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3/16/2016

LaparoscopicRightColectomy(RightHemicolectomy):Background,Indications,Contraindications

LaparoscopicRightColectomy(Right
Hemicolectomy)
Author:JanaLLewis,MDChiefEditor:KurtERoberts,MDmore...
Updated:Oct15,2015

Background
Laparoscopyhasemergedasthepreferredoperativeapproachformostintra
abdominalpathologicconditions.Nonetheless,eventhoughthefirstlaparoscopic
colectomywasreportedalmost20yearsago,mostcolectomiesintheUnitedStates
arestillbeingperformedviatheopenapproach. [1]
Thisdelayedacceptancecanbeattributedmainlytoinitialconcernsregardingthe
adequacyofoncologicmarginsandtrocarsiterecurrencesbelievedtooccurwith
laparoscopyconcernsnowlargelylaidtorestbytheresultsoflargerandomized
controlledtrialssuchastheClinicalOutcomesofSurgicalTherapy(COST)trial. [2]
Evidencesuchasthismayfinallystarttoturnthetideinfavoroflaparoscopy.
Thebenefitsoflaparoscopichemicolectomyincludethefollowing:
Smallerwoundsandimprovedcosmesis
Shorterhospitalstay
Lesspostoperativepain
Earlierreturntonormalactivity
Quickerrecoveryofpulmonaryfunction
Lowerincidenceandquickerresolutionofpostoperativeileus
Lowerincidenceofsurgicalsitecomplications
Lowerincidenceofpostoperativeadhesions [3]
Thegoalsoflaparoscopicrighthemicolectomy(rightcolectomy)performedinthe
settingofcoloncancerarethesameasthoseforopensurgery.Theyinvolve
appropriatevesselligation,creationofsufficientluminalmargins,andadequate
lymphnodesampling.Inaddition,athoroughinspectionoftheabdominalcavity
andliversurfaceisexpected,togetherwiththecreationofareliableanastomosis.
Laparoscopiccolectomyforresectablecoloncancerhasbeenreportedtobe
technicallyandoncologicallyfeasible.Thegeneralconsensus,basedonthe
literatureoverthepastseveralyears,isthatthereisnosignificantdifferencein
lymphnodeharvestbetweenlaparoscopicandopenrighthemicolectomiesfor
cancerwhenstrictoncologicprinciplesofresectionarefollowed.Todate,patient
survival,diseaseprogression,andcancerrecurrenceatportsiteshavebeenfound
tobeequivalentbetweenlaparoscopiccolectomyandtraditionalopencolectomy.
Severalshorttermbenefitssimilartothosedescribedforcoloncancerhavebeen
associatedwithlaparoscopicsegmentalcolonresectionforinflammatorybowel
disease(IBD).Inaddition,theoreticallongtermadvantagesincludeformationof
feweradhesions,decreasedratesofbowelobstruction,decreasedlikelihoodof
chronicpain,anddecreasedincidenceofinfertilityorwoundhernias.Two
randomizedcontrolledtrialsdemonstratedsomeshorttermbenefitstolaparoscopic
ileocolicresectionforCrohndisease.Ontheotherhand,currentevidenceon
laparoscopicsurgeryforulcerativecolitisdoesnotsupportitsroutineuseamong
nonexpertsurgeonsoutsideofspecializedcenters.
Laparoscopiccolonicresectionfordiverticulardiseaseappearstoprovideseveral
shorttermbenefits,thoughtheseadvantagesmaynottranslatetocasesof
complicateddiverticulitis.

Indications
Theindicationsforlaparoscopicrighthemicolectomyaresimilartothoseforopen
colectomy,asfollows:
Adenomatouspolypsnotamenabletocolonoscopicresection
Crohndiseaseanditscomplications
Bleedingsecondarytodiverticulosisorarteriovenousmalformation
Diverticulitis
Obstruction
Colontumors(benignormalignant)

Contraindications
Therearefewcontraindicationstoperformingalaparoscopicrighthemicolectomy.
Absolutecontraindicationsincludethefollowing:
Tumorinfiltrationintoadjacentstructures(T4)
Largephlegmonousmass
Obstruction,perforation,orileusleadingtomassiveboweldistentionand
lossofdomain
Carcinomatosis
Relativecontraindications(dependingonlocalexpertise)includethefollowing:
Morbidobesity
Multiplepreviousabdominalsurgicalprocedures

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Extensiveabdominaladhesions
Primarytumorwithresectablelivermetastasis [4]
Laparoscopicrightcolectomyforaneoplasmwasnotassociatedwithahigher
conversionrateorhgihermorbidityinpatientswithpriorabdominalsurgery
therefore,priorabdominalsurgeryisnotacontraindicationtolaparoscopicright
colectomy. [5]
IndicationsforconversiontoopensurgeryintheCOSTtrialincludedthefollowing[2]
:
Extensiveabdominaladhesions
Inabilityforthesurgeontomobilizeanddefinethetumorextent
Resectablemetastases
Ultimately,themethodofresection(laparoscopicvsopen)cannotcompromisethe
oncologicadequacyofresection,whichiswhyaverywelldefinedstepwise
techniqueissovital.

TechnicalConsiderations
Anatomicconsiderations
Therightcolonisderivedembryologicallyfromtheendodermroofoftheyolksac,
whichdevelopsintotheprimitiveguttube.Inthebeginningoftheweek3of
gestation,theguttubeseparatesintothemidgut,foregut,andhindgutsegments.
Themidgutgivesrisetothesegmentofthegastrointestinal(GI)tractextending
fromthedistalduodenumtothedistaltransversecolon.Itderivesitsbloodsupply
fromthesuperiormesentericartery(SMA).
Theterminalileumemptiesintothececumthroughtheileocecalvalve.Thececum
measuresapproximately7.5cmindiameterand10cminlength.Theappendix
extendsfromthececumandmeasures810cminlength.Theascendingcolonis
15cmlong.Theposteriorsurfaceisfixedagainsttheretroperitoneumalongthe
whitelineofToldt.Thelateralandanteriorsurfacesareintraperitoneal.The
transversecolonis45cminlength.Itisfixedbythenephrocolicligamentatthe
hepaticflexureandbythephrenocolicligamentatthesplenicflexure.Itis
completelyinvestedinvisceralperitoneum.
ThecolonhasspecificcharacteristicsthatdistinguishitfromotherpartsoftheGI
tract.Omentalappendicesarebodiesoffatenclosedbyperitoneum.Taeniaecoli
arethreebandsoflongitudinalmusclehaustraformbetweenthebands.
Allvascularstructuresandlymphnodesarelocatedinthemesocolon.Itiseasiest
tovisualizethecolonmesenteryasbeingnodifferentthansmallbowelmesentery.
Bothmesenteriesattachata90angleandcontainarterial,venous,andlymphatic
channels.Therightcolondiffersfromsmallbowelonlyinthatthebowelandits
mesenteryare"plasticwrapped"totheretroperitoneum.Thisdistinctionis
importantbecauseinordertoresectthisbowel,thecolonanditsmesenterymust
firstbemobilizedfromitsretroperitonealattachmentsonlythencanasegmental
resectionwithlymphadenectomybeperformed.
ThearterialsupplybranchesfromtheSMAtotheileocolic,rightcolic,andmiddle
colicarteries.TheSMAterritoryendsatthedistaltransversecolon,wherethe
inferiormesentericartery(IMA)takesovertosupplytheleftcolon.Amarginalartery
networkistheanastomoticwebbetweenthesevesselsalongthemesentericborder.
Vasarectabranchesofthemarginalarterydirectlysupplythebowelwall.
Themostcommonpatternofarterialsupplyrelevanttoarighthemicolectomy
consistsofthethreearterialbranchesarisingfromtheSMA(ileocolicartery,right
colicartery,andmiddlecolicartery).Theileocolicartery,themostconstanttributary
oftheSMA,suppliestheterminalileum,cecum,andappendix.Therightcolic
arterysuppliestheascendingcolonandhepaticflexureofthetransversecolon.
(Seetheimagebelow.)

Arterialsupplyoftherightcolon.

ThemiddlecolicarteryisthemostproximalbranchoftheSMA,supplyingthe
proximalanddistaltransversecolonviatherightandleftbranches.Themiddlecolic
arteryiscompletelyabsentinasmanyas25%ofindividualsitisreplacedbya

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largerightcolicartery. [6]ThearcofRiolan(meanderingmesentericartery)isa
collateralarterythatdirectlyconnectstheproximalSMAtotheproximalIMAand
mayserveasavitalconduitwhenarterialocclusionoccurs.
Manyvariationsoftherightcolicarteryanatomyexist(seetheimagebelow).It
arisesdirectlyfromtheSMAinapproximately40%ofindividuals,fromthemiddle
colicarteryin30%,andfromtheileocolicarteryin12%.Itiscompletelyabsentin
20%ofindividuals. [7]

Variationsoftherightcolicarteryanatomy.

Venousdrainagemimicsthearterialtree,withileocolicandrightcolicveinsdraining
intothesuperiormesentericvein(SMV).Thelymphaticdrainagefollowsthearteries
anddrainsintotheparaaorticnodalchain.Otherlymphnodesinvolvedinclude
epicolicnodesalongthebowelwall,paracolicnodesadjacenttothemarginalartery,
intermediatenodesalongthearterialandvenousbranches,andprimarynodesat
theSMAandSMV. [8,9,10]
Relevantdefinitionsandterminology
TheGerotafasciaisperinephricfasciathatenclosesthekidneysandadrenal
glands.Superiorly,ittapersovertheinferiordiaphragmaticsurface.Medially,the
fasciacrossesthemidlineandiscontiguouswiththecontralateralfascia.Laterally,
theGerotafasciaisanopenpotentialspacethatcontainstheureterandgonadal
vessels.
ThewhitelineofToldtrepresentsthefusionofcolicmesenterywiththeposterior
peritoneum.
Anadenomatouspolypisamassprojectingintothelumenofthebowel.These
polypsareclassifiedbytheirgrossappearanceaspedunculatedorsessileand
furtherclassifiedbyhistologyastubularorvillous.Themostcommoncolonicpolyp
isatubularadenoma.Theincidenceofcarcinomainapolypdependsonsizeand
histology.
Diverticulosisdescribesthepresenceofcolonicdiverticula.Adiverticulumisan
abnormalprotrusionofmucosathroughthemuscularlayersofthecolonicwall.
Diverticulaareassociatedwithincreasingageandlowfiberdiets. [9]

Complicationprevention
Becauseofthecloseproximityoftheduodenalsweeptotheileocolicpedicle,the
duodenumisatriskforsharporcauterizationinjuries.Topreventsuchinjury,the
duodenumshouldbeidentifiedandgentlysweptawaypriortodissectionand
divisionoftheileocolicpedicle.
Therightureterismostcommonlyinjuredovertherightiliacvesselsduringcecal
mobilizationaccordingly,careshouldbetakentoensurethatthedissectionplaneis
notoverlyposterior.Asarule,theuretershouldremainunderneaththeToldt
retroperitonealfascia.However,iftheToldtfasciacannotbeclearlyvisualizedviaa
medialapproachandthedissectionplaneisunclearduringtheisolationofthe
ileocolicpedicle,itisadvisabletoswitchtoaninferiorapproach.Theileumis
mobilizedofftheretroperitoneumsothattherighturetercanbeidentifiedand
tracedtowardtheduodenumbeforethepedicleisdivided. [3]
AggressivebluntdissectionaroundtheoriginoftheileocolicveinmakestheSMV
susceptibletoavulsioninjury.Ashortstumpshouldbeleftduringligationofthe
ileocolicpedicleinordertoavoidencroachmentintothesuperiormesenteric
vessels. [3]
Aberrantanatomymustbetakenintoaccount.In10%30%ofcases,anadditional
rightcolicveinarisesfromtheascendingcolonanddrainsintotheSMVbelowthe
thirdportionoftheduodenum.
Insomepatients,fusionofGerotafattotheposterioraspectofcoloncanincrease
theriskofeitherenteringGerotafatordissectingposteriortothekidneyduring
lateralmobilization.ThisproblemispreventedbypushingdownonToldt
retroperitonealfasciaandensuringthatthedissectionplanesremainanteriortoit.
Proximalligationoftherightcolicveinplacestherightgastroepiploicveinatriskfor
injuryordivision.Thistypeofinjuryispreventedbyliftingthetransversecolon

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anteriorlyanddividingonlytheveinsthattraveltothecolon.Thevasculature
travelingunderneaththecolontowardthestomachispreserved. [3]
Duringanastomosis,theterminalileumorthetransversecolonmaybecometwisted
arounditsmesentery.Often,thetwistingisnotvisiblethroughtheminilaparotomy
incisionandconsequentlygoesunnoticed.Topreventthiscomplication,placetwo
seromuscularstaysuturesintotheileum,oneproximalandonedistal,afterthe
rightcolonisexteriorizedandtheterminalileumandmesenterydivided.Thesestay
suturesareclampedindividuallyandarenevercrossed.Anothertechniqueinvolves
placingalaparoscopicgrasperontheterminalileum.Oncetheanastomosishas
beencreated,afinallookthroughthelaparoscopecanconfirmthatthemesenteric
orientationiscorrect. [3]

Outcomes
TheCOSTStudyGroupevaluatedlaparoscopicresectionsusedtotreatcolorectal
cancerintheUnitedStates.Thestudyconcludedthatcancerrecurrencerateswere
similarbetweenthelaparoscopicallyassistedcolectomyandopencolectomy
groups,suggestingthatthelaparoscopicapproachisanequivalentalternativeto
opensurgeryforcoloncancer. [2]
AsystematicreviewandmetaanalysisbyArezzoetal,whichexaminedthesafety
andoncologicadequacyoflaparoscopicrightcolectomyagainstthoseofopenright
colectomyin3049rectalcancerpatients,foundthatmorbidityandmortalitywere
significantlylowerwiththelaparoscopictechnique. [11]
Shorterhospitalizationandfewerpostoperativecomplicationsmightbeexpectedto
reduceoverallproceduralcosts,buttheseareoffsetbytheincreasedcostoflonger
operativetimesandmorecostlyinstrumentation.Bouvetetalfoundsimilartotal
hospitalchargeswhencomparinglaparoscopyversuslaparotomyforcolectomy. [12]
Likewise,Philipsonetaldidnotshowanycostbenefitoflaparoscopicassistedright
hemicolectomiescomparedwiththeopentechnique. [13]
PeriproceduralCare

ContributorInformationandDisclosures
Author
JanaLLewis,MDResidentPhysician,DepartmentofSurgery,MaimonidesMedicalCenter
Disclosure:Nothingtodisclose.
Coauthor(s)
DannyASherwinter,MDAttendingSurgeon,DepartmentofMimiallyInvasiveSurgeryandBariatrics,
AssociateProgramDirector,DepartmentofSurgery,MaimonidesMedicalCenterDirectorofMinimallyInvasive
andBariatricSurgery,AmericanSocietyforMetabolicandBariatricSurgery(ASMBS)CenterofExcellence
DannyASherwinter,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,
AmericanSocietyforMetabolicandBariatricSurgery,SocietyofAmericanGastrointestinalandEndoscopic
Surgeons,SocietyofLaparoendoscopicSurgeons
Disclosure:Nothingtodisclose.
HarryLAdler,MDAssistantClinicalProfessorofSurgery,MountSinaiHospitalAssistantDirectorand
ConsultingPhysician,MaimonidesMedicalCenter
HarryLAdler,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationforPhysician
Leadership,AmericanCollegeofSurgeons,AssociationforAcademicSurgery
Disclosure:Nothingtodisclose.
SunnyLeahFink,MDMultiOrganAbdominalTransplantFellow,DepartmentofTransplantSurgery,University
ofPittsburghMedicalCenter
SunnyLeahFink,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,American
MedicalStudentAssociation/Foundation
Disclosure:Nothingtodisclose.
SilvioGhirardo,MDResidentPhysician,DepartmentofGeneralSurgery,MaimonidesMedicalCenter
Disclosure:Nothingtodisclose.
SergeyTerushkin,MDBariatricandMinimallyInvasiveSurgery,NewYork
SergeyTerushkin,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,American
MedicalAssociation
Disclosure:Nothingtodisclose.
ChiefEditor
KurtERoberts,MDAssistantProfessor,SectionofSurgicalGastroenterology,DepartmentofSurgery,Director,
SurgicalEndoscopy,AssociateDirector,SurgicalSkillsandSimulationCenterandSurgicalClerkship,Yale
UniversitySchoolofMedicine
KurtERoberts,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,Societyof
AmericanGastrointestinalandEndoscopicSurgeons,SocietyofLaparoendoscopicSurgeons
Disclosure:Nothingtodisclose.
Acknowledgements
MaimonidesMedicalCenterGroupwouldliketothankCourtneySchlowforcreatingtheaboveillustrations.
MedscapeReferencethanksSAGESforthesingleincisionrighthemicolectomyvideointhisarticle.

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