Right hemicolectomy, laparoscopically assisted

  1. Surgically relevant anatomy
  2. Transverse colon
  3. Ascending colon
  4. Cecum

  • Prof. Dr. med. Gebhard Reiss

    Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Surgically relevant anatomy

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    • Hepatic flexure and right hemicolon
    • Ascending colon
    • Cecum with vermiform appendix

  • Transverse colon

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    • Synonym: Colon transversum
    • Location: Intraperitoneal; mobile fixation via its own mesentery - transverse mesocolon.
    • Identification: By the so-called
      taeniae = taeniae coli = condensations of longitudinal muscle fibers named according to their anatomical relations as
    • taenia libera (inferior)
    • taenia omentalis (greater omentum)
    • taenia mesocolica (transverse mesocolon)
    • omental appendices = fat-filled tunica serosa
    • Haustrae of colon = haustrae coli = visible sacculations in the wall of the colon wall by the arrangement of the circular muscle fibers (plicae semilunares; evident on endoscopy) which are discernible on the outer wall as crescentic folds.

  • Ascending colon

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    • Definition: Section of the large bowel from the ileocecal valve, where the small intestine (ileum) enters the colon, to the hepatic (right) flexure.
    • Synonym: Colon ascendens
    • Location: secondary] retroperitoneal - peritoneal fixation to the posterior abdominal wall by the so-called Toldt membrane
    • Identification: By the longitudinal bundles of muscle fibers- the taeniae, which keep their location-related terminology from the transverse colon; the diameter is markedly larger than that of the descending colon!

  • Cecum

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    • Definition: cul-de sacbeginning of the ascending colon corresponding with a bulge thereof; Latin: caecus = blind
    • Synonym: Blind gut
    • Location: Inferior to the ileocecal valve
    • Identification: By the taeniae and vermiform appendix
  1. Indications
  2. Contraindications
  3. Preoperative diagnostic work-up
  4. Special preparation
  5. Informed consent
  6. Anesthesia
  7. Positioning
  8. Operating room setup
  9. Special instruments and fixation systems
  10. Postoperative management

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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  1. Skin incision and Verres needle insertion
  2. Inserting the 10mm trocar; diagnostic laparoscopy
  3. Inserting the 5mm trocars; patient positioning
  4. Dissecting the ileocolic vessels
  5. Dividing the ileocolic artery and vein
  6. Dividing mesocolon and mesentery
  7. Mobilizing the terminal ileum
  8. Dividing the mesentery
  9. Dividing the right colic artery
  10. Dividing the transverse mesocolon
  11. Opening the omental bursa
  12. Dividing the peritoneal reflection
  13. Freeing the cecum
  14. Right supraumbilical minilaparotomy; exteriorizing the right hemicolon
  15. Transecting the right hemicolon
  16. Hand-sewn end-to-end anastomosis
  17. Checking and interiorizing the anastomosis
  18. Suturing the fascia of the minilaparotomy
  19. Laparoscopic check
  20. Closing the mesenteric defect and irrigating the abdominal cavity
  21. Removing the trocars and suturing the fascia; subcuticular skin suture and dressing
date of publication: 20.11.2011

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  • Skin incision and Verres needle insertion

    90-7

    Subcostal skin incision in the left medioclavicular line. Following infiltration of local anesthetic; insert the Verres needle; perform the safety tests and create the pneumoperitoneum.

  • Inserting the 10mm trocar; diagnostic laparoscopy

    90-8

    Remove the Verres needle; split the muscles with scissors and bluntly insert the 10mm trocar.
    Laparoscopic exploration: Minor fibrotic changes of the liver surface; small areas of adhesion of the cecal cancer with the parietal peritoneum at the lateral abdominal wall.

  • Inserting the 5mm trocars; patient positioning

    90-9

    Insert two 5mm trocars in the mid-abdomen in the left medioclavicular line and paramedian in the left lower abdomen - each under view after transillumination, infiltration of local anesthetic and skin incision.
    Trendelenburg positioning and left tilt of the table will displace the small intestine into the left upper quadrant.

  • Dissecting the ileocolic vessels

    90-10

    Stretching the mesentery at the ileocecal junction will pinpoint the ileocolic vessels.
    Free the ileocolic and superior mesenteric arteries at their origins. Then free the venous junctions.

  • Dividing the ileocolic artery and vein

    90-11

    Divide the ileocolic artery between Lapro-Clips® after also sealing its central trunk with the LigaSure™ V. Follow this by transecting the ileocolic vein after sealing it with the LigaSure™ V.

  • Dividing mesocolon and mesentery

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    Divide the mesocolon / mesentery off the retroperitoneum respecting the correct layer while exposing and preserving the duodenum and sparing the boundary of the Gerota fascia. Determine the proximal resection margin.

  • Mobilizing the terminal ileum

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    Free the right lateral mesenteric adhesions of the terminal ileum until the small intestine is completely mobile while exposing and sparing the right ureter.

  • Dividing the mesentery

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    With the LigaSure™ V divide the mesentery from the central transection of the ileocolic artery to the planned resection margin of the terminal ileum.

  • Dividing the right colic artery

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    Complete the layered mobilization of the right hemicolon from mediad while respecting the correct layer.. Expose the central trunk of the right colic artery and divide it with the LigaSure™ V.
    The right colic artery arises from the middle colic artery shortly after it departs from the superior mesenteric artery.

  • Dividing the transverse mesocolon

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    Seal and divide the transverse mesocolon to the right of the middle colic artery up to the planned resection margin on the transverse colon.

  • Opening the omental bursa

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    Free the greater omentum from the transverse colon while opening the lesser sac.

  • Dividing the peritoneal reflection

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    Divide the peritoneal reflection first at the hepatic flexure and then complete its release by dividing the reflection along the right paracolic gutter.

  • Freeing the cecum

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    With the monopolar hook tip electrode free the cecum from the abdominal wall including the parietal peritoneum and a layer of preperitoneal fatty tissue - without opening the tumor. The right hemicolon is now fully mobilized.

  • Right supraumbilical minilaparotomy; exteriorizing the right hemicolon

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    Transverse transrectal supraumbilical minilaparotomy on the right and insertion of the 7cm ring drape for wound edge protection. Exteriorize the right hemicolon through the minilaparotomy.

  • Transecting the right hemicolon

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    Ring the delivered right hemicolon with towels soaked in Lavanid® solution and sparingly skeletonize both resection margins. Apply crushing intestinal clamps on the specimen side and hand off to histopathology.

  • Hand-sewn end-to-end anastomosis

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    Coagulate point bleeders on both stumps and slit the ileal stump on its antimesenteric aspect to create matching lumina of both colon and ileum. Hand-sewn end-to-end anastomosis with one-layer inverting extramucosal continuous suture, PDS 4/0.

  • Checking and interiorizing the anastomosis

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    Check the non-bleeding tension-free and rotationally correct anastomosis with its still excellent blood supply for non-leakage and patency.
    Remove the towels and interiorize the anastomosed parts of the bowel.

  • Suturing the fascia of the minilaparotomy

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    Close the fascia with a two-layer continuous suture PDS 2/0.

  • Laparoscopic check

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    Recreate the pneumoperitoneum and once again check the field for continued dryness.

  • Closing the mesenteric defect and irrigating the abdominal cavity

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    Close the mesenteric defect with a continuous suture Vicryl® 3/0 without compromising the blood supply of the anastomosis. Thoroughly irrigate the entire abdominal cavity once more - under view - and suction the clear irrigation fluid.

  • Removing the trocars and suturing the fascia; subcuticular skin suture and dressing

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  1. Intraoperative complications
  2. Postoperative complications

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  • Intraoperative complications

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  • Postoperative complications

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  1. Literature summary
  2. Ongoing trials on this topic
  3. References on this topic
  4. Reviews
  5. Guidelines
  6. literature search

  • Edith Leisten

    MVZ St. Marien Köln - Ärztliche Leiterin

    Edith Leisten

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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • Reviews

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  • Guidelines

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  • literature search

    Literature search under: http://www.pubmed.com