Download Laparoscopic extended right hemicolectomy for transverse colon

Laparoscopic extended right hemicolectomy for transverse colon
cancer
Elsa B. Valsdottir, MD
Department of General Surgery
University Hospital of Iceland
Hringbraut
101 Reykjavik
Iceland
Phone +354 543 1000
Fax + 354 543 1016
E-mail: [email protected]
Roberto Bergamaschi, MD, PhD, FRCS, FASCRS, FACS
Department of Research and Development
Forde Health System
Forde, Norway
[email protected]
List of contribution:
Dr. Valsdottir: Concept, design, drafting text, final approval
Dr. Bergamaschi: Concept, design, revising content, final approval
Word count: 1693
Introduction
Tumors in the transverse colon pose several challenges for the
surgeon. They can receive blood supply from the right colic, middle colic
as well as the left colic artery and hence the lymph-bearing area can be
wide. A segmental resection of the transverse colon can result in tension
on the anastomosis secondary to the fixity of the ascending and
descending colon in the retroperitoneum. In addition, there is an
increased risk of anastomotic leak when performing colon to colon
anastomosis compared to ileocolic anastomosis. To avoid this, and make
sure that all the lymph-bearing area of the tumor has been removed, it is
common practice to perform either an extended right or left
hemicolectomy rather than a segmental resection of the transverse
colon. An extended right hemicolectomy requires division of the middle
colic artery, which can be challenging laparoscopically and requires
advanced laparoscopic skills.
Due to those complexities, tumors of the transverse colon have
been left out of the large, randomized controlled trials that compare
laparoscopic colon resection for cancer to open resection, such as
COST, COLOR and CLASICC. The results of these trials are therefore
not directly applicable to transverse colon tumors, and there remains
doubt regarding the best approach. Since cancer of the transverse colon
is rare (10% of all colon cancer cases), it is unfortunately unlikely that
separate trials will be conducted to settle this issue. There are however
in the literature a few single institution non-randomized cohort studies
and quantitative comparisons that strongly suggest that laparoscopic
surgery for transverse colon cancer is as safe and feasible as other
laparoscopic surgeries for colon cancer.
Indications
A tumor that is located at or just distal to the hepatic flexure can be
removed by extending the classic right hemicolectomy so that includes
ligation of the right branch of middle colic artery, as long as that gives a
safe 5 cm tumor-free margin. Similarly, a tumor at or just proximal to the
splenic flexure can be removed by extending the classic left
hemicolectomy so that it includes ligation of the left branch of the middle
colic artery. An extended right hemicolectomy, with ligation of the trunk of
the middle colic artery and an anastomosis between the ileum and
descending colon should be used for colon cancer arising between the
two flexures. This technique is contraindicated for T4 colon cancer
invading adjacent organs, except for cases where only the omentum is
involved.
Treatment options must be discussed with the patient. The
patient’s questions should be answered to the patient’s satisfaction. The
patient should understand the material facts, possible risks and
complications of the planned surgery before the patient signs an
informed consent.
Preoperative workup
A thorough history and physical exam are essential. Chest x-ray
and EKG should be performed in patients over the age of 50.
Preoperative workup includes a complete blood count, chemistries,
coagulation profile and a CEA level. Preoperative localization of colon
cancer is always important, but for transverse colon cancers, it is
imperative. Colonoscopy alone is not sufficient. CT scan of chest,
abdomen and pelvis with intravenous and oral contrast, and PET scan
can establish the exact location of the tumor and the TNM stage,
respectively. To further help with exact localization of the tumor, India ink
injection can be performed at the time of colonoscopy. The bowel should
be prepped orally with laxatives and antibiotics as per each institution’s
protocol, unless there is a narrow stricture. In such cases, no oral bowel
preparation should be used.
Operating room
The patient should be identified with an appropriate time out prior to the
induction of general anaesthesia with endo-tracheal intubation.
Perioperatively intravenous antibiotics should be administered.
A Foley catheter and nasogastric or orogastric tube should be inserted.
The patient is supine on the operating table with the lower limbs either in
stirrups or spread. Sequential compression devices are applied to the
legs. Both arms should be tucked. The patient should be securely
strapped to the table at the chest since tilting the table will be necessary.
All equipment including monitors should be placed on the patient’s right
side in clear view of the surgeon, who stands on the patient’s left side.
One assistant is needed to control the camera unless a robotic camera
holder is available. The abdomen and perineum should be prepped and
draped sterile.
Surgical technique
Extended right hemicolectomy starts out exactly like a standard right
hemicolectomy. The instruments used are long bowel graspers, scissors,
right angle forceps and needle holder. The dissecting energy source can
be either a ultrasonic-activated device or a electrosurgical vessel-sealing
device. If an ultrasonic device is used, a vascular stapler should be used
for the vascular pedicles. Choice of mode of access (open or lap) to the
peritoneal cavity should be based on the surgeon’s experience and
preference. A reusable 10 mm port is placed at the umbilicus. A reusable
5 mm port is placed 3 cm medial to the right anterior superior iliac spine.
A disposable threaded 12 mm port is placed in the left upper quadrant
lateral to the rectus muscle sheath and rostral to the umbilicus. A
reusable 12 mm port is placed 3cm rostral to the pubic tubercle just left
to the midline. A 30-degree scope (5 or 10 mm in diameter) should be
placed at the umbilicus.
Step 1: The surgeon and assistant begin by standing on the patient´s left
side. The table is turned into a moderate left tilt as well as into a slight
Trendelenburg position. The peritoneal surfaces and liver are inspected
for tumor growth. The ileocolic vessels are identified by gentle traction
applied by the assistant to the cecum and the superior mesenteric vein
(SMV) is located. A window beneath the ileocolic vessels is opened
incising the peritoneum close to the SMV and gently lifting the ileocolic
vessels with a closed grasper; the ileocolic artery crossing to the SMV is
assessed as anterior or posterior, and the ileocolic vessels are divided
after the duodenum has been identified.
Step 2: The right ureter is identified by inspection, and, if necessary, by
gentle palpation with a blunt instrument while the assistant gently
elevates the stump of the ileocolic vessels (specimen side) off the
retroperitoneum.
Step 3: The dissection starts at the origin of the ileocolic vessels and
proceeds along the SMV in a rostral direction; if present, the right colic
vessels are divided after having assessed whether the right colic artery
crosses anteriorly or posteriorly to the SMV. For now, the dissection
ends at the origin of the Henle’s gastrocolic trunk from the SMV. The
mesentery of the proximal transverse colon is gently elevated off the
duodenum.
Step 4: The table is leveled from the Trendelenburg position but kept in a
moderate left tilt; the omentum is divided and the lesser sac entered; the
division of the omentum is performed in a medial to lateral direction
caudal to the right gastroepiploic vessels using a dissecting device.
Step 5: The hepatic flexure is mobilized in a medial to lateral direction,
the lateral peritoneal reflection of the ascending colon is divided along
the white line of Toldt in a caudal to rostral direction and the mesentery
of the ascending colon is mobilized off the retroperitoneum.
Step 6: The terminal ileum is transected with a laparoscopic stapler and
the pole of the coecum mobilized.
Step 7: The surgeon and assistant now move to the patient´s right side.
The surgeon uses the right sided and suprapubic ports. The table is tilted
to the right and in reversed Trendelnburg position and the transverse
colon is gently elevated off the duodenum to identify the middle colic
vessels. It is important to recognize the anatomic location of the superior
mesenteric vein as well as the gastrocolic trunk of Henle. These vessels
are short and excessive traction can lead to profuse bleeding at the
inferior border of the pancreas. The middle colic vessels are divided
while the transverse mesentery is held up (also know as “Ole
maneuver”).
Step 8: Division of the greater omentum is continued towards the
patient’s left by grasping the gastrocolic ligament, thus fully opening the
lesser sac, always avoiding traction on the spleen. The splenic flexure is
mobilized laterally by retracting the colon gently medially and dividing the
lateral attachments as well as lifting the colon of the retroperitoneum,
carefully avoiding the tail of the pancreas. To fully mobilize the flexure
the retroperitoneum is incised 1 cm below the pancreas and the colon
peeled off the Gerotas fascia.
Step 9: The descending colon is transected with a laparoscopic stapler,
coming in from the right-sided port.
Step 10: The table is leveled from the right tilt; the antimesenteric side of
the stapled ends of the descending colon and terminal ileum are
approximated by a stay suture tied intracorporeally and then held by the
assistant. An antimesenteric enterotomy and an antimesenteric colotomy
are made 10 cm distal to the stapled ends of the transverse colon and
terminal ileum, respectively and a side-to-side anastomosis is fashioned
with a laparoscopic stapler, placed at the suprapubic port. The
enterotomy after stapler extraction is closed by two layers of silk sutures
tied intracorporeally. The mesenteric defect is left open.
Step 11: The specimen is delivered in a bag, or using a wound protector,
through an enlarged umbilical or suprapubic port site. Fascial defects
larger than 5 mm are closed with 0-polyglycolic acid sutures. Skin
incisions are closed with running subcuticular 4-0 polyglycolic acid
sutures.
Postoperative care
If a naso- or orogastric tube is used intraoperatively, this should be
removed at the end of the procedure. The patient is encouraged to
ambulate on the day of the procedure, since early mobilization is
imperative to prevent complications like atelectasis, pneumonia or vein
thrombosis. A liquid diet should be started on post operative day 1 if
there are no clinical signs of ileus. Usually oral pain medications are
tolerated on POD#1. The foley catheter should also be removed on
POD#1 unless there are clinical signs of hypovolemia. Most patients are
ready for discharge from the hospital on POD#3-4. Follow up should be
at 2 and 6 weeks and after that according to each institution’s protocol
for colon cancer.
References:
1. Schlachta CM, Mamazza J, Poulin EC. Are transverse colon cancers
suitable for laparoscopic resection? Surg Endosc 21:396-9
2. Kim HJ, Lee IK, Lee YS, Kang WK, Park JK, Oh ST, Kim JG, Kim YH.
A comparative study on the short-term clinicopathologic outcomes of
laparoscopic surgery versus conventional open surgery for transverse
colon cancer. Surg Endosc 23:1812-7
3. Kuzuaki K, Matsude S, Fushimi H, Ishikawa KB, Horiguchi H, Fujimori
K. Quantitative comparison of the difficulty of performing laparoscopic
colectomy at different tumor locations. World J surg 34:133-9
4. Ignjatovic D, Stimec B, Finjord T, Bergamaschi R. Venous anatomy of
the right colon: three-dimentional topographic mapping of the gastrocolic
trunk of Henle