Laparoscopic right colectomy for cancer

This video demonstrates a right hemicolectomy for a large cancer at the hepatic flexure. The patient has had a cholecystectomy and an appendectomy in the past and the adhesions make the case more difficult. The surgeon uses a medial approach to mobilize and divide the ileocolic vessels and the right branch of the middle colic. After full mobilization of the right colon, it is exteriorized through a small transverse incision at the umbilicus and an end-to-side anastomosis is made with an EEA stapler. The mesenteric window is not closed.

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Laparoscopic right colectomy for cancer

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Abstract

This video demonstrates a right hemicolectomy for a large cancer at the hepatic flexure. The patient has had a cholecystectomy and an appendectomy in the past and the adhesions make the case more difficult. The surgeon uses a medial approach to mobilize and divide the ileocolic vessels and the right branch of the middle colic. After full mobilization of the right colon, it is exteriorized through a small transverse incision at the umbilicus and an end-to-side anastomosis is made with an EEA stapler. The mesenteric window is not closed.

Classification

complex cases

Keywords

Right Hemicolectomy, laparoscopic, hepatic flexure cancer, medial approach, ileocolic vessels

Media type

Surgical video

Duration

25'00''

Publication

2005-08

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E-publication

WeBSurg.com, Aug 2005;5(08).
URL: http://www.websurg.com/doi-vd01en1823.htm

Laparoscopic right colectomy for cancer

1. Case description 00'10''

This patient had a gallbladder operation and appendectomy but there were a lot of adhesions. As you can see, I have spent some time dividing adhesions to get to the ileocolic. Here’s the terminal ileum here. This is the caecum still stuck with some adhesions up here. The liver is absolutely clear. We’ve looked at the liver already. He’s got a pretty redundant right transverse colon and there’s no gallbladder. Some surgeon has already taken it out. We start now by doing the operation. The duodenum is here so the base of the ileocolic is here and this will be the proper plane to start. I don’t know whether there is a right colic or not but we’ll see that as we go along. I’m going to divide the peritoneum there and the patient is head down and right side up. There’s a good view and there’s the duodenum as you see. Colon up there and I think we start.

2. Trocar and patient placement 01'20''

This is the umbilicus here and there are two 5mm ports, one epigastric, one suprapubic, and 5 to 12mm trocar here on the left so I never know exactly where to put this by the way, it just depends on where the ileocolic is. As you know it can be variable. This is the hepatic flexure so I think starting the ileocolic is better for me. It’s very difficult for the assistant because he’s not used to working with me at all. I use electrocautery to divide the peritoneum, just simple monopolar. We’re looking at the ileocolic.

3. Ileocolic vessels 02'57''

It should run to the duodenum here. So this is the vena cava I think.

4. Duodenum 03'07''

Here’s the duodenum. The 1st thing I do is to divide the ileocolic. I use the Ligasure. It always amazes me how high or close to the mesentery the dissection really is. Some of the mistakes I see people make is that they get very low down and the plane is actually much higher. You can begin to see the right branch here and we’ll take it. It’s my guess. We’re in the right place to begin with. The important thing is to go slow and fast with this. You can see that this is an avascular plane usually if you do it right. If we hold the omentum out of the way here, there you go. I’m going to take the right branch. It’s the oncologic resection. Everyone has different opinions about that. For me, the important thing is that you don’t manipulate the tumor ever, you make your incision big enough to extract the tumor so that there’s no pressure, there’s no trying to get a big tumor through a small incision and you’re reasonable in the dissection of the base of the vessels. For me, this is enough. This is the right branch and I’m very happy to divide it right here.

5. Right branch of middle colic vessels 06'29''

Once I do this, we really have sort of mesenteric dissection we’ll basically totally complete and then we can work up under medial to lateral and we can go out laterally to the gutter. (646)When you did this open, did you do the same dissection or have you changed? No I didn’t. I was always trained lateral to medial and that’s what I did. I think it’s very important number one to define exactly where you are anatomically because otherwise you make mistake at the time of doing the surgery, this can be a disaster. I concentrate my efforts very much on that. Honestly I really believe it makes a difference if the patient has nodal disease all the way down and you’re one centimetre away, my honest opinion is that doesn’t make any difference. This is the plane. It’s amazing how high we really need to be to be in the right tissue plane. It’s really next to the mesentery. Always medial to lateral. It’s fair to say in North America, most people do lateral to medial and in Europe people do medial to lateral. I think you can do an adequate cancer operation either way to be honest with you. That’s been pretty well been shown. I don’t see a problem when doing it lateral to medial and sometimes you need to mobilize the lateral. The ileum is there. It’s always good to have different options to handle issues. I’m dividing the ileal mesentery up to the ileum. Here’s the terminal ileum here. And then once I do that, I go and finish the other side of this thing. You have to make sure we get retroperitoneal to do this. I don’t need to do any more medial. Let’s go the transverse colon, right hepatic flexure, right side and then we should be able to mobilize it pretty well. Here’s the falciform. For me, this is plenty adequate for a cancer operation to be over here. And I show you where I have divided the right branch of the middle colic vessels. I’ve already divided. Let’s take that first.

6. Opening of greater omentum 11'19''

Let’s get the omentum out of the way. I want to make sure that I got the right amount of colon and I’m very happy with that for a cancer operation. We can see underneath that there is a substantial artery. What’s the name for it? I’ll tell you in a second. This is the kidney. I feel the tumor, which is underneath. I must say I didn’t get a good look at it at the beginning. There were lots of adhesions up there. I believe it’s the other side of the peritoneum. We always pass the colon over here. From the previous surgery, it’s like stuck. Here’s the tumor. I can feel it. It feels very heavy and on the CT-scan, it’s certainly circumferential but not invading all the tissue planes that are appropriate. I guess we’ll see blood vessels shortly. It’s just a matter of getting in the right plane. This is where I was on the other side.

7. Mobilization of right flexure 15'00''

This is the omentum to the gallbladder. See where the previous cholecystectomy was. There are little adhesions up there. These are 2 planes, with the omentum above and I guess this is the gastrocolic below. You can see the tumor is actually lateral to the gallbladder fossa I believe. I have still yet to see the tumor. I haven’t touched it yet. That’s a good thing. The less time we palpate this thing, the better off it would be. I think I need to suck out the aspirator. It seems a little bit harder for me to access that lateral because of the previous surgery so I think it’s going to be easier for me to look up down. It’s stuck from the adhesions. Once you get the right plane, it goes right up but it’s not yet. And the plane is absolutely very close. I still haven’t seen the tumor. I think I have to mobilize the ileum up in the pelvis, it’s stuck too. The assistant is so important in knowing what you want to do. Since my extraction side is transverse midline, then I’ll mobilize this all the way to the duodenum because I think once you’ve got mobilizing it’s a midline structure basically. And the easiest place to take is the mid-transverse colon. That’s the ureter here and I can see it moving. All we got left is really with the tumor, I believe, which is the hepatic flexure so let’s finish that off and then we can extract. I’m still trying not to touch, anyway we’re near this tumor and we’re going to make a pretty good incision. This tumor is large. Now I think it’s completely mobilized. Let’s double check it’s been totally mobilized. I believe we are. And I know that because the tumor then will go in to the left lower quadrant.

8. Specimen extraction and anastomosis 21'27''

Now we use a Babcock forceps and a sponge. It’s a circumferential tumor. It’s obstructing. There’s a lot of stools in the caecum. It’s not been prepped. The transverse colon here looks fine. The tumor is there. We’ve done a good job and now we’re doing an anastomosis. I like to make an enterotomy here. I need a scalpel and I plug in like this. This is about the right place. We’re going to transect there. I’m just putting it in and I’m going to exit the stapler. It’s easier. I don’t close the mesentery. I used to close it in open surgery only because that’s the way I was trained. I don’t think there’s any data to really support it.