The incision and initial access is very similar to a Hasson technique. The length of the skin incision can be usually less than the fascial incision size of about 3–4 cm. Once access into the peritoneum is achieved, the surrounding fascia is checked with a finger sweep to rule out any adhesions and the single-port device with preplaced trocars is inserted. The abdominal cavity is then explored in a standard fashion to rule out metastatic disease. Adhesiolysis can be performed (see Video 7.1).

The surgeon’s right hand is using a bowel grasper and retracting the cecum or the mesentery close to the cecum towards the right abdominal wall. This allows visualizing the ileocolic pedicle. The left hand is using a dissecting instrument such as a bipolar vessel sealer or monopolar hook or scissors to isolate the ileocolic pedicle and start the medial to lateral dissection separating the colon mesentery from the retroperitoneum. As the instruments cross, maximum fulcrum effect is achieved. Once the duodenum is identified, the pedicle can than be divided (see Video 7.2). In the alternative approach (“rollover technique”), the ileum and small bowel mesentery is divided first, and the ileocolic pedicle can be visualized by continuously alternating between lateral colon mobilization and mesenteric division until the duodenum and the base of the pedicle are identified.

After division of the ileocolic pedicle, the right hand continues to lift the cecum and the left hand dissects between the ascending colon mesentery and the retroperitoneum. The extent can be limited by the reduced ability to tent up the colon. During the alternative approach the dissection of this plane is from lateral and inferior.

The left hand now grasps the cecum with a bowel grasper and retracts medially and cephalad. The right hand is using an energy device or a monopolar hook or scissors to mobilize the colon along the line of Told and separating the remaining mesentery off the retroperitoneum. The instruments again cross to avoid instrument collision (see Video 7.3).

During the alternative rollover technique, this is the first step. The ileum is identified 10 cm proximal to the ileocecal valve, a mesenteric window is created, and the ileum divided using a laparoscopic stapler (see Video 7.4). The distal ileum is now tented up with the left hand in a medial and cephalad direction and the small bowel mesentery divided towards the base of the ileocolic pedicle. Once the division is close to the retroperitoneum, the cecum and colon mesentery is mobilized laterally for a section and the mesentery subsequently divided (see Video 7.5). The cecum and ascending colon “rolls over” medially and cephalad and the cycle is repeated until the duodenum and ileocolic pedicle is isolated.

The right hand now retracts the transverse colon inferiorly to achieve adequate tension of the omentum. The left hand divides the omentum to enter the lesser sac and the hepatocolic attachments (see Video 7.6).

During the rollover technique the lateral to medial dissection is continued around the hepatic flexure with ongoing retraction of the ascending and transverse colon medially and then inferiorly to divide the omentum from the right lateral side.

The division of the middle colic vessels is difficult from the inframesocolic approach because only one retracting instrument is available, and the transverse colon can often times not be lifted enough to have adequate exposure. The right branch can be divided though safely from superior and right lateral using the rollover technique.

Once the dissection is completed, the specimen is extracted through the single-port incision site. The limiting factor is often times the bulk of mesentery and/or the size of the tumor (Box 7.2). With the rollover technique the small bowel mesentery and terminal ileum are already divided intracorporeally and the specimen can be therefore extracted easier through a smaller fascial incision. The divided distal ileum is grasped and the specimen extracted as a tube and not a loop (see Fig. 7.2). The extracorporeal anastomosis is fashioned in a standard way and the abdomen reinspected prior to closure (see Video 7.7).

A medial to lateral approach is the most common utilized approach in a conventional laparoscopic right hemicolectomy is a logic choice. This follows steps 1–7. It should be emphasized that extra care should be taken for safe vessel ligation of the ileocolic pedicle as intraoperative bleeding is difficult to control with availability of only two working instruments and limited mobility.

A very safe and easy alternative to the standardized medial to lateral approach is a modification and combination of the lateral to medial and inferior approach (Box 7.3). It specifically addresses the often times difficult dissection of the ileocolic pedicle, which is the first step of the medial to lateral approach.

This alternative is also called the “rollover technique” because the cecum, ascending colon, and hepatic flexure are progressively rolled over in a clockwise fashion during different parts of dissection. This allows having adequate tissue exposure with traction through the instrument and countertraction through the attachment of the colon to the peritoneum along the line of Told and the hepatocolic ligament, mesenteric attachments to the root, and omental attachments to the stomach. The approach follows steps 1, alternating 3 and 4, 2, 5, 6, and 7. It should be emphasized that the procedure starts with creating a mesenteric window and dividing the terminal ileum first, followed by continuous division of the small bowel, and then colon mesentery alternating with dissection of the mesentery of the retroperitoneum and later duodenum.