Right hemicolectomy, laparoscopically assisted

  • 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

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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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date of publication: 21.11.2011

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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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  • Intraoperative complications

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  • Postoperative complications

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  • 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