There are several options for trocar positioning for laparoscopic right hemicolectomy with planned ECA or ICA. Over time, the surgeon will eventually identify their preferred configuration and alternatives when required based on body habitus, adhesions from prior surgery, and need for additional assist trocars. Most surgeons will place their 12 mm stapler port where they plan to extract the specimen, so that there are fewer incisions at risk for subsequent hernia formation. It is important to mark potential extraction sites at the start of the procedure as after insufflation; the abdominal wall will become distorted.
With the patient supine, a 5/12 mm trocar is placed just at the umbilicus for the 5/10 mm scope or endoscopic linear stapler. This trocar site can later be enlarged for specimen extraction via the umbilical incision when ECA is performed. A 5/12 mm trocar is placed in the suprapubic region, slightly to the left of the midline for the surgeon’s left-hand instruments like the grasping forceps, or the scope or the endoscopic linear stapler if introduced through this port. This latter trocar will be enlarged for specimen’s extraction via a Pfannenstiel incision after completion of ICA. A 5 mm trocar is placed in the epigastrium, slightly to the left of the midline for the surgeon’s right-hand instrument, like an energy device and the needle holder for suturing. If needed for added retraction, a 5 mm trocar can be placed along the right mid-clavicular line in the right upper quadrant for the assist grasping forceps. Additional assist trocars can be placed in any number of locations as needed. This is particularly useful in obese patients and in patients with extensive adhesions. When suturing is found to be challenging due to the suboptimal port placement, an existing assist port is firstly recommended. If this is still suboptimal, one or more additional trocars can be placed, so that the surgeon’s right and left hands are properly triangulated with the camera targeted on the relevant anatomy.
With the patient supine with split-leg or in low lithotomy position , a 12 mm trocar is placed in the suprapubic location for the 10 mm scope and for the endoscopic linear stapler. This trocar will be enlarged for specimen removal via a Pfannenstiel incision, after completion of intracorporeal anastomosis. A 5 mm trocar is placed on the left mid-clavicular line in the left iliac fossa for the surgeon’s right-hand instruments like the needle holder for suturing or for the introduction of 5 mm scope at the time of endoscopic stapling. A 5 mm trocar is placed on the right mid-clavicular line in the right iliac fossa for the surgeon’s left-hand instruments, like the grasping forceps . If needed for retraction, a 5 mm trocar is placed in the epigastrium, slightly to the left of the midline for the assist grasping forceps.
Options for Ileocolonic Reconstruction
When an ECA is performed, the specimen is extracted through the enlarged trocar site (e.g., 12 mm umbilical trocar). Both the ileum and trasnverse colon are transected extracorporeally using a standard linear stapler, and the specimen is handed off the field. The anastomosis is then created.
When an ICA is performed, following vascular dissection and mobilization of the ileum, right and transverse colon, the distal ileum and the proximal transverse colon are transected intracorporeally using an endoscopic linear stapler. The specimen is then placed above the liver or in the low pelvis and the ICA is created. The specimen will be later extracted through the incision of the surgeon’s choice.
Techniques of Intracorporeal and Extracorporeal Ileocolonic Anastomoses
Side-to-Side Stapled Anastomosis
The ileal loop is placed alongside the transverse colon ensuring no twisting of the mesentery. The limbs can be aligned in an isoperistaltic or antiperistaltic configuration, depending on the natural way the bowel lays and surgeon’s preference.
In the isoperistaltic anastomotic configuration, an enterotomy is created along the antimesenteric aspect of the ileum 1–2 cm proximal to the stapled end using monopolar cautery or any energy device. The transverse colon is opened as well along its antimesenteric aspect, keeping a 5–8 cm distance from its stapled end (Fig. 14.3). Each arm of a standard or endoscopic linear stapler (with a 45 mm or 60 mm load of the appropriate staple height) is inserted in each limb, and the stapler is closed and fired (Fig. 14.4). The staple line can be visualized through the enterotomy and checked for hemostasis. The enterocolotomy can then be closed by another firing of the stapler or by suturing. With the stapled closure, care must be taken not to narrow the anastomosis or staple across the mesentery to the anastomosis. Authors’ preference for sutured closure of the enterocolotomy is a single layer anastomosis by two converging running sutures, using absorbable material (e.g., polydioxanone/PDS 2/0), started at both corners of the anastomosis (Fig. 14.5). There are several options for suture closure of the enterocolotomy based on the surgeon’s preference.
In the antiperistaltic anastomotic configuration, an enterocolotomy is created along the ileum 1–2 cm proximal to its stapled end. The transverse colon is opened close to its stapled end as well (Fig. 14.6). Each arm of a standard or endoscopic linear stapler is inserted in each limb, and the stapler is closed and fired (Fig. 14.7). The enterocolotomy is then closed using two converging running sutures of absorbable material (e.g., PDS 2/0), started at both corners (Fig. 14.8) or using the other options described above.
An alternative technique during right colectomy with ECA consists in exteriorizing the specimen en bloc with the distal ileum and proximal transverse colon without transecting the bowel first. Upon exteriorization, rather than transecting the bowel, the enterotomy and colotomy are made with insertion of the linear stapler and creation of the anastomosis. The enterocolotomy is transected along with the attached ileum and transverse colon using a second load of linear stapler. This approach only requires a total of two stapler loads rather than three to four loads, when the bowel is transected prior to creation of the anastomosis.
Side-to-Side Handsewn Anastomosis
The ileal loop is placed alongside the transverse colon, in either an isoperistaltic or antiperistaltic configuration. A continuous running suture is placed aligning the ileum to the colon using absorbable material (e.g., PDS 2/0) (Fig. 14.9). After completing this first running suture (typically ~5 cm in length), which constitutes the posterior anastomotic layer, a second running suture for the anterior layer is started at the planned apex of the anastomosis. After taking the first bite with the suture, a transverse colotomy and ileal enterotomy are created using monopolar cautery or any energy device (Fig. 14.10). The second running suture is used to construct the anterior layer of the anastomosis. At the opposite corner of the anastomosis, the posterior running suture is continued onto the anterior layer for a few bites in order to oversew the corner of the anastomosis (Fig. 14.11). The two running sutures are then tied together.
Side-to-End Stapled Anastomosis
For this type of anastomosis, the bowel is aligned in an isoperistaltic configuration with the terminal ileum oriented at 90 degrees relative to the transverse colon. The ileal loop is placed with its lateral (antimesenteric) side against the stapled end of the transverse colon. The ileum is opened by making an enterotomy close to its stapled end. The transverse colon is also opened close to its stapled end (Fig. 14.12). A standard or endoscopic linear stapler is inserted in each limb and fired (Fig. 14.13). The enterocolotomy is closed by any method previously described (Fig. 14.14).