TECHNICAL NOTES
John A. Coller, M.D., Editor
Laparoscopic-Assisted Right Hemicolectomy Richard T. Schlinkert, M.D. From the Department of Surgery, Mayo Clinic Scottsdale, Scottsdale, Arizona A laparoscopic technique to assist in the performance of right hemicolectomy is described. [Key words: Colon resection; Laparoscopy; Laparoscopic colon resection; Surgical technique] Schlinkert RT. Laparoscopic-assisted right hemicolectomy. Dis Colon Rectum 1991;34:1030-1031. his report describes a technique for performing laparoscopic-assisted right hemicotectomy. A standard cancer operation I was performed in two patients with complete staging of the tumor.
T
TECHNIQUE Patients were placed in the supine position with the legs in low stirrups. Figure 1 demonstrates the operating room setup. The surgeon and camera operator stood on the patient's left side, with the first assistant between the patient's legs. This allowed all instruments to be utilized in line with the camera without undue crowding on one side of the operating table. Carbon dioxide was insufflated into the peritoneal cavity through a Veress needle inserted through the umbilicus. Trocar placement is illustrated in Figure 2. A 5-mm trocar was inserted through the umbilicus and a 5-mm camera placed through this trocar. Under direct vision, a 10-mm trocar was placed in the left lower quadrant for insertion of the 10-mm camera. A second 10-mm trocar was placed to the right of the midline in the upper abdomen; the surgeon then utilized this port as well as the umbilical port for his instruments. Five-millimeter trocars were placed in the lower midline and in the right lower quadrant; these ports were utilized by the first assistant. The peritoneal reflection of the right Address reprint requests to Dr. Schlinkert: 13400 East Shea Boulevard, Scottsdale,Arizona85259. 1030
colon was divided using electrocautery, and the ureter was identified. Likewise, the duodenum was identified and reflected posteriorly. The hepatic flexure was taken down using electrocautery, clipping the larger vessels. By placing the mesocolon under tension, the ileocolic artery could be readily identified. The leafs of the mesentery on either side of the artery were divided, and a tie or clip was placed about the artery. The artery was then grasped, divided, and further secured with endoloops. The mesentery to the ileum, as well as the transverse colon, was then divided using clips. At this point, the colon was readily movable. An incision was made to the right of the umbilicus, and the rectus muscle was divided along its fibers; the bowel was delivered through this incision. Removing carbon dioxide from the abdomen allowed the colon to be more readily delivered through the incision. The ends of the bowel were divided using a gastrointestinal stapler, and a side-to-side ileotransverse colostomy was performed using staples. The mesenteric defect may be closed either through the incision or with the aid of the laparoscope. After the largest incision was closed, trocars were reinserted and carbon dioxide was again insufflated into the peritoneal cavity. Hemostasis was checked, and the abdominal cavity was irrigated. The trocars were then removed under direct vision, and the incisions were closed with Vicryl (Ethicon, Somerville, NJ). TM
DISCUSSION Laparoscopic surgery has revolutionized the management of gallstones. >6 The feasibility of performing a right hemicolectomy with laparoscopic assistance has been demonstrated in the current
LAPAROSCOPIC-ASSISTED HEMICOLECTOMY
Vol. 34, No. 11
Anesthesia Mayo Stand
Video Monitors
1031
[~ Scrub Nurse
Surgeon
D
Camera Operator
I
3
1st Assistant
!
Figure 1. Operating room setup for laparoscopic right hemicolectomy: the scrub nurse, surgeon, and camera operator stand on the patient's left; the first assistant stands between the patient's legs.
2 5
study. The procedure appears to be safe, and there is no compromise in the standard cancer operation which would ordinarily be performed for a tumor in the right c o l o n . 1 Whereas laparoscopic techniques for anastomosing the ends of the bowel together could allow this procedure to be performed completely within the abdominal cavity, accurate pathologic staging of the tumor can only be obtained if the specimen is removed intact. Therefore, a small incision will be required with laparoscopic techniques to allow removal of the specimen. By placing the patient in low stirrups, there is less crowding at the operating table as one assistant stands between the legs. Furthermore, all instruments are kept in a relatively direct line with the camera, which facilitates control of the instruments by the operators. Long-term success of this procedure, as well as an assessment of whether this will be superior to a standard right hemicolectomy, is yet to be determined and certainly cannot be ascertained from this small group of patients. However, these patients demonstrate the feasibility of performing laparoscopic right hemicolectomy, and further studies are being performed to determine the longterm results of this technique.
4
Figure 2. Incisions for laparoscopic right hemicolectomy: 1,4, and 5 are the 5-mm trocar sites, 2 and 3 are the lOmm trocar sites, and 6 is the incision for removing the specimen.
REFERENCES
1. Goligher J, Duthie H, Nixon H. Surgery of the anus, rectum, and colon. 5th ed. London: Bailliere Tindall, 1984:530-3. 2. Berci G, Sackier JM. The Los Angeles experience with laparoscopic cholecystectomy. Am J Surg 1991; 161:382-4. 3. Cuschier A, Dubois F, Mouiel J, e t al. The European experience with laparoscopic cholecystectomy. Am J Surg 1991;161:385-8. 4. Flowers JL, Bailey RW, Scovill WA, Zucker KA. The Baltimore experience with laparoscopic management of acute cholecystitis. Am J Surg 1991;161: 388-92. 5. Gadacz TR, Talamini MA, Lillemoe KD, Yeo CJ. LaparoscopiC cholecystectomy. Surg Clin North Am 1990;70:1249-62. 6. Reddick EJ, Olsen DO. Outpatient laparoscopic laser cholecystectomy. Am J Surg 1990;160:485-9.
John A. Coller, M.D., Editor
Laparoscopic-Assisted Right Hemicolectomy Richard T. Schlinkert, M.D. From the Department of Surgery, Mayo Clinic Scottsdale, Scottsdale, Arizona A laparoscopic technique to assist in the performance of right hemicolectomy is described. [Key words: Colon resection; Laparoscopy; Laparoscopic colon resection; Surgical technique] Schlinkert RT. Laparoscopic-assisted right hemicolectomy. Dis Colon Rectum 1991;34:1030-1031. his report describes a technique for performing laparoscopic-assisted right hemicotectomy. A standard cancer operation I was performed in two patients with complete staging of the tumor.
T
TECHNIQUE Patients were placed in the supine position with the legs in low stirrups. Figure 1 demonstrates the operating room setup. The surgeon and camera operator stood on the patient's left side, with the first assistant between the patient's legs. This allowed all instruments to be utilized in line with the camera without undue crowding on one side of the operating table. Carbon dioxide was insufflated into the peritoneal cavity through a Veress needle inserted through the umbilicus. Trocar placement is illustrated in Figure 2. A 5-mm trocar was inserted through the umbilicus and a 5-mm camera placed through this trocar. Under direct vision, a 10-mm trocar was placed in the left lower quadrant for insertion of the 10-mm camera. A second 10-mm trocar was placed to the right of the midline in the upper abdomen; the surgeon then utilized this port as well as the umbilical port for his instruments. Five-millimeter trocars were placed in the lower midline and in the right lower quadrant; these ports were utilized by the first assistant. The peritoneal reflection of the right Address reprint requests to Dr. Schlinkert: 13400 East Shea Boulevard, Scottsdale,Arizona85259. 1030
colon was divided using electrocautery, and the ureter was identified. Likewise, the duodenum was identified and reflected posteriorly. The hepatic flexure was taken down using electrocautery, clipping the larger vessels. By placing the mesocolon under tension, the ileocolic artery could be readily identified. The leafs of the mesentery on either side of the artery were divided, and a tie or clip was placed about the artery. The artery was then grasped, divided, and further secured with endoloops. The mesentery to the ileum, as well as the transverse colon, was then divided using clips. At this point, the colon was readily movable. An incision was made to the right of the umbilicus, and the rectus muscle was divided along its fibers; the bowel was delivered through this incision. Removing carbon dioxide from the abdomen allowed the colon to be more readily delivered through the incision. The ends of the bowel were divided using a gastrointestinal stapler, and a side-to-side ileotransverse colostomy was performed using staples. The mesenteric defect may be closed either through the incision or with the aid of the laparoscope. After the largest incision was closed, trocars were reinserted and carbon dioxide was again insufflated into the peritoneal cavity. Hemostasis was checked, and the abdominal cavity was irrigated. The trocars were then removed under direct vision, and the incisions were closed with Vicryl (Ethicon, Somerville, NJ). TM
DISCUSSION Laparoscopic surgery has revolutionized the management of gallstones. >6 The feasibility of performing a right hemicolectomy with laparoscopic assistance has been demonstrated in the current
LAPAROSCOPIC-ASSISTED HEMICOLECTOMY
Vol. 34, No. 11
Anesthesia Mayo Stand
Video Monitors
1031
[~ Scrub Nurse
Surgeon
D
Camera Operator
I
3
1st Assistant
!
Figure 1. Operating room setup for laparoscopic right hemicolectomy: the scrub nurse, surgeon, and camera operator stand on the patient's left; the first assistant stands between the patient's legs.
2 5
study. The procedure appears to be safe, and there is no compromise in the standard cancer operation which would ordinarily be performed for a tumor in the right c o l o n . 1 Whereas laparoscopic techniques for anastomosing the ends of the bowel together could allow this procedure to be performed completely within the abdominal cavity, accurate pathologic staging of the tumor can only be obtained if the specimen is removed intact. Therefore, a small incision will be required with laparoscopic techniques to allow removal of the specimen. By placing the patient in low stirrups, there is less crowding at the operating table as one assistant stands between the legs. Furthermore, all instruments are kept in a relatively direct line with the camera, which facilitates control of the instruments by the operators. Long-term success of this procedure, as well as an assessment of whether this will be superior to a standard right hemicolectomy, is yet to be determined and certainly cannot be ascertained from this small group of patients. However, these patients demonstrate the feasibility of performing laparoscopic right hemicolectomy, and further studies are being performed to determine the longterm results of this technique.
4
Figure 2. Incisions for laparoscopic right hemicolectomy: 1,4, and 5 are the 5-mm trocar sites, 2 and 3 are the lOmm trocar sites, and 6 is the incision for removing the specimen.
REFERENCES
1. Goligher J, Duthie H, Nixon H. Surgery of the anus, rectum, and colon. 5th ed. London: Bailliere Tindall, 1984:530-3. 2. Berci G, Sackier JM. The Los Angeles experience with laparoscopic cholecystectomy. Am J Surg 1991; 161:382-4. 3. Cuschier A, Dubois F, Mouiel J, e t al. The European experience with laparoscopic cholecystectomy. Am J Surg 1991;161:385-8. 4. Flowers JL, Bailey RW, Scovill WA, Zucker KA. The Baltimore experience with laparoscopic management of acute cholecystitis. Am J Surg 1991;161: 388-92. 5. Gadacz TR, Talamini MA, Lillemoe KD, Yeo CJ. LaparoscopiC cholecystectomy. Surg Clin North Am 1990;70:1249-62. 6. Reddick EJ, Olsen DO. Outpatient laparoscopic laser cholecystectomy. Am J Surg 1990;160:485-9.
