This chapter describes techniques for laparoscopic right colon resection for cancer. Although early studies report a high port-site recurrence rate, the most important randomized controlled multicenter studies such as Barcelona, COST, COLOR, CLASICC trials (Bonjer et al., 2007) appear to refute this risk and demonstrate that the oncological outcomes are at least equivalent. Additionally, the “Lacy” trial demonstrated improved cancer-related survival for stage III disease in the laparoscopic group (Lacy et al., 2008).
While the data for long-term survival still needs to be confirmed, the multiple short-term benefits of laparoscopy have been confirmed by many studies: these are smaller wounds, less postoperative pain, shorter hospital stay and earlier oral food intake.
The method used in this laparoscopic right colectomy will be analysed and discussed, thus allowing for a constructive comparison of the varying techniques utilized by other experts.
This chapter will describe the technique that was used for this intervention so that it may be reproduced, but it is important to note that the approach can vary according to each case.
There are two main arteries, the ileocolic and the right colic. These arteries anastomose to become the often fragile marginal artery network.
The venous network is denser. The draining veins coalesce into two main trunks, the ileocolic and the right colic.
2. Jejunal branches
3. Middle colic artery (gives right colic branch)
4. Right colic artery (isolated in 10% of cases)
5. Ileocolic artery
6. Marginal arteries
7. Ileal branch
2. Right gastro-omental vein
3. Marginal veins
4. Pancreatic branch
5. Gastrocolic trunk (right colic pancreaticoduodenal veins)
6. Ileocolic vein
7. Superior mesenteric vein
PV: portal vein
SV: splenic vein
SMV: superior mesenteric vein
GT: gastrocolic trunk
RGOV: right gastro-omental vein
See schematics of the right colic artery (RCA), ileocolic artery (ICA), superior mesenteric artery (SMA) and superior mesenteric vein (SMV).
A and B: positioning of the right colic arteries in relation to the SMV (Shatari et al., 2003)
A, with RCA; B, without RCA.
There are several anatomical variations in the number and position of the vessels (see A, B, C, D). In the study by Lange et al., the CT-scan highlights that the gastrocolic trunk is not present in 10% of patients.
2. Toldt's fascia
3. Superior aspect of the transverse mesocolon
4. Inferior aspect of the transverse mesocolon
5. Posterior aspect of the right mesocolon
6. Anterior aspect of the right mesocolon
The vessels are located in the mesocolon, often hidden in the adipose tissue. Therefore, in obese patients, it is harder to identify them. To find them, it is important to have good anatomical landmarks. Good landmarks are the virtual line between the duodenojejunal and ileocecal junction (root of the mesentery), and the exposure of the inferior aspect of the right and transverse mesocolon.
The peritoneum is initially incised along or lateral to the superior mesenteric vessels. This maneuver is the key to early vascular control.
The vessels are approached cephalad along or lateral to the anterior surface of the superior mesenteric vein. This reveals sequentially the ileocolic vessels, followed by the right colic vessels.
The right colic vein can be clipped electively (see step 10-Vascular division) preserving the gastrocolic trunk. This maneuver also applies to colectomies performed for malignancies.
In 10% to 30% of cases, an additional right colic vein can be found, arising from the ascending colon and draining into the superior mesenteric vein below the third portion of the duodenum.
Accepted indications for laparoscopic right colectomy include:
- inflammatory bowel diseases;
- right colonic diverticulosis;
- malignant tumors < T3, with no evidence of local metastasis (Veldkamp et al., 2004).
In cancer, the worldwide consensus is to respect oncologic principles: primary vascular approach, large lymph node resection depending on the bowel segment to be removed, 5cm distal margin, and 10cm proximal margin, and R0 resection.
The vascular division will be performed first. Then the colon and ileum will be divided followed by complete mobilization of the right colon. Finally, the anastomosis is done before or after the specimen’s removal in or out of the abdominal cavity.
The operating room should be spacious to provide ample room for all the equipment required in this type of surgery.
The surgeon’s position is very important. In a total right colectomy, he/she stands between the patient’s legs in order to dissect along a straight axis. In a partial segmental resection (ileocecectomy), the surgeon and the 1st assistant stand on the left side of the patient. The second assistant stands between the patient's legs.
- left tilt;
- reverse Trendelenburg;
- pressure areas are protected;
- pneumatic compression stockings;
- orogastric tube;
- urinary catheter.
2. First assistant
3. Second assistant
4. Scrub nurse
1. Anesthetic unit
2. Instrument table
3. Electronic equipment
2. Anterior superior iliac spine (ASIS)
3. Pubic symphysis
B. Mid-clavicular line
C. Anterior axillary line
Ports are introduced according to the following order of appearance numbered on the schematic (from P1 to P5).
The optical port, a 0 degree scope, (P1) is placed on the midline above the umbilicus at the beginning of the procedure. An angled laparoscope (30-45 degrees) may be useful to mobilize the hepatic flexure. After a panoramic exploration of the abdominal cavity, the optical port (P2) is placed on the midline underneath the umbilicus.
We use 2 operating ports (P3 and P5), and one retracting port (P4).
After the introduction of the first trocar, the abdominal cavity is inspected. Based on this exploration, the decision on whether or not to pursue the operation laparoscopically is made, and the ideal trocar positioning determined. Indications for conversion to laparotomy at this operative stage include:
- extensive, dense adhesions;
- inability to locate the lesion;
- evidence of a T4 malignancy (invasion of adjacent structures).
The abdominal cavity is scrutinized for the presence of secondary lesions or adhesions. The quality of the preoperative bowel preparation, which facilitates the procedure, is also assessed.
A perfect control of this pressure ensures a good exposure.
The greater omentum is retracted cephalad toward the subphrenic space. The transverse colon is then elevated to expose the inferior aspect of the transverse mesocolon.
The grasping instrument must never be used directly on the colon, but on the mesentery or omental folds to retract and stretch anteriorly the transverse mesocolon.
This is our technique of choice; it allows to open the retromesocolic space and to mobilize the colon from its retroperitoneal attachments without excessive manipulation.
This reveals the superior mesenteric vein and opens the right retroperitoneal space. The third duodenum and the head of the pancreas are the best landmarks to find the right plane.
Once this step is done, the right transverse colon is separated from the left transverse colon.
In some cases, this operative step may also be carried out after mobilizing the caecum (ileocaecal adhesions). However, care must be taken to avoid injuring the underlying ureter, particularly in the case of adhesions caused by a previous surgery or by an inflammatory disease. The right colon is now completely separated from the left transverse colon and from the ileum.
When freeing the retrocecal attachments, care must be taken to identify the genital vessels and right ureter, especially in cases of associated inflammation.
Having the surgeon stand to the left of the patient facilitates this step.
A lot of different techniques can be applied. Here, the anastomosis is performed inside the abdominal cavity before removing the specimen through a smaller suprapubic cosmetic incision. We perform a side-to-side isoperistaltic ileocolic anastomosis using a mechanical linear stapler (60mm blue cartridge Endo-GIA), which is completed with a manual suture.
The anastomosis can also be achieved out of the abdomen through a small incision protected by a plastic wound protector with a 7cm diameter (Vi-Drape® manufactured by Becton Dickinson, USA) following the removal of the specimen.
The stapling line is controlled through the incision to rule out any bleeding. The stapler’s introduction sites are re-approximated with sutures (interrupted stitches or two half-running sutures of monofilament absorbable material – Maxon 3/0).
The anastomosis can be performed outside the abdominal cavity or through the incision. The latter necessitates less freeing of the bowel but the incision must be as close to the bowel as possible.
Some authors no longer perform this closure. The risk of bowel obstruction due to the incarceration of an intestinal loop seems to be lower in the case of a wide defect (Sereno et al., 2007). However, if closed, the closure must be perfect.
One of the advantages of the laparoscopic approach is that the extraction site of the operative specimen can be chosen in the region of the abdominal wall. The objective is to reduce the risk of parietal trauma and incisional hernia and to preserve cosmesis.
FOR CANCER, EFFECTIVE PARIETAL PROTECTION IS INDISPENSABLE. The specimen must not be compressed in the abdominal cavity during its extraction. Placing the operative specimen in a closed airtight plastic bag is the best means of protection. This is always done along with the insertion of a plastic wound protector in the extraction site, which also allows to reduce the size of the incision.
Whenever possible, we perform a suprapubic extraction through a transverse mini-incision.
If an extracorporeal ileocolic anastomosis is intended, then a higher extraction site may be preferable depending on the mobility of the left transverse colon. The size of the incision depends on the volume of the specimen to be extracted.
The double plastic wound protector prevents parietal and peritoneal contamination.
Once the bag is brought outside, it is opened. The colon is grasped by one of its ends to facilitate its extraction without tearing the protective bag.
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