Users Online : 185 About us |  Subscribe |  e-Alerts  | Feedback | Login   
Journal of Minimal Access Surgery Current Issue | Archives | Ahead Of Print Journal of Minimal Access Surgery
           Print this page Email this page   Small font sizeDefault font sizeIncrease font size 
  Search
 
  
 ¤   Similar in PUBMED
 ¤  Search Pubmed for
 ¤  Search in Google Scholar for
 ¤Related articles
 ¤   Article in PDF (4,183 KB)
 ¤   Citation Manager
 ¤   Access Statistics
 ¤   Reader Comments
 ¤   Email Alert *
 ¤   Add to My List *
* Registration required (free)  


 ¤  Abstract
 ¤ Introduction
 ¤  Preoperative Eva...
 ¤  Positioning and ...
 ¤ Operative Steps
 ¤ Postoperative Care
 ¤ Conclusion
 ¤  References
 ¤  Article Figures

 Article Access Statistics
    Viewed4930    
    Printed120    
    Emailed1    
    PDF Downloaded172    
    Comments [Add]    

Recommend this journal

 


 
 Table of Contents     
HOW DO I DO IT?
Year : 2012  |  Volume : 8  |  Issue : 1  |  Page : 21-24
 

Laparoscopic right radical hemicolectomy


1 Department of General Surgery, B. J. Medical College, Pune, India
2 Director, Galaxy Care Hospital Pune, Maharashtra, India

Date of Submission11-Dec-2010
Date of Acceptance09-Jun-2011
Date of Web Publication13-Jan-2012

Correspondence Address:
Sadhana V Deo
43/67 Nav Sahyadri Society, Akshay, Karvenagar, Pune – 411 052, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.91779

Rights and Permissions

 ¤ Abstract 

Laparoscopic right hemicolectomy is an advanced cancer surgery in today's era. With increasing experience, we have described novel technique for this procedure. To prevent falling down of the colon in the operative field and to have early control on vessels, we go from medial to lateral approach.


Keywords: Carcinoma, extracorporeal, ileotransverse anastomoses, laparoscopic, radical hemicolectomy


How to cite this article:
Deo SV, Puntambekar SP. Laparoscopic right radical hemicolectomy. J Min Access Surg 2012;8:21-4

How to cite this URL:
Deo SV, Puntambekar SP. Laparoscopic right radical hemicolectomy. J Min Access Surg [serial online] 2012 [cited 2020 Dec 1];8:21-4. Available from: https://www.journalofmas.com/text.asp?2012/8/1/21/91779



 ¤ Introduction Top


Colorectal cancer is the second most common cause of cancer death in westernized countries. Approximately 130,000 new cases of colorectal cancer are diagnosed per year in the United States, of which 75% occurred in people who have no predisposing risk factors. [1],[2],[3],[4] In recent years, there has been a paradigm shift towards minimally invasive approaches even for cases of malignancies. Laparoscopic right hemicolectomy gives all benefits of laparoscopy as well as helps in radical removal of tumor. [2],[3]


 ¤ Preoperative Evaluation Top


It is very important to perform a complete workup to allow the previous localization of the tumor by means of barium enema, ultrasonography, computed tomography (CT) scan with contrast, and colonoscopy-guided biopsy. A baseline chemical profile including complete blood count, carcinoembryonic antigen, preoperative electrocardiogram, and chest radiograph should be performed as needed. Pulmonary function tests for patients with compromised respiratory function and additional tests according to patient's specific problems are also in order. CT scan of abdomen for liver secondaries and X-ray chest for pulmonary metastasis are required.


 ¤ Positioning and Ports Top


The patient is kept nil by mouth for 8 hours.

Ryle's tube is placed and bladder is catheterized under general anesthesia.

The position of patient is right side up (oblique), semi-lateral with support of saline bottle of 1 liter behind and upper leg extended, with pillow in between the legs. Broad stickings are applied across the body of patient for support.

The operating surgeon and camera person stand on the left side of the patient and the monitor on right side of the patient at level of eyes of the surgeon.

Pneumoperitoneum is done with veress needle through umbilicus. Following ports are inserted [Figure 1].
Figure 1: Ports position for Right Hemicolectomy

Click here to view


  • 10 mm umbilical, camera port for 0 degree telescope
  • 10 mm epigastric port pararectally 4 fingers away from umbilicus (right hand working)
  • 5 mm right lumbar, pararectally, to form triangulation with camera port (left hand working)
  • 5 mm suprapubic for holding bowel.



 ¤ Operative Steps Top


Laparoscopic radical right hemicolectomy medial to lateral approach

First, assess the mass for its resectability. Now lift up transverse colon and identify C of duodenum. Just on the inferior side of duodenum make the incision over peritoneum with Harmonic Ace (Ethicon Endosurgery, Cincinnati). Pass a gauze piece and CO 2 itself insufflates in to dissect duodenum and kept away from operative injury.

Which vessels are clipped?

The medial-to-lateral approach has gained popularity for identifying and isolating the blood vessels prior to lateral dissection. As with open right colectomy for cancer, the vessels are taken very near to the origin of the superior mesenteric artery with clearance of lymph nodes [Figure 2], [Figure 3], [Figure 4] and [Figure 5].
Figure 2: Dissection of Ileocolic Vessels

Click here to view
Figure 3: Dissection of Ileocolic Artery

Click here to view
Figure 4: Clipping of Ileocolic vessels

Click here to view
Figure 5: Division of Clipped Ileocolic Artery

Click here to view


For carcinoma of caecum, ileocolic and right branch of middle colic vessels are clipped proximally and on specimen side and divide them with harmonic ace. [2],[3],[4]

All fibro fatty tissue and lymph nodes are dissected towards the specimen.

True right colic vessels are present only in about 10 to 15% of patients. [3],[5]

Usually only right branch of middle colic vessels is clipped.

The entire middle colic vessel is divided for right colon cancer near hepatic flexure or in transverse colon. Divide the mesentery completely from colon to caecum with Liga Sure coagulator (Valley Lab) [Figure 6]. [6],[7]
Figure 6: Clipping of Right Colic Vessels

Click here to view


Now along the white line of Toldt, mobilize entire right colon with Harmonic Ace up to midtransverse level. This step is done with care to prevent injury to right ureter and gonadal vessels. Doing this step last helps operating surgeon in preventing falling of the colon in operative field [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10] and [Figure 11].
Figure 7: Omentectomy from Transverse colon

Click here to view
Figure 8: Dissection of Caecum from Lateral Pelvic wall

Click here to view
Figure 9: Lateral Pelvic Wall showing Ureter and Gonadal vessels

Click here to view
Figure 10: Division of Transverse colon With Stapler

Click here to view
Figure 11: Division of Ileal mesentery

Click here to view


Now the resection and anastomoses can be done extra corporeally by delivering colon through 5cm sized incision in right iliac fossa. Or one can also do resection of colon intracorporeally with Endo GIA staplers. Extra corporeally one can do resection with Linear Staplers (Ethicon) or with intestinal clamps depending upon affordability. [8] On either side of tumor, the resectional margin of colon should be at least of 5 cms. For specimen removal, we use glove bag so as to prevent contamination of wound by tumor cells.

End-to-end or end-to-side ileotransverse anastomoses in four layers done with silk 2 zero. Drain 32 French No. is kept after irrigation with normal saline. All ports and incision are closed with Vicryl and Ethilon sutures.


 ¤ Postoperative Care Top


Patient is given injectable antibiotics such as flagyl, taxim, and gentamycin postoperatively. Ryle's tube is removed when bowel sounds are present, usually on postoperative day 2. On the second postoperative day, clear liquid diet is started, and bladder catheter is routinely removed at this time. Diet is advanced as tolerated. The patient is discharged from the hospital when he has return of bowel function, can tolerate a regular diet, and have adequate pain control with oral analgesics.

The average number of lymph nodes harvested in resected specimens was 31 (range 10-57) and about 60% to 90% tend to be positive.

The average operative time was 165 min (50-140 min).


 ¤ Conclusion Top


Results indicate that a structured approach to laparoscopic right colectomy is associated with reasonable operative times, acceptable morbidity, and reductions in hospital stay. [9],[10],[11]

The rates of recurrent cancer are similar after laparoscopic right colectomy than open colectomy, suggesting that the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.

Although the cost of procedure is high and requires laparoscopic training for surgeons, laparoscopic colectomy is an acceptable alternative to open colectomy.

 
 ¤ References Top

1.Greenlee RT, Murray T, Bolden S, Wingo PA, Greznlee RT, Murray T, et al. Cancer statistics, 2000. CA Cancer J Clin 2000;50:7-33.  Back to cited text no. 1
    
2.Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350:2050-9.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Croce E, Olmi S, Azzola M, Russo R, Di Bonifacio M. Laparoscopic colectomy: Indications, standardized technique and results after 6 years experience. Hepatogastroenterology 2000;47:683-91.  Back to cited text no. 3
[PUBMED]    
4.Maxwell-Armstrong CA, Robinson MH, Scholefield JH. Laparoscopic colorectal cancer surgery. Am J Surg 2000;179:500-7.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Garcia-Ruiz A, Milsom JW, Ludwig KA, Marchesa P. Right colonic arterial anatomy. Implications for laparoscopic surgery. Dis Colon Rectum 1996;39:906-11.  Back to cited text no. 5
    
6.Devine R, Pemberton JH. Right and left hemicolectomy. In: Donohue J, Van Heerden J, Monson J, editors. Atlas of Surgical Oncology. Cambridge, MA: Blackwell Science; 1995. p. 215.  Back to cited text no. 6
    
7.Meagher AP, Wolff BG. Right hemicolectomy with a linear cutting stapler. Dis Colon Rectum 1994;37:1043-5.  Back to cited text no. 7
[PUBMED]    
8.Casciola L, Ceccarelli G, Di Zitti L, Valeri R, Bellochi R, Bartoli A, et al. Laparoscopic right hemicolectomy with intracorporeal anastomosis. Technical aspects and personal experience. Minerva Chir 2003;58:621-7  Back to cited text no. 8
    
9.Milsom JW, Böhm B, Hammerhofer KA, Fazio V, Steiger E, Elson P. A prospective, randomized trial comparing laparoscopic versus conventional techniques in colorectal cancer surgery: A preliminary report. J Am Coll Surg 1998;187:46-54; discussion 54-5.  Back to cited text no. 9
    
10.Kahokehr A, Zargar-Shoshtari K, Srinivasa S, Hill AG. Recovery after open and laparoscopic right hemicolectomy: A comparison. J Surg Res 2010;162:11-6.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  
11.Lacy AM, García-Valdecasas JC, Delgado S, Castells A, Taurá P, Piqué JM, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: A randomised trial. Lancet 2002;359:2224-9.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

Top
Print this article  Email this article
 

    

© 2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04