腹腔镜右半结肠肿瘤（图文演示）

10. Primary vascular division

Once the peritoneal layer of the right mesocolon is opened caudad to cephalad, the ileocolic vessels are divided, followed by the right colic vessels.
This is our technique of choice; it allows to open the retromesocolic space and to mobilize the colon from its retroperitoneal attachments without excessive manipulation.

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The peritoneal layer of the mesocolon is opened anterior to the mesenteric axis, along the right margin of the root of the mesentery.
This reveals the superior mesenteric vein and opens the right retroperitoneal space. The third duodenum and the head of the pancreas are the best landmarks to find the right plane.

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The gastrocolic trunk and its branches are identified first. The right colic vein is divided in isolation, preserving the other branches, after applying clips or staples at its junction with the gastrocolic trunk. This trunk may also be divided at the level of the superior mesenteric vein. In this case, all of the afferent branches, notably the pancreatic branches, must be ligated to avoid bleeding. It is important to know the varying anatomies of the vessels.

11. Transection of transverse colon

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After dividing the vessels, the transverse mesocolon followed by the transverse colon and greater omentum are divided.

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The mesocolon is divided from its root up to the colon. The marginal vessels must be controlled with clips or electrocautery (Ligasure device). Ultrasonic dissectors or hemostasis devices have proven very useful for this step by shortening operative time. The vasculature of the left transverse colon must be preserved.

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The transverse colon is divided using an endoscopic linear stapler (60mm blue cartridge Endo-GIA by Covidien). The division is done to the right side to the colica media vessels while making sure to preserving the vasculature of the left transverse colon. The stapler must be applied perpendicular to the colon. In the case of cancer, the limit of the division is chosen depending on the localization of the tumor.

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The sagittal transection of the greater omentum is facilitated by the use of a high frequency device (10mm Ligasure Atlas, 5mm Ligasure Advance by Covidien). The transection is performed in a straight line from caudad to cephalad, allowing the entire omentum to stay in the upper part of the abdominal cavity. This keeps the operative field clear, especially in cases of a voluminous, fatty omentum.
Once this step is done, the right transverse colon is separated from the left transverse colon.

12. Division of ileum / mobilization of ascending colon

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The procedure is followed by transection of the ileum about 20cm from the ileocaecal valve. The mobilization of the right colon necessitates the division of the posterior and lateral attachments of the right mesocolon, of the lateral attachments of the hepatic flexure and right transverse colon. Since the mobilization begins after the division of the ileocolic and right colic vessels, oncologic principles of the “no touch” technique (according to the low-risk dissemination criteria of Turnbull) are respected. Such an approach avoids excessive manipulation of the colon, especially in obese patients. The posterior retroperitoneal attachments of the right colon are freed medially to laterally. Division of the lateral attachments of the colon follows this.

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The ileum is transected using the 60mm white cartridge linear stapler. The mesenteric residual bridge is then divided.
In some cases, this operative step may also be carried out after mobilizing the caecum (ileocaecal adhesions). However, care must be taken to avoid injuring the underlying ureter, particularly in the case of adhesions caused by a previous surgery or by an inflammatory disease. The right colon is now completely separated from the left transverse colon and from the ileum.

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The division of the right paracolic gutter’s colonic attachments is performed caudad to cephalad while the first assistant retracts the cecum toward the left hypochondrium.
When freeing the retrocecal attachments, care must be taken to identify the genital vessels and right ureter, especially in cases of associated inflammation.
Having the surgeon stand to the left of the patient facilitates this step.

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Division of the right phrenocolic ligament is possible either by extending the incision of the right paracolic gutter, or by lowering the hepatic flexure after freeing the right transverse colon from its superior attachments.

13. Anastomosis

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The anastomosis is a crucial step. The small bowel should not twist and contamination of the abdominal cavity should be avoided.
A lot of different techniques can be applied. Here, the anastomosis is performed inside the abdominal cavity before removing the specimen through a smaller suprapubic cosmetic incision. We perform a side-to-side isoperistaltic ileocolic anastomosis using a mechanical linear stapler (60mm blue cartridge Endo-GIA), which is completed with a manual suture.
The anastomosis can also be achieved out of the abdomen through a small incision protected by a plastic wound protector with a 7cm diameter (Vi-Drape® manufactured by Becton Dickinson, USA) following the removal of the specimen.

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We routinely perform a side-to-side “in” isoperistaltic anastomosis. A linear articulated stapler (Endo-GIA, blue cartridge 60mm) is used to perform the side-to-side isoperistaltic anastomosis. The stapler is introduced through a 12mm operating trocar (Port 1 or Port 5), depending on the mobility of the colon and of the small bowel.
The stapling line is controlled through the incision to rule out any bleeding. The stapler’s introduction sites are re-approximated with sutures (interrupted stitches or two half-running sutures of monofilament absorbable material – Maxon 3/0).

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The anastomosis must be performed extracorporeally with the same principles described for the anastomosis “in”.
The anastomosis can be performed outside the abdominal cavity or through the incision. The latter necessitates less freeing of the bowel but the incision must be as close to the bowel as possible.

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We always close the mesenteric defect. This closure is performed with staples or sutures. Compared to suturing, stapling takes less time and is not as risky as it is more superficial.
Some authors no longer perform this closure. The risk of bowel obstruction due to the incarceration of an intestinal loop seems to be lower in the case of a wide defect (Sereno et al., 2007). However, if closed, the closure must be perfect.

14. Specimen extraction

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Choosing the site:
One of the advantages of the laparoscopic approach is that the extraction site of the operative specimen can be chosen in the region of the abdominal wall. The objective is to reduce the risk of parietal trauma and incisional hernia and to preserve cosmesis.
FOR CANCER, EFFECTIVE PARIETAL PROTECTION IS INDISPENSABLE. The specimen must not be compressed in the abdominal cavity during its extraction. Placing the operative specimen in a closed airtight plastic bag is the best means of protection. This is always done along with the insertion of a plastic wound protector in the extraction site, which also allows to reduce the size of the incision.
Whenever possible, we perform a suprapubic extraction through a transverse mini-incision.
If an extracorporeal ileocolic anastomosis is intended, then a higher extraction site may be preferable depending on the mobility of the left transverse colon. The size of the incision depends on the volume of the specimen to be extracted.

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The colon segment is placed in a plastic bag until its extraction, which is often performed at the end of the procedure, after intracorporeal anastomosis.
The double plastic wound protector prevents parietal and peritoneal contamination.
Once the bag is brought outside, it is opened. The colon is grasped by one of its ends to facilitate its extraction without tearing the protective bag.

15. Postoperative period
The gastric tube is removed when patient awakes in the recovery room. A liquid diet is resumed D1 or D2 with gradual normal food intake depending on the degree of bowel transit restoration. Normal physical activity is generally resumed between D8 and D15.

16. Reference

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Bonjer HJ, Hop WC, Nelson H, Sargent DJ, Lacy AM, Castells A, Guillou PJ, Thorpe H, Brown J, Delgado S, Kuhrij E, Haglind E, Pahlman L; Transatlantic Laparoscopically Assisted vs Open Colectomy Trials Study Group. Laparoscopically assisted vs open colectomy for colon cancer: a meta-analysis. Arch Surg 2007;142:298-303.

Chung CC, Ng DC, Tsang WW, Tang WL, Yau KK, Cheung HY, Wong JC, Li MK. Hand-assisted laparoscopic versus open right colectomy: a randomized controlled trial. Ann Surg 2007;246:728-33.

Fleshman J, Marcello P, Stamos MJ, Wexner SD; American Society of Colon and Rectal Surgeons (ASCRS); The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Focus Group on Laparoscopic Colectomy Education as endorsed by The American Society of Colon and Rectal Surgeons (ASCRS) and The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Dis Colon Rectum 2006;49:945-9.

Lacy AM, Delgado S, Castells A, Prins HA, Arroyo V, Ibarzabal A, Pique JM. The long-term results of a randomized clinical trial of laparoscopy-assisted versus open surgery for colon cancer. Ann Surg 2008;248:8-9.

Lange JF, Koppert S, van Eyck CH, Kazemier G, Kleinrensink GJ, Godschalk M. The gastrocolic trunk of Henle in pancreatic surgery: an anatomo-clinical study. J Hepat Pancreat Surg 2000;7:401-3.

Leroy J, Ananian P, Rubino F, ClaudonB, Mutter D, Marescaux J. The impact of obesity on technical feasibility and postoperative outcomes of laparoscopic left colectomy. Ann Surg 2005;242:747-8.

Mori H, McGrath FP, Malone DE, Stevenson GW. The gastrocolic trunk and its tributaries: CT evaluation. Radiology 1992;182:871-7.

Rawlings AL, Woodland JH, Vegunta RK, Crawford DL. Robotic versus laparoscopic colectomy. Surg Endosc 2007;21:1701-8.

Sereno S, M Anvari, Leroy J, Marescaux J. Prevalence of internal hernias after laparoscopic colorectal resection. Surg Endosc 2007; 21:S342.

Shatari T, Fujita M, Nozawa K, Haku K, Niimi M, Ikeda Y, Kodaira S. Vascular anatomy for right colon lymphadenectomy. Surg Radiol Anat 2003;25:86-8.

Veldkamp R, Gholghesaei M, Bonjer HJ, Meijer DW, Buunen M, Jeekel J, Anderberg B, Cuesta MA, Cuschierl A, Fingerhut A, Fleshman JW, Guillou PJ, Haglind E, Himpens J, Jacobi CA, Jakimowicz JJ, Koeckerling F, Lacy AM, Lezoche E, Monson JR, Morino M, Neugebauer E, Wexner SD, Whelan RL; European Association of Endoscopic Surgery (EAES). Laparoscopic resection of colon Cancer: consensus of the European Association of Endoscopic Surgery (EAES). Surg Endosc 2004;18:1163-85.