How is laparoscopic right colon resection (colectomy) performed?

Updated: Apr 05, 2021
  • Author: David E Stein, MD, MHCM; Chief Editor: Vikram Kate, FRCS, MS, MBBS, PhD, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed)  more...
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The abdomen is entered as above. Ports are placed in the left upper and lower quadrants. The patient is placed in the Trendelenburg position and tilted to the left.

The terminal ileum is identified and the mesocolon traced. By raising the terminal ileum, the mesentery is draped over the ileocolic artery. The takeoff of the ileocolic artery is identified at the level of the inferior margin of the duodenum. The vessels are skeletonized and transected. The plane under the mesentery is developed up to hepatic flexure and distal to the terminal ileum. The ureter should be seen in the retroperitoneum.

The mesocolon is then divided medial to the ileocolic vessel with an energy source. The ileum is transected 5 cm proximal to the cecum with an endoscopic stapler. The white line of Toldt is mobilized up to and including the hepatic flexure until the original plane of dissection at the inferior margin of the duodenum is encountered. The right branch of the middle colic artery is then taken with an energy source. A grasper is placed on the ileum and the appendix/cecum. The gas is exsufflated through the ports, and an extraction site is made at the umbilicus, as described above.

The colon is transected with a linear cutting stapler and the specimen sent to pathology. An anchor stitch is placed to orient the small intestine, and the proximal and distal crotch stitches are placed. A side-to-side functional end-to-end anastomosis is created with 75-mm cutting staplers. The end is closed with a noncutting linear stapler. The staple lines are oversewn, and the mesenteric defect is approximated, if feasible.

The bowel is then replaced into the abdominal cavity. Gowns, gloves, and instruments are changed, and irrigation is performed. The authors do not routinely reinsufflate unless there is very bloody irrigation. Fascial closure followed by skin closure is performed.

If a medial-to-lateral dissection cannot be performed, a lateral-to-medial approach can substituted. This approach is often used because of an inability to visualize the vessels owing to adhesions or redundant bowel. In addition, if the vital structures are difficult to identify, conversion to open surgery should take place. Prior to this, it is acceptable to use a hand-assist device.

In a review of the evolution of right colon resection, Gachabayov et al described techniques such as the medial-to-lateral mobilization used in minimal access surgery and the lateral-to-medial mobilization used in open surgery and D2 and D3 lymphadenectomy. [36] They also described various anastomotic configurations (eg, isoperistaltic and antiperistaltic anastomoses) and methods of anastomosis which are used in minimal access surgery (eg, intracorporeal, extracorporeal, totally stapled, and stapled-handsewn techniques). The review also covered laparoscopic and robotic suturing, mucosal eversion and inversion, and specimen extraction sites.

For additional information, see Laparoscopic Right Colectomy (Right Hemicolectomy).

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