Step by step for right colectomy by laparoscopic approach

This video is focused in the main steps to perform a right colectomy by minimal invasive surgery.

The patient was placed in supine position, the leading surgeon standing on the left plus two assistant surgeons, one on each side of the patient.

A total of five trocars were used: a 12-mm trocar to the left of the umbilicus for a 30° scope, another 12-mm trocar at the epigastrium, and a 5-mm trocar at the hypogastrium. These were the working channels for the leading surgeon.

Two extra 5-mm trocars were placed at the right iliac fossa and the right flank as working channels for the assistant surgeon.

The first maneuver is to accommodate the mesocolon. The patient was moved into a reverse Trendelemburg position and slightly to his left. Performing  traction at the cecum helps to identify the right ileocolic vessels. The assistance surgeon must maintain the traction of the vessels and the transverse colon.

Vascular dissection begins by opening a window at the peritoneum using the hook. There are several ways to perform vascular ligation; the most delicate one is to identify the artery and the vein prior to the section.

>A dissector is necessary to individualize the vessels from the surrounding fatty tissue. As can be seen  two clips are placed at the origin of the artery and a distal is placed to ensure hemostatic control. The vein can be sectioned with the LigaSure™.

Other option is to fire a vascular mechanical suture, making sure that the duodenum is respected. Ligation of the right colic artery and the right branch of the medial colic artery must be included in cases of colonic adenocarcinoma.

The assistant surgeon then performed traction from the vessels stump exposing the retroperitoneal plane. Medial to lateral mobilization is carried out as far as possible which facilitates the lateral detachment of the colon. The hook makes sharp dissection possible, and laparoscopic DeBakeys are used to improve traction and exposure. This plane can be fused in patients with previous renal surgery.

The landmark is the hepatic flexure; the duodenum should always be borne in mind to prevent unexpected injuries.  A piece of gauze is placed below of the colon at the end of the medial mobilization. At this stage, the assistant surgeon performed a cranial traction from the gallbladder and pulled the colon towards the pelvis. The gauze was identified and revealed the correct plane for lateral dissection.

Once again the hook was used to open a window at the peritoneum, enabling the LigaSure to perform the rest of the job by detaching the ascending colon. It is important to mobilize until the duodenum is visualised, in order to enable correct exteriorization of the specimen.

The appendix can be used to change the exposure of the cecum and complete its dissection with the energy devices. The mesentery of the terminal ileum is also sectioned to release tension and avoid bleeding during the exteriorization of the specimen

The assistance incision is performed by enlarging the right-flank trocar wound. It is about 5 cm long, depending on the size of the colon, the lesion, and the mesentery.

A bag is placed to protect the wound and the specimen is pulled out. After checking that margins are correct the mesocolon is prepared. Section of the colon and terminal ileum is performed with mechanical sutures.

Making a knot at the stapler line to perform traction during the anastomosis is recommended.

A enterotomy and a colotomy was made to introduce the mechanical suture and create the anastomotic lumen.

One surgeon makes a knot at the medial aspect of the anastomosis to release tension while other surgeon checks for for bleeding of the stapler line.

A last mechanical firing seals the anastomosis.