Laparoscopic right colectomy for cancer

Laparoscopic colorectal surgery has gained wide acceptance as a treatment in a variety of benign and malignant diseases. The reproducibility and safety of all the principal colorectal procedures has been demonstrated. Surgeons performing right hemicolectomy using the laparo-assisted technique consider it more difficult than open colectomy. It is possible to perform a completely laparoscopic right hemicolectomy in advanced laparoscopic centers with many benefits: less postoperative pain, short-term postoperative ileus, earlier return to daily activity. This chapter describes surgical anatomy, indications and techniques of laparoscopic right colon resection for cancer.

Browse the WORLD
Virtual University

LAPAROSCOPIC   RIGHT   COLECTOMY   FOR   CANCER

Authors
Abstract
Laparoscopic colorectal surgery has gained wide acceptance as a treatment in a variety of benign and malignant diseases. The reproducibility and safety of all the principal colorectal procedures has been demonstrated. Surgeons performing right hemicolectomy using the laparo-assisted technique consider it more difficult than open colectomy. It is possible to perform a completely laparoscopic right hemicolectomy in advanced laparoscopic centers with many benefits: less postoperative pain, short-term postoperative ileus, earlier return to daily activity. This chapter describes surgical anatomy, indications and techniques of laparoscopic right colon resection for cancer.
Media type
Publication
2009-05
Popular
Favorites
Favorites Media
Audio
en es pt fr


E-publication
WeBSurg.com, May 2009;9(05).
URL: http://www.websurg.com/doi-ot02en335.htm

LAPAROSCOPIC   RIGHT   COLECTOMY   FOR   CANCER

1. Introduction
Laparoscopic colon resection for malignancy is performed in advanced laparoscopic centers in order to have the patient benefit of the advantages of a minimally invasive procedure (smaller wounds, shorter hospital stay and earlier food intake). However, because an open right colectomy is a straightforward and simple procedure in comparison to the laparoscopic approach which demands more time, resources and equipment, many are questioning whether or not the laparoscopic approach offers any added benefits.
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.
2. Anatomy
• Attachments of the colon
The vasculature of the right colon is based on the superior mesenteric vessels.
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.
• Arterial network
1. Superior mesenteric artery
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
• Venous network
1. Right colic vein
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
• Gastrocolic trunk
Frontal view of the anatomy of the gastrocolic trunk (GT) and its tributaries:
PV: portal vein
SV: splenic vein
SMV: superior mesenteric vein
GT: gastrocolic trunk
RGOV: right gastro-omental vein
• Variations
• Right colic vessels
There are several anatomical variations concerning the right colic vessels.
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.
• Gastrocolic trunk and tributaries
(Mori et al., 1992; Lange et al., 2000)
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.
3. Surgical anatomy
• Generalities
1. Attachment site
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
7. Mesentery
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.
• Middle colic artery
The right branch of the middle colic artery, which is the first branch of the superior mesenteric artery, is situated to the left of the gastrocolic trunk and superior mesenteric vein. The right branch must be divided separately to preserve the vascular supply of the left transverse colon. The trunk of the middle colic artery, which is often quite long, must be dissected in order to see the right branch. The lymph nodes present along the right colic artery are also dissected.
• Gastrocolic trunk
The gastrocolic trunk results from the junction of the right colic and right gastro-omental veins. It drains into the superior mesenteric vein on the inferior margin of the pancreatic head, above the third portion of the duodenum. Fragile pancreatic branches join it.
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.
• Ileocolic vessels
The ileocolic vein is exposed by incising the peritoneum overlying the superior mesenteric vein caudad to cephalad. This vein can sometimes be quite large and is located on the right border of the superior mesenteric vein. It is mostly situated inferior to the ileocolic artery. The latter crosses behind the superior mesenteric vein in 70% of cases (in front of it in the remaining 30%) after originating from the superior mesenteric artery.
4. Indications
Laparoscopic colon resection for malignancy is gradually gaining acceptance in select centers of expertise with highly skilled surgical teams. Because of the ease and simplicity of open right colectomy, many have questioned if the laparoscopic approach offers any added benefits. In some subgroups of patients such as obese patients, the laparoscopic approach gives more advantages with a lower morbidity (Leroy et al., 2005). Whether performed totally laparoscopically or in a laparoscopic-assisted fashion, it reduces parietal trauma and thus minimizes the immediate morbidities related to a large abdominal incision. A good operative strategy is important to minimize the difficulties of the laparoscopic approach.
Accepted indications for laparoscopic right colectomy include:
- inflammatory bowel diseases;
- polyps;
- angiodysplasia;
- 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.
5. Basic principles
We perform a MEDIAL POSTERIOR RIGHT COLECTOMY. The surgeon, standing between the patient’s legs, separates the right and left colon respecting oncological principles.
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.
6. Operating room set-up
• Organization
An organized operating room, along with good positioning of the patient and surgical team, plays a crucial role in the success of the surgical procedure.
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.
• Patient
The patient is in supine position with his left arm alongside his body, his right arm abducted at a 90° angle to the body, his legs are slightly bent, abducted, and in stirrups.
- left tilt;
- reverse Trendelenburg;
- pressure areas are protected;
- pneumatic compression stockings;
- orogastric tube;
- urinary catheter.
• Team
1. Surgeon
2. First assistant
3. Second assistant
4. Scrub nurse
• Equipment
Use of a laparoscopic ultrasound is recommended for proper staging of the liver.
1. Anesthetic unit
2. Instrument table
3. Electronic equipment
7. Trocars
• Anatomical landmarks
1. Costal margin
2. Anterior superior iliac spine (ASIS)
3. Pubic symphysis
4. Umbilicus
A. Midline
B. Mid-clavicular line
C. Anterior axillary line
• Trocar types and positions
The number of ports varies from 3 to 5 depending on the surgeons and operative difficulties. Their position is also variable, but our standard approach uses the following protocol.
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).
8. Exploration
Abdominal cavity inspection:
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).
Further inspection:
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.
9. Exposure
• Pneumoperitoneum
The pressure induced by the pneumoperitoneum (12mmHg) creates the operative space but also pushes the visceral organs downwards.
A perfect control of this pressure ensures a good exposure.
• Gravity
The use of gravity is the simplest way to retract the mobile organs. Exposure of the right colon and its mesentery is greatly assisted by placing the patient in a left lateral tilt, head up, causing the small intestine and sigmoid colon to slide into the left lower part of the abdominal cavity.
• Retraction
The superior mesenteric vascular axis is exposed with blunt retraction following these steps:
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.
• Operating field view
• Suprapubic position
After exploring the abdominal cavity through the supra-umbilical trocar, the laparoscope (0° or 30°) is inserted into the subumbilical trocar. This allows excellent visualization of the root of the mesentery, the right mesocolon, the superior mesenteric axis and the base of the transverse mesocolon. In this position, complete visualization of the abdominal cavity is possible, from the ileocecal region up to the transverse colon, allowing 90% of the operation to be performed with a 0° laparoscope.
• Supraumbilical position
Inserting the laparoscope in a supra-umbilical position is sometimes useful to free the hepatic flexure. However, this can be avoided by using a 30 degree scope.
10. Primary vascular division
• The technique’s principles
Once the peritoneal layer of the right mesocolon is opened caudad to cephalad, the ileocolic vessels are divided, followed by the right colic vessels.
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.
• Ileocolic vessels division
The peritoneal layer of the mesocolon is opened anterior to the mesenteric axis, along the right margin of the root of the mesentery.
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.
• Right colic vessels division
The gastrocolic trunk and its branches are identified first. The right colic vein is divided in isolation, preserving the other branches, after applying clips or staples at its junction with the gastrocolic trunk. This trunk may also be divided at the level of the superior mesenteric vein. In this case, all of the afferent branches, notably the pancreatic branches, must be ligated to avoid bleeding. It is important to know the varying anatomies of the vessels.
11. Transection of transverse colon
• Principles
After dividing the vessels, the transverse mesocolon followed by the transverse colon and greater omentum are divided.
• Transverse mesocolon transection
The mesocolon is divided from its root up to the colon. The marginal vessels must be controlled with clips or electrocautery (Ligasure device). Ultrasonic dissectors or hemostasis devices have proven very useful for this step by shortening operative time. The vasculature of the left transverse colon must be preserved.
• Division of transverse colon
The transverse colon is divided using an endoscopic linear stapler (60mm blue cartridge Endo-GIA by Covidien). The division is done to the right side to the colica media vessels while making sure to preserving the vasculature of the left transverse colon. The stapler must be applied perpendicular to the colon. In the case of cancer, the limit of the division is chosen depending on the localization of the tumor.
• Greater omentum transection
The sagittal transection of the greater omentum is facilitated by the use of a high frequency device (10mm Ligasure Atlas, 5mm Ligasure Advance by Covidien). The transection is performed in a straight line from caudad to cephalad, allowing the entire omentum to stay in the upper part of the abdominal cavity. This keeps the operative field clear, especially in cases of a voluminous, fatty omentum.
Once this step is done, the right transverse colon is separated from the left transverse colon.
12. Division of ileum / mobilization of ascending colon
• Principles
The procedure is followed by transection of the ileum about 20cm from the ileocaecal valve. The mobilization of the right colon necessitates the division of the posterior and lateral attachments of the right mesocolon, of the lateral attachments of the hepatic flexure and right transverse colon. Since the mobilization begins after the division of the ileocolic and right colic vessels, oncologic principles of the “no touch” technique (according to the low-risk dissemination criteria of Turnbull) are respected. Such an approach avoids excessive manipulation of the colon, especially in obese patients. The posterior retroperitoneal attachments of the right colon are freed medially to laterally. Division of the lateral attachments of the colon follows this.
• Transection of ileum
The ileum is transected using the 60mm white cartridge linear stapler. The mesenteric residual bridge is then divided.
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.
• Mobilization of ascending colon
The division of the right paracolic gutter’s colonic attachments is performed caudad to cephalad while the first assistant retracts the cecum toward the left hypochondrium.
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.
• Freeing of hepatic flexure
Division of the right phrenocolic ligament is possible either by extending the incision of the right paracolic gutter, or by lowering the hepatic flexure after freeing the right transverse colon from its superior attachments.
13. Anastomosis
• Principles
The anastomosis is a crucial step. The small bowel should not twist and contamination of the abdominal cavity should be avoided.
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.
• Anastomosis ''in''
We routinely perform a side-to-side “in” isoperistaltic anastomosis. A linear articulated stapler (Endo-GIA, blue cartridge 60mm) is used to perform the side-to-side isoperistaltic anastomosis. The stapler is introduced through a 12mm operating trocar (Port 1 or Port 5), depending on the mobility of the colon and of the small bowel.
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).
• Anastomosis ''out''
The anastomosis must be performed extracorporeally with the same principles described for the anastomosis “in”.
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.
• Closure of mesocolic defect
We always close the mesenteric defect. This closure is performed with staples or sutures. Compared to suturing, stapling takes less time and is not as risky as it is more superficial.
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.
14. Specimen extraction
• Principles and extraction site
Choosing the site:
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.
• Specimen retrieval
The colon segment is placed in a plastic bag until its extraction, which is often performed at the end of the procedure, after intracorporeal anastomosis.
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.
15. Postoperative period
The gastric tube is removed when patient awakes in the recovery room. A liquid diet is resumed D1 or D2 with gradual normal food intake depending on the degree of bowel transit restoration. Normal physical activity is generally resumed between D8 and D15.
16. Reference
Bonjer HJ, Hop WC, Nelson H, Sargent DJ, Lacy AM, Castells A, Guillou PJ, Thorpe H, Brown J, Delgado S, Kuhrij E, Haglind E, Pahlman L; Transatlantic Laparoscopically Assisted vs Open Colectomy Trials Study Group. Laparoscopically assisted vs open colectomy for colon cancer: a meta-analysis. Arch Surg 2007;142:298-303.

Chung CC, Ng DC, Tsang WW, Tang WL, Yau KK, Cheung HY, Wong JC, Li MK. Hand-assisted laparoscopic versus open right colectomy: a randomized controlled trial. Ann Surg 2007;246:728-33.

Fleshman J, Marcello P, Stamos MJ, Wexner SD; American Society of Colon and Rectal Surgeons (ASCRS); The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Focus Group on Laparoscopic Colectomy Education as endorsed by The American Society of Colon and Rectal Surgeons (ASCRS) and The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Dis Colon Rectum 2006;49:945-9.

Lacy AM, Delgado S, Castells A, Prins HA, Arroyo V, Ibarzabal A, Pique JM. The long-term results of a randomized clinical trial of laparoscopy-assisted versus open surgery for colon cancer. Ann Surg 2008;248:8-9.

Lange JF, Koppert S, van Eyck CH, Kazemier G, Kleinrensink GJ, Godschalk M. The gastrocolic trunk of Henle in pancreatic surgery: an anatomo-clinical study. J Hepat Pancreat Surg 2000;7:401-3.

Leroy J, Ananian P, Rubino F, ClaudonB, Mutter D, Marescaux J. The impact of obesity on technical feasibility and postoperative outcomes of laparoscopic left colectomy. Ann Surg 2005;242:747-8.

Mori H, McGrath FP, Malone DE, Stevenson GW. The gastrocolic trunk and its tributaries: CT evaluation. Radiology 1992;182:871-7.

Rawlings AL, Woodland JH, Vegunta RK, Crawford DL. Robotic versus laparoscopic colectomy. Surg Endosc 2007;21:1701-8.

Sereno S, M Anvari, Leroy J, Marescaux J. Prevalence of internal hernias after laparoscopic colorectal resection. Surg Endosc 2007; 21:S342.

Shatari T, Fujita M, Nozawa K, Haku K, Niimi M, Ikeda Y, Kodaira S. Vascular anatomy for right colon lymphadenectomy. Surg Radiol Anat 2003;25:86-8.

Veldkamp R, Gholghesaei M, Bonjer HJ, Meijer DW, Buunen M, Jeekel J, Anderberg B, Cuesta MA, Cuschierl A, Fingerhut A, Fleshman JW, Guillou PJ, Haglind E, Himpens J, Jacobi CA, Jakimowicz JJ, Koeckerling F, Lacy AM, Lezoche E, Monson JR, Morino M, Neugebauer E, Wexner SD, Whelan RL; European Association of Endoscopic Surgery (EAES). Laparoscopic resection of colon Cancer: consensus of the European Association of Endoscopic Surgery (EAES). Surg Endosc 2004;18:1163-85.