Chapter19
Right Hemicolectomy
Matthew C.Koopmann and Charles P.Hei
19.1Indications
Colon cancer or large adenomas are the major indications for right hemicolec-tomy,as it is the most appropriate oncologic rection.Though adenocarcinoma account for the great majority of colon cancers,other tumors such as carcinoids, lymphomas,and leiomyosarcomas may rarely occur.Right hemicolectomy is also the procedure of choice for appendiceal neoplasms(adenocarcinoma,appendiceal lymphoma)involving the cecum or mentery[1]and appendiceal carcinoid tumors larger than1.5cm or smaller than1cm with extension into the mesoappendix[2].猫喜欢咬人
Benign conditions may also be treated by right hemicolectomy.The include Crohn’s dia(although ileocecectomy is often sufficient),ischemia,trauma, right-sided diverticulitis,and volvulus.Colonic rection for benign dia differs from rection for malignant dia in that the extent of rection
usually involves only grossly involved bowel and mentery,whereas rection for malignant dis-ea requires en bloc removal of the cancerous bowel with wide margins and the draining menteric lymph nodes.This chapter will describe right hemicolectomy for malignant dia.
财务总监的职责Right hemicolectomy can be performed as an open procedure or as a laparoscopic-assisted procedure.The safety and efficacy of laparoscopic colectomy for colon cancer has been established by recent randomized controlled trials such as the North American-bad COST Trial,which showed equivalent oncologic out-comes and complication rates between open and laparoscopic colon rections for cancer,with the benefit of a reduced hospital length of stay[3].The decision to u an open or laparoscopic approach should be made bad upon surgeon’s experience and patient factors.
M.C.Koopmann(B)
Department of Surgery,University of Wisconsin School of Medicine
and Public Health,Madison,WI,USA
149 H.Chen(ed.),Illustrative Handbook of General Surgery,
DOI10.1007/978-1-84882-089-0_19,C Springer-Verlag London Limited2010
150M.C.Koopmann and C.P.Hei 19.2Preoperative Preparation
Colon cancer may be asymptomatic and discovered as a result of screening pro-grams or become symptomatic due to bleeding,obstruction,or metastatic dia. Both symptomatic and asymptomatic proximal colon cancer is definitively diag-nod by colonoscopy.For smaller lesions,it is important during colonoscopy that the endoscopist marks the site of the lesion via India ink tattoo,to facilitate accu-rate intraoperative localization during rection(especially important if approached laparoscopically).A chest x-ray and CT of the abdomen and pelvis is indicated to identify distant metastas.Preoperative carcinoembryonic antigen(CEA)may be obtained to assist in postoperative surveillance of recurrence.Though its u is cur-rently being questioned[2],preoperative mechanical bowel preparation is still most commonly utilized at this time.
19.3Positioning and Anesthesia
The patient is placed in the supine position.Arms may be tucked at the sides for a laparoscopic approach.Deep vein thrombosis(DVT)prophylaxis with subcuta-neous heparin injection and quential compression devices should be performed prior to the induction of anesthesia.General en
dotracheal anesthesia is the preferred method of anesthesia,although spinal anesthesia alone is feasible in high-risk cas [4].The addition of a preoperatively placed thoracic epidural catheter may reduce postoperative pain,reduce narcotic requirements,and facilitate early return of bowel function[5].A Foley urinary catheter should be placed and removed in the early postoperative period.Preoperative antibiotics with activity against anaerobic and Gram-negative and Gram-positive aerobic bacteria should be infud30–60min prior to incision and re-dod as appropriately during the ca.
望雪19.4Description of the Procedure
19.4.1Open Right Hemicolectomy
The incision is made in the midline of the abdomen from just above to just below the umbilicus.A right transver incision may also be ud,especially for smaller proximal tumors.The subcutaneous tissues and linea alba is divided using electro-cautery,the peritoneum is elevated by DeBakey forceps,and the peritoneal cavity is entered sharply with a scalpel or Metzenbaum scissors.
Upon entering the abdomen,a lf-retaining retractor may be ud to enhance exposure.The liver is examined for evidence of metastatic spread and the tumor is located,however,manipulation of the tu
mor should be minimized.The peritoneal reflection lateral to the cecum is incid and the terminal ileum is mobilized off the retroperitoneum.This disction is continued distally along the lateral right colon
19Right Hemicolectomy151 and up to the hepaticflexure using electrocautery,making sure to avoid the right ureter as it pass anterior to the right common iliac bifurcation It is necessary to identify the duodenum during mobilization of the hepaticflexure from the retroperi-toneum,as the cond and third portions may be injured by electrocautery during this step(Fig.19.1).Theduodenum is kept posterior,mobilizing the colon anteri-orly.The vesls contained within the hepatocolic ligament should be ligated and divided.This completes the mobilization around the hepaticflexure(Fig.19.2).
The omentum is then freed off the transver colon at the distal rection site and divided using the clamp and tie technique to include as part of the rection speci-men.The rection site should be chon to allow at least a5–10cm distal rection margin[6].A window is created in the mentery adjacent to the distal tranction site.The marginal artery of Drummond is ligated and divided,and the transver mesocolon is divided with electrocautery to the middle colic vesl bifurcation.The right branch of the middle colic vesl is ligated and divided at its origin and the left branch is spared(for lesions at the hepaticflexure or proximal transver colon,the right hemicolectomy may be
extended to include ligation of the middle colic ves-ls at their ba and rection of the proximal and mid-transver colon).The right colic vesls are identified,ligated,and divided.The mentery is further divided inferiorly to the ba of the ileocolic vesls(Fig.19.3),whichare ligated with a
Fig.19.1After complete mobilization,the right colon can be retracted medially to expo the underlying retroperitoneal structures.Disction at the hepaticflexure must be made carefully in order to avoid injuring the cond and third portions of the duodenum
152M.C.Koopmann and C.P.Hei
Fig.19.2This image
demonstrates the fully
mobilized right colon
elevated medially and
anteriorly out of the
abdomen.Note the third
portion of the duodenum and
its proximity to the Ileocolic
artery
heavy suture ligature and divided.The remaining small bowel mentery is ligated and divided up to the terminal ileum.An area of the terminal ileum at least5–10cm proximal to the ileocecal valve is identified as the proximal margin(though a larger margin may be included for cecal tumors).At this po
int the menteric rection is complete and preparation should be made for the ileocolic anastomosis.
The ileocolic anastomosis can be created using a side-to-side stapled approach. We describe a linear cutting stapler approach.The remaining proximal ileum and transver colon are aligned in a side-to-side fashion.The viable margins can usu-ally be visualized easily.Two enterotomies are then created(one in the colon and one in the ileum)at the edge of the non-viable regions and a75mm linear stapler is pasd through the enterotomies(Fig.19.4),asmbled,and deployed to create a side-to-side stapled ileocolic anastomosis.The staple line is inspected for bleed-ing and the anterior and posterior staple lines should be offt in order to prevent closing the staple lines on top of each other.A60mm thoracoabdominal(TA)sta-pler is then ud to complete the anastomosis by stapling transverly across both limbs of viable bowel to include the enterotomy site in the rection(Fig.19.5). Thebowel is divided on the stapler with heavy scissors.The specimen is inspected on the back table and nt to surgical pathology for further evaluation.The staple line may be reinforced with interrupted imbricating sutures.The menteric window
19Right Hemicolectomy153
地瓜会胖吗Fig.19.3The mentery of the right and proximal colon is divided.Generally,the ileocolic,right colic,and right branch of the middle colic vesls are divided as demonstrated in this picture.When the rection is for malignancy,the right colic and ileocolic arteries are ligated clo to their origin. This allows for a more complete lymph node sampling
may be clod with running absorbable sutures to prevent internal hernia.The bowel is then returned to the abdominal cavity and the abdomen is irrigated,inspected for bleeding,and the midline fascia clod with running absorbable sutures followed by skin closure.
写真拍照Fig.19.4The stapled
side-to-side anastomosis
垂的笔画顺序begins with enterotomies
being made in the ileum and
colon.A75mm linear,
cutting stapler is introduced
活到九十九
伟大的人民教师and asmbled.When the
stapler isfired,an
antimenteric side-to-side
anastomosis is created
