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Tumor in the right colic flexure


Medical editor Arild Nesbakken MD
Gastroenterological Surgeon
Oslo University Hospital
Norway

General

For cancer in the right colic flexure an extended right-sided hemicolectomy and a resection of colon- and lymph nodes are performed.

Arteria ileocolica and colica media are divided centrally and the mesentery of transverse colon is divided slightly to the left for the arteria colica media.



Equipment

  • Laparotomy- or laparascopic equipment

Preparation

Patient preparation:

  • bowel emptying. The routines variy between hospitals.
  • intravenously antibiotic prophylaxis at the latest at the beginning of the anesthesia. It should be considered whether the patients in addition should have oral antibiotics from the day before the surgery.
  • thrombosis prophylaxis with low molecular weight heparin.

During the surgery it is inserted:

  • epidural catheter for pain management.
  • urinary catheter.
  • naso-gastric tube which is removed by the end of the surgery.

Implementation

A laparascopic right-sided hemicolectomy is performed. The surgery is identical with “Tumor in the cecum and ascending colon” except for the following:

  • After the arteria ileocolica is divided centrally one goes further up and the arteria colica media is divided centrally. The mesentery of transverse colon is divided to the left of the place where the colica media vessels are coming up in the mesentery.

Laparoscopic right sided hemicolectomy

Step 1 – Trochar insertion and diagnostic laparoscopy

  • The patient in anti-Trendelenburg position and turned to the left.
  • Trochar insertion with visiport medial to the left medioclavicular line at the level of umbilicus, possibly slightly more to the left in adipose patients. Thereafter 5 mm port medial to the left fossa, 5 mm in the right fossa and 5 mm in the epigastric to the left of the midline (12 mm in case of intracorporeal anastomosis). Avoid the inferior epigastric vessels and insertion of the trochar too low on the abdomen which may impede the angulation within the abdominal cavity.
  • Examine the primary tumor for perforation and/or infiltration into adjacent organs. Thereafter the liver and the total abdominal cavity is inspected with regard to metastases, peritoneal carsinomatosis (especially the pelvis and the paracolic gutters) and other pathology.

Step2 – Release the transverse colon from the middle to the right flexure.

  • The gastrocolic ligament (the greater omentum) is opened and the cranial surface of the transverse mesenterium is freed from the middle of the transverse colon to the right flexure.
  • Dissect the whole width towards the root of the mesentery. The medial colic vessels will be visualized to the right of the duodenum. This plane is mainly avascular, but the vein between the gastrocolic trunc and the left gastroepiploic must be divided and secured.
  • If necessary introduce a longitudinal compress along the root of the transverse mesocolon.

Step 3 – Perform central ligation of the vessels, lymph nodes and mesentery.

  • The patient in Trendenburg’s position, turned to the left.
  • Position the omentum above the liver, Lift the transverse colon cranially and luxate the small bowel package over the midline to the left.
  • Put tension to the ileocolic vessels. Try to localize the origin of the ileocolic vessels on the superior mesenteric vessels.
  • 2-3 cm distal to the origin the peritoneum is incised vertically, the incision is followed superior mesenteric vein to the dorsal surface of the mesenteric root.
  • Start distally and dissect on to the superior mesenteric vein and follow these until the ileocolic vessels. These are dissected free at the right side of the mesenteric vein and divided here. The ileocolic artery appears dorsal to the superior mesenteric vein in 75%, anterior in 25% of the patients. Avoid dissecting too far laterally (to the right) of the mesenteric vessels distally and at the ileocolic vessels which will result in remaining lymph nodes.
  • Continue along the right side of the mesenteric vein cranially to the ileocolic and identify a possible right colic artery departing from the superior mesenteric artery. This is found in 20% of the patients. Divide this similarly.
  • Continue the peritoneal incision from the root of the mesentery cranially on the dorsal aspect of the transversal mesentery.
  • Identify the middle colic vessels and extend the incision just on the right side of these.
  • Thereafter the transverse mesocolon is divided, including the vessels leaving from the middle colic artery to the right flexure. The latter are divided at the origin from the middle artery.
  • Dissect on to the bowel wall along the whole circumference where the transverse colon is to be transected.

Step 4 – Dissect in the mesocolic plane on the dorsal aspect of the mesentery/ bowel wall.

  • Grip the ileocolic vessels and lift forward/laterally.
  • Incise peritoneum to the planned location for the ileal resection, around 8-10 cm orally to the ieocoecal valve. Maintain the vessel archades all along the ileum.
  • Dissect in the anatomical plane dorsal to the mesocolon of the transversal and  ascending colon and coecum. This is anterior to the uncinated process of the pancreas, anterior and caudally to the duodenum and in front of the Gerota’s capsule.
  • Develop the plane all along to the lateral abdominal wall till the anterior dissection plane is reached.
  • Divide the last adherances all the way from the dorsal aspect of the distal ileum and coecum and dissect further laterally from the coecum/ ascendens towards the flexure.

Step 5 – Extracorporeal anastomosis

  • 5-6 cm transverse incision in the rectal sheath just cranially to the umbilicus. Protecting plastic.
  • Exteriorize the specimen with the ileum and the transverse colon. Either prepare an aniso-peristaltic or iso- peristaltic side-by-side anastomosis with stapler instrument.
  • Thereafter divide the specimen with the stapler.
  • Interiorize the bowel to the abdominal cavity.
  • Close the abdominal fascia and skin.
  • Control the rotation by laparoscopic inspection. Examine the total surgical area for possible operative injuries.

Step 5 alternative – Intracorporeal anastomosis

  • Divide the ileum and transverse colon with stapler.
  • Position the specimen above the liver.
  • Prepare iso-peristatic anastomosis with stapler from the epigastric port: Enterotomy 1 cm from the end of the ileum and colotomy 7 cm from the end of the colon, the anastomosis is positioned anti-mesenterially.
  • The remaining bowel opening is closed with 3-0 Vicryl in one layer.
  • The specimen is removed through a suprapubic horizontal minilaparotomy. The abdominal wound is protected by plastic drape during the exteriorization.
  • Close the abdominal fascia and skin.

Step 6 – Laparoscopic control and removal of ports.

  • Repeat inspection of the abdominal cavity.Control correct rotation of the anastomosis.
  • Examine the total abdominal for iatrogenic injuries.
  • Close the ports.

Follow-up

  • The patient is mobilized in the evening the day of surgery, or possibly the next day.
  • The patient can start to drink and eat carefully on the first postoperative day.
  • The urinary catheter is removed on the first postoperative day or when the patient is mobilized.
  • The epidural catheter is usually removed on the continues on peroral analgetics.

Complications

  • Cardiopulmonary complications depend on the patient´s general condition, comorbidity and the extent of the surgery. Cardial infarction and arhythmias and dysrythmia may occur. Basal atelectasis and/or pleural fluid and possibly pneumonia are more common.
  • Approximately 5% develop anastomosis leakage. Preoperative radiation therapy increases the risk of leakage. Intraperitoneal and/or pelvic infections, diffuse or localized, are rare, in the abscence of anastomosis leakage.
  • Intraabdominal bleeding, including bleeding from anastomosis is relatively rare.
  • After an open surgery wound dehiscence and infection in the abdominal wound occur to varying degrees, from light superficial infection up to an abdominal wall abscess.
  • Paralytic ileus is common in the presence of another complication but can also appear without any specific cause.
  • Mechanical ileus is relatively rare, but if there is a lack of intestinal activity in the first week and increasing abdominal pains, a mechanical ileus is suspected.
  • Port-site hernia occurs after a laparoscopy.
  • Deep vein thrombosis and lung embolism are rare if prophylaxis is used according to guidelines.
  • Urinary retention.

Late complications

  • Ventral hernia in the abdominal wound may occur.
  • Postoperative ileus occurs in about 5%.

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