identification and dissection of superior mesenteric vein

../images/465809_1_En_13_Chapter/465809_1_En_13_Fig8_HTML.jpg — Fig. 13.8

Identification and dissection of ileocolic artery

../images/465809_1_En_13_Chapter/465809_1_En_13_Fig9_HTML.jpg — Fig. 13.9

Identification and dissection gastrocolic trunk of Henle

../images/465809_1_En_13_Chapter/465809_1_En_13_Fig10_HTML.jpg — Fig. 13.10

Middle colic trunk

../images/465809_1_En_13_Chapter/465809_1_En_13_Fig11_HTML.jpg — Fig. 13.11

Completion of central vascular dissection . (a) Middle colic vein. (b) Middle colic artery. (c) Pancreas

In laparoscopic right colectomy with extracorporeal anastomosis (ECA) , the camera trocar is removed, and a periumbilical incision is made around the left side of the umbilicus to create a mini-laparotomy. A 4- or 5-cm incision is typically adequate. A wound protector is placed, and the mobilized right colon is exteriorized. Alternative extraction sites would be the right lower abdominal trocar site (transverse incision) or a Pfannenstiel incision which may bear a lower risk of hernias, but both alternatives would demand a more comprehensive mobilization of the transverse colon for optimal reach to create a tension-free anastomosis.

Alternatively, laparoscopic right colectomy can be combined with intracorporeal anastomosis (ICA), which facilitates specimen extraction through a Pfannenstiel incision, since extensive mobilization of the transverse colon and terminal ileum is not needed. For detailed techniques of ECA and ICA during laparoscopic and robotic right colectomy, please refer to the chapters on options for ileocolonic reconstruction (Chap. 14) and robotic right-sided colon resection (Chap. 15), respectively.

The position of the tumor is verified by careful palpation. Mesenteric transection is completed toward the ileum and transverse colon at the sites of planned transection. The bowel is divided using a linear stapler. Photo documentation of the specimen may be performed with a ruler next to it. The central transection areas of the major vessels may be marked using sutures of different colors based on institutional availability. The ileocolic anastomosis is performed with proper orientation of the ileum and colon. The oncologic principles of conventional surgery do not change as the omentum is taken off the right transverse colon in cancers proximally to the hepatic flexure and taken along en bloc with the specimen in tumors of the hepatic flexure and right transverse colon.

Operative Technique: Comparison with Lateral-to-Medial Approach

The technique of creating a retroperitoneal tunnel in the medial-to-lateral approach offers several advantages such as a minimized risk of injury to the retroperitoneal envelope which covers the right ureter and the gonadal vessels. Furthermore, the named arteries are clearly visible posteriorly at their origins, and they may be ligated early, proximally, and safely to minimize the risk of bleeding and keeping the small intestine out of the operative field; an early proximal ligation of the mesenteric vessels (observation of no-touch isolation technique) is achieved. By leaving the lateral attachments of the colon intact until the mesenteric division has been carried out, important natural anatomic countertraction is applied to the bowel as the mesentery and bowel are mobilized. Colectomy is facilitated by leaving the lateral attachments intact, and the described anatomic landmarks are highlighted clearly. Only minimal manipulation of the tumor-bearing colon is needed, as most of the colon mobilization and dissection of the mesentery are accomplished before the cecum and ascending colon are freed from their lateral attachments (no-touch isolation technique).

In a lateral-to-medial approach, the tumor-bearing colon is mobilized first. The lateral dissection is started by elevating the colon on its vascular pedicle, and then both planes of Gerota’s fascia must be entered laterally and dissected apart from each other. The mesenteric and vascular division is the same as in a medial-to-lateral approach with respect to the principles of CME. The vessels are ligated intra- or extracorporeally in a second step; however, it must be ensured that the superior mesenteric vessels and the origins of the mesenteric vessels are clearly identified and divided at their origins. An assistant has to pull on the tumor-bearing bowel to create traction and countertraction for central exposure of the mesentery and avoid the risk of tearing the colon and mesentery. It is important to note that the mobilized colon and small bowel become more difficult to manage laparoscopic surgery relative to open surgery.

Pitfalls and Troubleshooting

For carcinomas of the hepatic flexure and right transverse colon, an extended right hemicolectomy is indicated. The omentum is not dissected off the colon, but the dissection is continued along the lower edge of the duodenum toward the right aspect of the greater curvature of the stomach. The gastrocolic ligament is transected at the left transverse colon. The middle colic vein and artery are dissected and transected centrally at the level of the SMV and SMA to assure a complete lymphovascular resection. The right branches of the middle colic vessels are also divided. In patients where a tension-free anastomosis may be challenging, such as those who are obese, splenic flexure mobilization in combination with further takedown of the omentum may be beneficial as well as a total laparoscopic approach with intraabdominal bowel transection and creation of an intracorporeal ileocolonic anastomosis (ICA) to avoid tension from an extracorporeal approach (ECA).

In obese patients, the landmarks of dissection are more difficult to find, especially the SMV. In such cases, a laparoscopic lateral-to-medial approach may provide improved exposure. In particularly challenging cases, the laparoscopic colon mobilization may be followed by central mesocolic and lymph node dissection in an open technique through a relatively short midline incision.

If the tumor has not been tattooed and cannot be identified at exploration, intraoperative colonoscopy may be necessary. CO₂ insufflation should be used to minimize dilatation of the colon that will hinder further laparoscopic dissection. If the tumor cannot be localized laparoscopically or endoscopically, conversion to laparotomy and careful palpation of the colon may be necessary. As pointed out previously, a conversion to a hand-assisted approach can facilitate medial-to-lateral mobilization, especially in reoperative and obese cases.

The most frequently described intraoperative complication is bleeding. In order to avoid any vascular injury which may be hazardous especially with SMV, SMA, and middle colic vessels, a very slow and meticulous dissection technique is imperative. The laparoscopic energy devices and instruments used for dissection should be carefully observed to avoid contact with vessels. Especially in obese patients, the visualization may be difficult, and the threshold for conversion should be kept very low. As explained above, in a medial-to-lateral approach, the risk of injury to adjacent organs is low: duodenal adhesions by small ligaments toward the posterior mesocolon should be taken down cautiously. The same applies to adhesions between the pancreatic head and the mesocolon. In cases of previous pancreatitis with firm adhesions, conversion is recommended. The ureter normally stays safely below the surface of the retroperitoneal envelope; whenever possible it should be visualized.

If against expectations from preoperative staging by CT scans a T4 tumor is found at exploration, conversion to open approach for planned en bloc resection is recommended.

There are no data of the learning curve in oncologic laparoscopic right hemicolectomy. However, when possible, the technique of CME should be mastered first in the context of open surgery to better understand variations in the relevant anatomy. Also, the laparoscopic expertise required to perform these cases should be advanced, and it may be helpful to practice the procedure first in benign cases, especially adenomas. The retroperitoneal tunnel approach has advantages also when applied in Crohn’s disease and may be practiced in such cases first to gain confidence and become familiar with the technique.

Outcomes

Numerous retrospective studies have shown that a laparoscopic oncologic approach for right colon cancer has results comparable to that of open procedures [28] (Table 13.1). The laparoscopic approach to right hemicolectomy , specifically, has been shown equivalent to the open approach with regard to key oncologic outcome measures. These include the ability to obtain R0 resection with negative resection margins, disease-free and overall survival, lymph node harvest, and incidence of local and systemic recurrence. With experience, some would argue the laparoscopic view provides an advantage over open resection regarding lymph node harvest. With the magnified view provided by the laparoscopic camera, surgical planes can be visualized and dissected with more accuracy and less trauma to surrounding structures.

Table 13.1

Studies comparing results of laparoscopic oncologic right hemicolectomy

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