The main steps to perform a right colectomy + demonstration movie
Victor Tomulescu
Indications
There are 2 major indications for laparoscopic right hemicolectomy: neoplasms of the cecal appendix and right colon and patients with inflammatory bowel disease in whom medical treatment has been unsuccessful, leading to complications requiring surgery.
This chapter deals with oncology targeted surgery.
Radical surgery for colon cancer involves excision of the tumor with adequate margins (at least 10 cm from the visible edges of the tumor) along with draining vessels and lymphatic tissue. En bloc excision of the mesocolon is based on the same oncological principles as the complete mesorectal excision, on dissection in the avascular embryological planes – dissection between Toldt’s fusion fascia and the deep subperitoneal fascia, which ensures excision of the entire peritumoral envelope and draining lymphatic tissue.
The patient was placed supine, with the main surgeon sitting on the left plus two assistant surgeons, one on each side of the patient.
A total of five trocars were used: a 10/12 mm trocar to the left of the umbilicus for a 30°/45° laparoscope, another 12 mm trocar at the epigastrium and a 5 mm trocar at the hypogastrium. These are the trocars for the main surgeon.
Two additional 5mm trocars were placed at the right iliac fossa and right flank, as access ports for the assistant surgeon.
This positioning of the trocars is recommended by us but their location is at the surgeon’s discretion.
- The trocars must be inserted at 90 degrees to the abdominal wall
- Trocar tip in view at all times during insertion
The first maneuver is the inspection of intra-abdominal contents with laparoscopic camera (liver, hepatic flexure, left hepatic lobe, stomach, right colon, left colon, pelvis, ovaries in women) including confirmation of lesion site / tattoo visualization.
Thenext step is to expose and identify the ileocolic vascular pedicle by traction on the cecum and mesocolon. The patient was moved to a reverse Trendelemburg position and slightly to the left. We prefer to delineate the resection area to the left of the patient by sectioning the omentum in two using an advanced bipolar clamp or ultrasound dissector as an intermediate time.
Vascular dissection begins by opening a window in the peritoneum using the monopolar hook (of course the use of scissors or advanced electrosurgery is possible but we prefer this fine instrument for dissection).
- It enters an avascular plane without harming any other structure
- The retroperitoneum appears smooth without bleeding
There are several ways to perform vascular ligation; the most delicate is to identify the artery and vein before sectioning, a dissector is needed to individualize the vessels in the surrounding fatty tissue. Using a Robby -Storz bipolar clamp is very helpful. Vessels are secured by placement of clips (at least 2 proximal and one distal), ligatures or use of mechanical sutures.
- In the evaluation of surgery, circumferential dissection of the vessels without injury to the vessels, duodenum, ureter or gross violation of the retroperitoneum is very important
- The application of clips at an angle of no more than 45 degrees from perpendicular, with the applicator’s jaw showing and the clip being fully applied, is also evaluated
- Sectioning at more than 2 cm from SMA, SMV
- The vein can be transected with an advanced electrosurgical instrument
The assistant surgeon gently pulls the vessel bluntly exposing the retroperitoneal plane. We identify and dissect the anterior wall of the duodenum from the mesocolon without an injury to the duodenum or pancreas in an avascular plane. The posterior ascending mesocolon fuses with the parietal retroperitoneum to become the right-sided Toldt’s fusion fascia.
The mobilization of the ascending colon involves dissection between Toldt’s fusion fascia and the deep subperitoneal fascia, this being the avascular plane.
The medial to lateral mobilization is performed as much as possible, which facilitates the lateral detachment of the colon. The hook makes the sharp dissection possible, as does the scissors or ultrasound dissector. The operator must guide the positioning of the laparoscopic forceps being used, so as to improve traction and exposure.
The dissection should continue in an avascular plane (of the Toldt’s fascia medial to lateral above the duodenum and below the transverse mesocolon to the abdominal wall and liver or cholecyst. In the case of a tumour that goes beyond the plane of the Toldt’s fascia, the dissection will be more bloody with violation of the retroperitoneum beyond the Gerota fascia.
The marker is the liver flexure; the duodenum should always be considered, so as to prevent unexpected injuries. A compress or tent is placed under the colon at the end of the medial mobilization.The procedure continues with transection of the transverse mesocolon from the ileocolic vessels to the marker established for colon transection, depending on the position of the lesion.
- Careful dissection without injury to the colon or adjacent structures will be followed in the evaluation of the intervention
Sectioning of the straight colonic vessels and/or the straight branches of the middle colonic vessels will be done following the dissection steps described in the ileocolic pedicle ligation
Next, the assistant on the right side positions his/her forceps and performs a cranial traction on the liver or gall bladder, without producing an injury at this level, and pulls the colon towards the pelvis. The placed compress is identified, revealing the correct plane for lateral dissection.
The monopolar hook is used to open a window into the peritoneum, allowing advanced electrosurgical instruments to perform detachment of the ascending colon along Toldt’s white line. It is important to mobilize until the duodenum is visualized, to allow for proper exteriorization of the specimen.
The appendix can be used to modify the exposure of the cecum and complete its dissection. At this point it is helpful to position the patient in Trendelenburg and place the small bowel in the upper abdomen so that the attachments of the distal ileum, cecum and appendix are clearly visible for safer mobilization.
The terminal ileum is also mobilized and sectioned according to the location of the tumor. The next step may consist of sectioning the attachments of the omentum to the transverse colon at the level chosen for the colon transection and subsequently sectioning the omentum if this step was not performed at the beginning.
The procedure continues with the opening of the omental pouch and visualization of the stomach by dissection on an avascular plane between the gastroepiploic fat and the omentum. Subsequently, the omentum is removed and the hepatic angle of the colon is lowered.
In assessing the surgery, the following will be taken into consideration:
- Dissection in the avascular plane between the gastroepiploic fat and the omentum
- Stomach visualization
- Performing dissection without the duodenum, stomach, pancreas, gastroepiploic vessels.
The small bowel and colon are sectioned using mechanical sutures (intracorporeal or extracorporeal) after carefully assessing the remaining colon and small bowel vascularity (the use of indocyanine green is beneficial).
The way of stapling the ileum and colon to viable tissue will be evaluated.
The specimen can be placed in an endobag but it is mandatory to protect the wound at the time of extraction with a wound protector.
We prefer to use both endo bag and wound protector and extract the piece through a Pfannenstiel incision.
The correct use of the wound protector will be assessed, the use of the endo-bag is not mandatory.
Anastomosis can be performed intracorporeally or extracorporeally.
Our recommendation is to perform intracorporeal anastomosis, this way the tension in the mesos at the time of anastomosis is reduced, the risk of wound infection decreases and once learned, you may find it is the optimal solution for obese patients. The use of traction wires orients the anastomosis for correct stapling.
We always check the bleeding of the stapling line by asking the anesthesiologist to increase the patient’s blood pressure, adding metal clips if necessary for hemostasis.
The performance of anastomosis, extracorporeal or intracorporeal, will be evaluated for correctness of performance (must appear on the videos to be evaluated and on the scoring sheets).
The mesenteric defect can be closed or left wide open depending on the surgeon’s preference; we prefer to close the defect every time after having to operate on a few cases of internal hernias.
It is mandatory to assess haemostasis and control the mesentery and the mesocolon, checking that they are not twisted by an incorrect positioning at the time of anastomosis (especially when this is performed extracorporeally); It is also mandatory to close the parietal defects at the trocars over 10 mm.
We consider the medial-to-lateral approach as the logical approach for initial control of vascularisation. Depending on the surgeon’s experience and familiarity, both the lateral to medial or inferior to superior or superior to inferior approach may be an option. We believe that these alternatives should be known and used according to the particularities of each case (e.g. in large lesions adherent to the abdominal wall or in obese patients, the initial lateral take-off allows the meso to be stretched and the ileocolic vessels to be better highlighted).
Locally advanced lesions will probably require dissection beyond the avascular plane of the Toldt’s fascia. These can be approached minimally invasive with increasing experience, but always bearing in mind that a rapid conversion to open surgery should be the rule if safe resection for the patient is in question.