Laparoscopic right colectomy: vascular anatomy

This video demonstrates the dissection of the vascular anatomy of the right colon for a right hemicolectomy. The surgeon uses a medial approach to mesenteric mobilization to show an excellent dissection of ileocolic, right and middle colic vessels.

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Laparoscopic   right   colectomy:   vascular   anatomy

Authors
J Leroy, F Jamali
Abstract
This video demonstrates the dissection of the vascular anatomy of the right colon for a right hemicolectomy. The surgeon uses a medial approach to mesenteric mobilization to show an excellent dissection of ileocolic, right and middle colic vessels.
Classification
basic techniques
Keywords
right colon,operation,resection,vascular supply
Media type
Duration
10'00''
Publication
2002-09
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Sept 2002;2(09).
URL: http://www.websurg.com/doi-vd01en1223e.htm

Laparoscopic   right   colectomy:   vascular   anatomy

1. Script 00'14''
Laparoscopic right colectomy is often considered by many experts to be a complex procedure due to intricacies in vascular anatomy. This video demonstrates the important vascular landmarks encountered during the course of a right colectomy. We begin by a schematic representation of the anatomy. The operation began by a peritoneal incision along the axis of the mesenteric vessels. The initial step of the procedure is the identification and division of the ileocolic vessels. The dissection is then carried out cephalad with identification and division as well of the right colic vessels. Here we demonstrate the important venous landmarks at the level of the superior mesenteric vein, namely the joining of the gastroepiploic vein, the right colic and the pancreatic branch to form a common trunk of Henlé that goes into the superior mesenteric vein. In this procedure, we use 5 trocars. We use a 10mm, 10-12mm operating trocar at the level of the umbilicus, another 10-12mm trocar in the suprapubic area for the camera insertion, two operating 5mm trocars in the left and right lower quadrant and a 5mm retracting trocar in the left upper quadrant. The procedure is begun by retraction of the omentum as well as the right colon to the upper part of the abdomen. Exposure is achieved by retracting the bowel loops to the right side of the abdomen and complete retraction cephalad of the transverse colon. The dissection is begun by incising the peritoneum in the direction that is parallel to the axis of the superior mesenteric artery and vein. This incision is carried on cephalad to the base of the transverse mesocolon. Having incised the peritoneum, a gentle step by step dissection is then carried out to identify the superior mesenteric vein and artery and the takeoff of the ileocolic vessels. Here we can see the superior mesenteric vein coming into view. Along the superior mesenteric artery and the vein, there is an avascular sheath, which can be used to develop this plane of dissection. The dissection is carried out on the right-hand axis of the superior mesenteric vein to allow for identification of the ileocolic vessels. Here we can see the ileocolic artery and vein skeletonized. Clips are applied on both the artery that we see here and at the 2nd time at the level of the vein before division of these ileocolic vessels. Two clips are applied on the proximal side and one clip applied distally. The ileocolic vessels are hereby divided. The dissection is then carried through the mesocolon to expose the white line of Toldt and the retroperitoneal structures. Here we can clearly see the duodenum, which is being taken down in the retroperitoneal area. This dissection can be done in an avascular plane using a traction counter-traction technique. The dissection is then continued around the duodenum in a retroperitoneal plane to reach the base of the transverse mesocolon. The duodenal attachments to the transverse mesocolon are separated and here we can see the head of the pancreas and the duodenal C-loop as well as the gastroepiploic vein, and the pancreatic branch, which will be lead to the Henlé trunk. Continuing dissection in this plane will lead to the lesser sac. Here we can see by transparency the lesser sac. The lesser sac is not opened at this point to avoid the organs falling into view. The dissection is then taken to the root of the mesentery of the transverse mesocolon where we demonstrate very clearly the middle colic artery. This middle colic artery will branch to give off the left branch of the middle colic, which we hereby see, and a right branch. Similarly here we see the common trunk of Henlé, which is the junction of the gastroepiploic, pancreatic as well as right colic venous branches that form the common trunk before draining into the superior mesenteric vein. The middle colic vessels are now completely skeletonized. Here we can see the middle colic artery and vein skeletonized at the base of the transverse mesocolon. The left branch of the middle colic artery is hereby demonstrated at its takeoff. This left branch will be preserved to ensure an adequate blood supply to the left transverse colon in the area of the anastomosis following the right colectomy. Here we can see the middle colic artery with its left branch being demonstrated and its right branch right here. The middle colic vein is hereby demonstrated. It will be skeletonized and clipped separately. Clipping the middle colic vein at this level will lead to preservation of the common trunk, which we see right here. This common trunk is constituted by the junction of the gastroepiploic vein, which will join with the pancreatic vein branch that is demonstrated right here. The joining of this gastroepiploic and pancreatic vein along with the middle colic vein will lead to the common trunk of Henlé and the superior mesenteric vein. The right branch of the middle colic artery is clipped as is the middle colic vein. Those will be divided. Following division of the middle colic vessels, we can proceed through the transverse mesocolon to the area of the lesser sac, which is hereby opened and we are looking at the posterior aspect of the stomach. Dissection is then carried out to preserve the gastroepiploic vein leading to the common trunk. The omentum will now need to be divided at this level taking care to preserve this gastroepiploic vein. The remainder of the mesocolon is divided all the way up to the transverse colic wall. The transverse colon is then transected using an Endo-GIA stapler with 3.5mm charge. Similarly, completion of the transection of the omentum is carried out using an Endo-GIA. At the end of this film, we’ll take a moment to re-demonstrate to you the important vascular landmarks. Here we can clearly see the left branch of the middle colic artery. Here we can see the base of the middle colic artery and the clipped right branch of this artery. A trans-mesocolic approach to the lesser sac is hereby shown. Similarly, a retrogastric passage is also demonstrated. Here again we’ll see the gastroepiploic vein, which joins with a pancreatic branch. These 2 again join with the middle colic vein to lead into the common trunk, which in turn will lead into the superior mesenteric vein. We thank you for your attention and hope you have enjoyed this movie.