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: elsava@landspitali.is Roberto Bergamaschi, MD, PhD, FRCS, FASCRS, FACS Department of Research and Development Forde Health System Forde, Norway rcmbergamaschi@gmail.com List of contribution: Dr. Valsdottir: Concept, design, drafting text, final approval Dr. Bergamaschi: Concept, design, revising content, final approval
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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