Laparoscopic Right Colectomy (Right Hemicolectomy) Technique

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.