Laparoscopic right radical hemicolectomy.

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.

INTRODUCTION

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.[1-4] 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.[23]

PREOPERATIVE EVALUATION

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

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

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

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 CO2 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 [Figures 2–5].

Figure 2

Dissection of Ileocolic Vessels

Figure 5

Division of Clipped Ileocolic Artery

Dissection of Ileocolic Artery

Clipping of Ileocolic vessels

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.[2-4]

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.[35]

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].[67]

Figure 6

Clipping of Right Colic Vessels

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 [Figures 5–10].

Figure 10

Division of Transverse colon With Stapler

Omentectomy from Transverse colon

Dissection of Caecum from Lateral Pelvic wall

Lateral Pelvic Wall showing Ureter and Gonadal vessels

Division of Ileal mesentery

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

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

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

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.