Laparoscopic Right Colectomy (Right Hemicolectomy)

Laparoscopy has emerged as the preferred operative approach for most intra-abdominal pathologic conditions. Nonetheless, even though the first laparoscopic colectomy was reported decades ago, the majority of colectomies in the United States are still being performed via the open approach.

This delay in acceptance has mainly been attributable to initial concerns regarding the adequacy of oncologic margins and trocar site recurrences believed to occur with laparoscopy—concerns now largely laid to rest by the results of large randomized controlled trials such as the Clinical Outcomes of Surgical Therapy (COST) trial.[1]  Minimally invasive colectomy has been growing in popularity.[2]

The benefits of laparoscopic hemicolectomy include the following:

• Smaller wounds and improved cosmesis
• Shorter hospital stay
• Less postoperative pain
• Earlier return to normal activity
• Quicker recovery of pulmonary function
• Lower incidence and quicker resolution of postoperative ileus
• Lower incidence of surgical site complications
• Lower incidence of postoperative adhesions ^[3]

The goals of laparoscopic right hemicolectomy (right colectomy) performed in the setting of colon cancer are the same as those of the equivalent open procedure. They involve appropriate vessel ligation, creation of sufficient luminal margins, and adequate lymph node sampling. In addition, a thorough inspection of the abdominal cavity and liver surface is expected, together with the creation of a reliable anastomosis.

Laparoscopic colectomy for resectable colon cancer has been reported to be technically and oncologically feasible. The general consensus, based on the literature over the past several years, is that there is no significant difference in lymph node harvest between laparoscopic and open right hemicolectomies for cancer when strict oncologic principles of resection are followed. To date, patient survival, disease progression, and cancer recurrence at port sites have been found to be equivalent between laparoscopic colectomy and traditional open colectomy.

Several short-term benefits similar to those described for colon cancer have been associated with laparoscopic segmental colon resection for inflammatory bowel disease (IBD). In addition, theoretical long-term advantages include formation of fewer adhesions, decreased rates of bowel obstruction, decreased likelihood of chronic pain, and decreased incidence of infertility or wound hernias. Two randomized controlled trials demonstrated some short-term benefits to laparoscopic ileocolic resection for Crohn disease. On the other hand, evidence on laparoscopic surgery for ulcerative colitis has not supported its routine use among nonexpert surgeons outside of specialized centers.

Laparoscopic colonic resection for diverticular disease appears to provide several short-term benefits, though these advantages may not translate to cases of complicated diverticulitis.

The indications for laparoscopic right hemicolectomy are similar to those for open right hemicolectomy, as follows:

• Adenomatous polyps not amenable to colonoscopic resection
• Crohn disease and its complications
• Bleeding secondary to diverticulosis or arteriovenous malformation
• Diverticulitis
• Obstruction
• Colon tumors (benign or malignant)

There are few contraindications for laparoscopic right hemicolectomy.

Absolute contraindications include the following:

• Tumor infiltration into adjacent structures (T4)
• Large phlegmonous mass
• Obstruction, perforation, or ileus leading to massive bowel distention and loss of domain
• Carcinomatosis

Relative contraindications (depending on local expertise) include the following:

• Morbid obesity
• Multiple previous abdominal surgical procedures
• Extensive abdominal adhesions
• Primary tumor with resectable liver metastasis ^[4]

Laparoscopic right colectomy for a neoplasm was not associated with a higher conversion rate or higher morbidity in patients with prior abdominal surgery; therefore, prior abdominal surgery is not a contraindication for laparoscopic right colectomy.[5]

Indications for conversion to open surgery in the COST trial included the following[1] :

• Extensive abdominal adhesions
• Inability for the surgeon to mobilize and define the tumor extent
• Resectable metastases

Ultimately, the method of resection (laparoscopic vs open) cannot compromise the oncologic adequacy of resection, which is why a very well-defined stepwise technique is so vital.

Anatomy

The right colon is derived embryologically from the endoderm roof of the yolk sac, which develops into the primitive gut tube. In the beginning of the week 3 of gestation, the gut tube separates into the midgut, foregut, and hindgut segments. The midgut gives rise to the segment of the gastrointestinal (GI) tract extending from the distal duodenum to the distal transverse colon.[6] It derives its blood supply from the superior mesenteric artery (SMA).

The terminal ileum empties into the cecum through the ileocecal valve. The cecum measures approximately 7.5 cm in diameter and 10 cm in length. The appendix extends from the cecum and measures 8-10 cm in length. The ascending colon is 15 cm long. The posterior surface is fixed against the retroperitoneum along the white line of Toldt. The lateral and anterior surfaces are intraperitoneal. The transverse colon is 45 cm in length. It is fixed by the nephrocolic ligament at the hepatic flexure and by the phrenocolic ligament at the splenic flexure. It is completely invested in visceral peritoneum.

The colon has specific characteristics that distinguish it from other parts of the GI tract. The omental appendices are bodies of fat enclosed by peritoneum. The taeniae coli are three bands of longitudinal muscle; haustra form between the bands.

All vascular structures and lymph nodes are located in the mesocolon. It is easiest to visualize the colon mesentery as being no different from the small-bowel mesentery. Both mesenteries attach at a 90º angle and contain arterial, venous, and lymphatic channels. The right colon differs from small bowel only in that the bowel and its mesentery are "plastic-wrapped" to the retroperitoneum. This distinction is important because in order to resect this bowel, the colon and its mesentery must first be mobilized from its retroperitoneal attachments; only then can a segmental resection with lymphadenectomy be performed.

The arterial supply branches from the SMA to the ileocolic, right colic, and middle colic arteries. The SMA territory ends at the distal transverse colon, where the inferior mesenteric artery (IMA) takes over to supply the left colon. A marginal artery network is the anastomotic web between these vessels along the mesenteric border. Vasa recta branches of the marginal artery directly supply the bowel wall.

The most common pattern of arterial supply relevant to a right hemicolectomy consists of the three arterial branches arising from the SMA (ileocolic artery, right colic artery, and middle colic artery). The ileocolic artery, the most constant tributary of the SMA, supplies the terminal ileum, cecum, and appendix. The right colic artery supplies the ascending colon and hepatic flexure of the transverse colon. (See the image below.)

The middle colic artery is the most proximal branch of the SMA, supplying the proximal and distal transverse colon via the right and left branches. The middle colic artery is completely absent in as many as 25% of individuals; it is replaced by a large right colic artery.[7] The arc of Riolan (meandering mesenteric artery) is a collateral artery that directly connects the proximal SMA to the proximal IMA and may serve as a vital conduit when arterial occlusion occurs.

Many variations of the right colic artery anatomy exist (see the image below). It arises directly from the SMA in approximately 40% of individuals, from the middle colic artery in 30%, and from the ileocolic artery in 12%. It is completely absent in 20% of individuals.

Venous drainage mimics the arterial tree, with ileocolic and right colic veins draining into the superior mesenteric vein (SMV). The lymphatic drainage follows the arteries and drains into the para-aortic nodal chain. Other lymph nodes involved include epicolic nodes along the bowel wall, paracolic nodes adjacent to the marginal artery, intermediate nodes along the arterial and venous branches, and primary nodes at the SMA and SMV.[8, 9]

Relevant definitions and terminology

The Gerota fascia is a perinephric fascia that encloses the kidneys and adrenal glands. Superiorly, it tapers over the inferior diaphragmatic surface. Medially, the fascia crosses the midline and is contiguous with the contralateral fascia. Laterally, the Gerota fascia is an open potential space that contains the ureter and gonadal vessels.

The white line of Toldt represents the fusion of colic mesentery with the posterior peritoneum.

An adenomatous polyp is a mass projecting into the lumen of the bowel. These polyps are classified by their gross appearance as pedunculated or sessile and further classified by histology as tubular or villous. The most common colonic polyp is a tubular adenoma. The incidence of carcinoma in a polyp depends on size and histology.

Diverticulosis describes the presence of colonic diverticula. A diverticulum is an abnormal protrusion of mucosa through the muscular layers of the colonic wall. Diverticula are associated with increasing age and low-fiber diets.[9]

Complication prevention

Because of the close proximity of the duodenal sweep to the ileocolic pedicle, the duodenum is at risk for sharp or cauterization injuries. To prevent such injury, the duodenum should be identified and gently swept away prior to dissection and division of the ileocolic pedicle.

The right ureter is most commonly injured over the right iliac vessels during cecal mobilization; accordingly, care should be taken to ensure that the dissection plane is not overly posterior. As a rule, the ureter should remain underneath the Toldt retroperitoneal fascia. However, if the Toldt fascia cannot be clearly visualized via a medial approach and the dissection plane is unclear during the isolation of the ileocolic pedicle, it is advisable to switch to an inferior approach. The ileum is mobilized off the retroperitoneum so that the right ureter can be identified and traced toward the duodenum before the pedicle is divided.[3]

Aggressive blunt dissection around the origin of the ileocolic vein makes the SMV susceptible to avulsion injury. A short stump should be left during ligation of the ileocolic pedicle in order to avoid encroachment into the superior mesenteric vessels.[3]

Aberrant anatomy must be taken into account. In 10%-30% of cases, an additional right colic vein arises from the ascending colon and drains into the SMV below the third portion of the duodenum.

In some patients, fusion of Gerota fat to the posterior aspect of colon can increase the risk of either entering Gerota fat or dissecting posterior to the kidney during lateral mobilization. This problem is prevented by pushing down on Toldt retroperitoneal fascia and ensuring that the dissection planes remain anterior to it.

Proximal ligation of the right colic vein places the right gastroepiploic vein at risk for injury or division. This type of injury is prevented by lifting the transverse colon anteriorly and dividing only the veins that travel to the colon. The vasculature traveling underneath the colon toward the stomach is preserved.[3]

During anastomosis, the terminal ileum or the transverse colon may become twisted around its mesentery. Often, the twisting is not visible through the minilaparotomy incision and consequently goes unnoticed. To prevent this complication, place two seromuscular stay sutures into the ileum, one proximal and one distal, after the right colon is exteriorized and the terminal ileum and mesentery divided. These stay sutures are clamped individually and are never crossed. Another technique involves placing a laparoscopic grasper on the terminal ileum. Once the anastomosis has been created, a final look through the laparoscope can confirm that the mesenteric orientation is correct.[3]

The average mortality following laparoscopic colorectal surgery is less than 2%. A randomized trial by Lacy et al reported that perioperative mortality was 1% for laparoscopic resection and 3% for open resection.[10]

The COST Study Group evaluated laparoscopic resections used to treat colorectal cancer in the United States. The study concluded that cancer recurrence rates were similar between the laparoscopically assisted colectomy and open colectomy groups, suggesting that the laparoscopic approach is an equivalent alternative to open surgery for colon cancer.[1]

A systematic review and meta-analysis by Arezzo et al, which examined the safety and oncologic adequacy of laparoscopic right colectomy against those of open right colectomy in 3049 rectal cancer patients, found that morbidity and mortality were significantly lower with the laparoscopic technique.[11]

From 2009 to 2010, Yun et al analyzed 159 patients with colon cancer who underwent single-incision laparoscopic right colectomy. They concluded that the procedure is safe and can provide outcomes equal to those of conventional laparoscopic colectomy.[12]  These findings were supported in a study by Pedraza et al.[13] ​

In a systematic review and meta-analysis that included 11 studies (N = 8257), Solaini et al compared the safety of robotic right colectomy with that of laparoscopic right colectomy.[14] Operating time was significantly shorter for the laparoscopic procedures, and conversion to open surgery was more common in this setting as well. There were no significant differences in mortality or postoperative complications between the laparoscopic and robotic approaches. The pooled mean time to first flatus was greater with laparoscopic procedures. Hospital costs were significantly higher for robotic procedures.

Shorter hospitalization and fewer postoperative complications might be expected to reduce overall procedural costs, but these can be offset by the increased cost of longer operating times and more costly instrumentation. Bouvet et al found similar total hospital charges when comparing laparoscopy versus laparotomy for colectomy.[15] Likewise, Philipson et al did not show any cost benefit of laparoscopic-assisted right hemicolectomies compared with the open technique.[16]

In a retrospective study using data from a population-based database, however, Wei et al found that minimally invasive (ie, laparoscopic or robotic) colectomy, as compared with open colectomy, was associated not only with a significantly lower risk of major perioperative complications but also with lower total hospital costs, despite the longer operating times.[2]

Equipment used for laparoscopic right colectomy (right hemicolectomy) includes the following:

• A light source with two video monitors for the surgeon and assistant
• A 30° laparoscope
• Standard gas insufflation equipment
• Hasson trocar
• Two 5-mm trocars and one 12-mm trocar
• Three bowel-safe graspers
• Laparoscopic ultrasonic shears (eg, Harmonic Scalpel, Sonosurg)
• Electrocautery equipment
• Laparoscopic suction irrigator
• Laparoscopic clip applier
• Medium wound protector
• Laparoscopic linear cutting stapler with both white and blue reloads (eg, Echelon 60 mm or EndoGIA 60 mm)
• Standard 75-mm gastrointestinal anastomosis (GIA) stapler with two blue reloads
• Linear noncutting (eg, TA) stapler (60 mm) with a single blue load
• Foley catheter

Anesthesia

General anesthesia is required for a laparoscopic right hemicolectomy.

Antibiotic prophylaxis is recommended for prevention of surgical site infections. The recommendation is that this be administered by the anesthesiologist as a single dose prior to the skin incision.

Positioning

Confirm and mark the surgical site preoperatively in the holding area. Shave the surgical site with electric clippers. Prepare and drape the surgical site in the standard surgical fashion, exposing an area from below the xiphoid to above the pubis. The prepared area should be wide enough to allow conversion to an open technique, if necessary.

The patient is placed in a supine position, and straps are used to secure the patient during steep changes of table position. The patient’s left arm is tucked along his or her side and the right arm extended on an arm board.

A urinary catheter is placed in the bladder, and the stomach is decompressed with an orogastric tube.

The positioning of the surgical personnel varies, but the authors recommend the following. The nurse is on the patient’s right side. This is also where the assistant starts, with the surgeon on the patient's left side facing the right colon. Once all the trocars are in place, the assistant moves to the patient's left side to direct the camera and to help with retraction.

Monitor placement is crucial. One monitor should be placed at the right side of the patient so that the surgeon who is positioned on the left has an unobstructed view. A second monitor can be placed at the left side to help the assistant during insertion of the first trocar and to help the nurse follow the procedure.

A right hemicolectomy (right colectomy) for benign disease involves the resection of the terminal ileum, right colon, and proximal transverse colon followed by ileocolic anastomosis.

The extent of resection required for malignant disease depends on the tumor margin and the need for adequate oncologic lymphadenectomy as defined by the blood supply. Guidelines for colorectal cancer recommend a 5-cm margin, both proximally and distally, for adequate tumor resection and a minimum of 12 lymph nodes for complete lymphadenectomy.[17]

Depending on the exact location of the lesion, the line of resection varies. Thus, for tumors in the cecum and proximal right colon, a standard right hemicolectomy is performed, with the line of resection extending to the proximal transverse colon and the level of the right branch of the middle colic artery. However, an extended right hemicolectomy may be required for lesions closer to the hepatic flexure, in which case the resection must extend to include the entire middle colic artery territory.

In general, an ileocolic anastomosis is preferred to a colocolic anastomosis, owing to the superior blood supply of the former.

The right colon lies in very close proximity to the duodenum, necessitating careful dissection to achieve full colonic mobility.[18]

Robotic approaches to this procedure have been described.[19, 14]

The skin is prepared with chlorhexidine antiseptic from just below the nipple line to the inguinal ligaments and laterally to the anterior superior iliac spine.[20] The operative field is then draped with sterile drapes.

A 1.5-cm longitudinal incision is made at the inferior aspect of the umbilicus and deepened through the subcutaneous fat to the anterior rectus sheath. The reflection of the linea alba onto the umbilicus is grasped with a Kocher clamp and elevated cephalad. With a No. 15 blade, a 1.2-cm longitudinal incision is made in the linea alba. A 0 polyglactin stitch on a UR needle is used to place U stitches on either side of the fascial incision.

The peritoneum is then elevated between two straight clamps and incised with a Metzenbaum scissors, affording entry into the abdominal cavity. A 12-mm blunt Hasson trocar is then placed into the abdominal cavity, and gas insufflation is initiated to a maximum pressure of 15 mm Hg.

A 30° laparoscope is indispensable for all advanced laparoscopic surgery because it offers visualization of the structures from multiple vantage points. It should be noted that a 30° scope requires a more skilled camera operator.

The laparoscope is then white-balanced and advanced slowly into the abdominal cavity. Complete peritoneoscopy is then performed, with special care taken to evaluate the liver, peritoneal surface, and omentum for signs of metastatic disease.

Under direct vision, three more trocars are placed (see the image below).

A single-incision transumbilical approach has also been described; initial experience suggests that this approach may be feasible and safe.[21, 22] Single-incision laparoscopic right hemicolectomy may have a longer learning curve than conventional laparoscopic right hemicolectomy.[23]

The authors have found that the following two rules are helpful for this procedure:

• Dissection and mobilization is best carried out by using ultrasonic shears to divide thin attachments; a blunt/gentle pushing maneuver is then used to take advantage of and develop the avascular fusion planes between the bowel and the retroperitoneum; these attachments are best compared to an onion peeled back layer by layer
• After each step of mobilization, the bowel must be returned to its anatomic position before the surgeon moves on to the next step; this is crucial because, in many cases, the right colon/transverse colon is distended, can be very floppy, or is encased in fat, making it easy to disorient the surgeon; returning everything to its anatomic position throughout the procedure takes only seconds and can save heartache down the line

Different techniques have been described for colonic mobilization. The authors prefer the lateral-to-medial technique, which is described in detail below. Ultimately, however, the choice of technique depends on the individual surgeon’s preference

The procedure can be summarized in five steps, as follows:

• Mobilization of right colon
• Mobilization of transverse colon
• Control of mesentery and proximal margin
• Creation of ileocolic anastomosis
• Final inspection and closure

Right colon mobilization

The patient is placed in the Trendelenburg position with the right side up.

The congenital attachments of the terminal ileum to the retroperitoneum are taken down with the ultrasonic shears. This line is then followed onto the white line of Toldt (see the video below).

The authors’ technique involves incision into the thin peritoneal layer with the ultrasonic shears, followed by a gentle pushing action to deflect the right colon/cecum medially. With this method, the plane between the colon and the Gerota fascia is carefully delineated. The combination of division of the thin layers and gentle medial distraction defines the avascular planes and allows medial mobilization of the bowel until a point above the second and third portions of the duodenum is reached.

During this mobilization, the surgeon will notice that the colon is tethered to the hepatic flexure attachments. The urge to come around this corner must be resisted; this is best reached from above. Great care must be used to avoid diving into the retroperitoneum; this will cause injury to the kidney, ureters, and/or duodenum. In addition, the great vessels lie in these deep planes.

It is vital to return the colon to its anatomic position.

Transverse colon mobilization

The patient is now placed in the reverse Trendelenburg position. The assistant is instructed to put traction on the gastrocolic omentum just to the right of the falciform while the surgeon elevates the stomach via the 5-mm left-upper-quadrant (LUQ) port. The ultrasonic shears is introduced through the left-lower-quadrant (LLQ) 12-mm port, and the lesser sac is entered. (See the video below.)

As progress continues toward the patient’s right, a thin layer of peritoneum is divided between the colon and distal stomach. Great care must be used to take only this thin layer; the duodenal sweep lies beneath it. An important landmark for the duodenum is the gallbladder (the descending [second] portion [D2] lies approximately under the gallbladder). This is also an excellent time to obtain good visualization of the duodenum so it can be avoided during the mesenteric division.

As progress continues farther right toward the hepatic flexure attachments, the previous plane of dissection will be encountered. This dissection, as in the technique used for the white line of Toldt, is best carried out through division of thin layers with the ultrasonic shears, followed by a gentle blunt pushing motion. At this point, the first and second portions of the duodenum and the beginning of the third portion should be clearly visible.

Further dissection of the attachments of the right colon mesentery to the duodenum at the angle between the second and third portions completes the mobilization. In many cases, this region contains at least one large vein and at times multiple vascular variants, and care must be taken to control these vessels with endoclips prior to division.

Again, it is vital to return the colon to its anatomic position.

Control of mesentery and proximal margin

The assistant now retracts the right colon toward the right lateral abdominal wall while the surgeon elevates the proximal transverse colon to expose the root of the mesentery. A thin layer of peritoneum with a bluish hue opposite the hepatic flexure will become noticeable. This is a bare area of mesocolon that was mobilized off of the duodenal C loop during a previous step. This thin avascular peritoneum is then opened bluntly, exposing a mesenteric bundle to the left of it (right colic pedicle) and a second bundle to the right of it (middle colic pedicle). (See the video below.)

The mesenteric peritoneum that lies over the right and ileocolic vessels is then scored, and the vessels are controlled and divided. The authors prefer to clip and divide these vessels individually, but it is easier to use a vascular load laparoscopic stapler and fire it from the base of the mesentery, directing it toward the proximal resection margin on the terminal ileum.

The middle colic vessels can be approached the same way, either with individual endoclips or with a stapler. For lesions in the right colon, only the right branch of the middle colic vessels need to be divided. One should avoid overaggressive and unnecessary division of the middle colic trunk, so as to maximize anastomotic blood supply.

Great care must be exercised if a stapler is chosen for mesenteric division. Before the stapler is fired, full visualization of both sides of it must be ensured to avoid inadvertent injury to small bowel or retroperitoneal structures (eg, duodenum). In addition, firing a stapler does not guarantee hemostasis; often, additional maneuvers such as endoclips or sutures must be added to the staple line for reinforcement.

Electrosurgical sealing devices (eg, Ligasure) have been described for dividing the mesentery, but the authors have found them lacking, especially for calcified vessels (older patients) or thickened mesentery (inflammatory bowel disease [IBD]). Both of these issues are especially common in the populations undergoing bowel resection.

Once again, the colon must be returned to its anatomic position.

Ileocolic anastomosis

Although an intracorporeal anastomosis may be considered in this setting, the role of this approach in laparoscopic right hemicolectomy remains to be determined.[24, 25]

The authors prefer an extracorporeal anastomosis, for the following reasons:

• First, it allows palpation of the colon and confirmation of margins, which can be distorted with the laparoscopic view; less experienced surgeons have resected huge tracts of colon because of inaccurate judgment of the margins on the laparoscopic view
• Second, extracorporeal anastomosis is quick and easy to perform even with assistants who are not experienced in laparoscopy (eg, residents)
• Third, extracorporeal anastomosis does not add to the size of the incision, which must be adequate for specimen extraction regardless

The authors prefer dividing the terminal ileum just proximal to the ligament of Treves but leaving the colon attached distally. The specimen is then brought out via a wound protector. Great care must be exercised to avoid twisting of the distal ileum and transverse colon. This point cannot be overstated. The authors avoid this potentially catastrophic mistake by placing a laparoscopic grasper through the 5-mm suprapubic trocar and holding the distal ileum in proper orientation prior to desufflation. This grasper is then additionally clipped to the drapes with a penetrating clamp. (See the image below.)

The technique for extracorporeal anastomosis is described in the video below.

A second grasper (one has already been placed on the distal ileum, as described above) is placed through the 12-mm LLQ trocar and is used to hold the proximal resection margin. With the abdomen insufflated, the skin incision at the umbilicus is extended to a total of 4.5 cm.

The authors curve the incision around the umbilicus to help hide 30% of the incision in the umbilical fold. With the trocar serving as a guide, the fascia is incised. An Army-Navy retractor is used to retract the superior and inferior aspects of the skin incision alternately, and the fascial incision is increased to approximately 6.5 cm. A medium wound protector (eg, Alexis; Applied Medical, CA) is placed at the umbilical site and the proximal margin delivered to the skin surface with the grasper.

On the basis of palpation, an appropriate distal margin is chosen, and the colon is divided with a 75-mm gastrointestinal anastomosis (GIA) stapler. The distal ileum is then delivered through the wound again, with care taken to avoid a twist. A side-to-side functional end-to-end anastomosis is performed with a second 75-mm GIA stapler by approximating the two ends of the bowel and placing the stapler down their barrels and through the fascial defect. This last point allows the surgeon to take advantage of the fascial defect to perform the anastomosis without the need for overmobilization of the bowel to the point at which it lies loosely on the skin surface.

The anastomotic staple line is examined for hemostasis, patency, and integrity. The common enterotomy is closed using a 60-mm linear noncutting (eg, TA) stapler. In firing the stapler, great care must be taken to encompass all layers of the bowel, specifically at the crotch-staple line, where the bowel serosa tends to retract or becomes distorted. This is the most common point of leakage, and the staple line should be very carefully inspected both before and after firing the stapler. The authors neither routinely oversew this staple line nor routinely close the mesenteric defect.

Final inspection and closure

At this point, the anastomosis is dropped back into the peritoneal cavity and the fascial defect closed with a running mass closure of the surgeon’s preference. The abdomen is then reinsufflated. All areas of dissection, the anastomosis itself, and the anastomotic orientation are reevaluated. Irrigation and aspiration are then carried out until clear. The abdomen is then desufflated and the trocars removed.

Overall, the incidence of port-site hernias is very low. Tonouchi et al reported an incidence of 0.65-2.8%. Their recommendation is to close all port sites larger than 10 mm.[26] All of the skin incisions are then closed with 4-0 absorbable monofilament suture followed by Dermabond. The patient is then extubated, transferred to the postanesthesia care unit (PACU), and monitored for 4-6 hours.

Pearls

Introduction of the first trocar is followed by a thorough inspection of the abdominal cavity. On the basis of this exploration, the decision on whether to pursue the operation laparoscopically is made and the ideal trocar positioning determined.

Indications for conversion to laparotomy at this operative stage include the following:

• Extensive or dense adhesions
• Inability to locate the lesion
• Evidence of a T4 malignancy (invasion of adjacent structures)

The mesenteric vessels are located in the mesocolon and are often hidden in the adipose tissue, which complicates their identification in obese patients. To find them, it is important to have good anatomic landmarks. Examples of reliable landmarks include 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 in order to obtain early vascular control. The vessels are approached cephalad or lateral to the anterior surface of the superior mesenteric vein (SMV). This reveals the ileocolic vessels followed by the right colic vessels.

Preoperative endoscopic India ink marking of the lesion’s location aids in rapid laparoscopic identification.

Some authors no longer perform closure of the mesenteric defect. The risk of bowel obstruction due to the incarceration of an intestinal loop seems to be lower in the case of a wide defect. However, if the defect is closed, the closure must be perfect.

Intraoperative

Intraoperative complication rates associated with laparoscopic right hemicolectomy have been similar to those reported for open surgery.

Between 2002 and 2005, the results of several important studies were published, including the Barcelona Trial, the Clinical Outcomes of Surgical Therapy (COST) study, the Colon Cancer Laparoscopic or Open Resection trial, and the Conventional Versus Laparoscopic-Assisted Surgery in Patients With Colorectal Cancer trial. These trials showed that laparoscopic colon surgery is more effective than open colectomy in patients with colon cancer in terms of morbidity and length of stay, with similar mortality. A 2008 meta-analysis of 1765 patients from these four trials showed that at 3 years, laparoscopic colectomy was oncologically safe, with disease-free and overall survival rates similr to those of open resection.[27]

In addition, decreased wound infection rates after laparoscopic approach have been observed in several retrospective series. In a meta-analysis of the literature, Rondelli et al concluded that laparoscopic-assisted right colectomy resulted in less blood loss, shorter hospital stays,and lower postoperative short-term morbidity than open right colectomy.[28]

Ureteral injury is a rare complication that has been observed with both open and laparoscopic techniques. Some surgeons routinely place lighted ureteral stents prior to the procedure in order to visualize the structure, but this increases the operating room time. In patients with IBD, patients with diverticular disease, and patients with colon cancer who have undergone prior colonic surgery near the ureter, the dissection planes are harder to discern with the laparoscopic technique; thus, ureteral stents become a useful aid in identifying ureteral injury.

Inadvertent and undetected small-bowel perforation is another significant injury. This presumably occurs because the grasping instruments can traumatize the bowel wall, or the cauterizing instruments can cause thermal injury to the bowel wall outside the viewing range of the laparoscope.

Other injuries include uncontrolled hemorrhage, bladder injury, and hypercapnia-induced cardiac arrhythmias or decompensation.[29]

Postoperative

In addition to intraoperative events, the postoperative complications can be further divided into early and late.

Early postoperative complications may include the following:

• Hemorrhage
• Ileus/bowel obstruction
• Wound infection
• Anastomotic leakage ^[30]
• Urinary tract infection
• Cardiac events
• Pulmonary embolism (PE)/ deep vein thrombosis (DVT)
• Respiratory insufficiency/pneumonia

Late postoperative complications may include the following:

• Trocar-site hernia
• Ureteral stenosis (retroperitoneal fibrosis)
• Trocar-site implantations

Without evidence-based support, the authors have found postoperative day 3 to be a "sink or swim” type of turning point in patients with anastomoses. Abdominal distention, persistent pain, and lethargy may indicate a leak and should lead to a high index of suspicion by the clinician. Supportive findings such as decreased urinary output or an increased white blood cell (WBC) count or fever should prompt urgent computed tomography (CT). Unfortunately, CT findings may not be contributory in patients who have recently undergone surgery, because free air and free fluid are common in these patients.

Conversion to open procedure

Conversion rates as high as 29% have been described, highlighting the steep learning curve associated with this procedure. Several studies found that patients undergoing attempted laparoscopic resection who are subsequently converted to traditional laparotomy fared substantially worse in terms of both short-term and long-term outcomes than those who undergo nonconverted laparoscopic resection or planned open procedures.

A 2004 report by Moloo et al reviewing 377 consecutive cases of laparoscopic resections for colorectal cancer described a significantly lower overall 2-year survival rate among converted patients who had curable stage I-III malignancies, compared with those who had their colectomy completed laparoscopically (75.7% vs 87.2%).[31] Reasons for conversion to open surgery included hemorrhage, extensive adhesions and inflammations, increase in carbon dioxide, and clinical T4 cancer.