Overview
Definition:
Laparoscopic right colectomy is a minimally invasive surgical procedure to remove the ascending colon and often the terminal ileum, with the bowel ends rejoined within the abdominal cavity (intracorporeal anastomosis)
This technique aims to treat various benign and malignant conditions of the right colon, offering advantages of reduced pain, shorter hospital stays, and quicker recovery compared to open surgery.
Epidemiology:
Right colectomy is one of the most frequently performed colonic resections
Indications include colorectal cancer, Crohn's disease, complicated diverticular disease, and adenomatous polyps that cannot be removed endoscopically
Laparoscopic approaches are increasingly favored, accounting for a significant proportion of all colectomies performed globally.
Clinical Significance:
This procedure is vital for managing malignant and complex benign diseases of the right colon
Proficiency in laparoscopic techniques and intracorporeal anastomosis is crucial for surgical residents preparing for DNB and NEET SS examinations, as it represents a standard of modern surgical care and is frequently tested.
Indications
Malignancy:
Colorectal cancer of the cecum, ascending colon, hepatic flexure, or proximal transverse colon
Staging is crucial for oncological resection margins.
Inflammatory Bowel Disease:
Unresectable or complicated Crohn's disease involving the terminal ileum and/or right colon
Acute fulminant colitis unresponsive to medical management.
Benign Conditions:
Large or symptomatic adenomatous polyps not amenable to endoscopic removal
Chronic appendicitis with complications
Intestinal obstruction secondary to benign strictures
Diverticulitis of the right colon (less common but can occur).
Other:
Intussusception, Meckel's diverticulum with complications, or other rare causes of right-sided colonic pathology.
Preoperative Preparation
Patient Assessment:
Thorough history, physical examination, and review of comorbidities
Assess nutritional status and smoking history.
Bowel Preparation:
Mechanical bowel preparation is typically required
Common regimens include polyethylene glycol solutions or sodium phosphate
Oral antibiotics may be administered as per institutional protocol.
Imaging And Staging:
CT scan of the abdomen and pelvis is essential for staging of malignancy, assessing extent of disease, and evaluating for metastatic spread
Colonoscopy confirms diagnosis and extent.
Anesthesia And Access:
General anesthesia with endotracheal intubation
Careful pneumoperitoneum induction
Creation of multiple port sites for laparoscopic instruments and camera.
Procedure Steps Intracorporeal Anastomosis
Port Placement:
Standard ports typically include a supraumbilical or infraumbilical camera port, two working ports in the right lower and right upper quadrants, and one assisting port in the left lower quadrant.
Mobilization Of Colon:
The right colon is mobilized from the retroperitoneum
This involves dividing the white line of Toldt, dissecting the hepatic flexure, and mobilizing the mesentery to ensure adequate length for tension-free anastomosis.
Division Of Vessels:
The ileocolic artery and vein, and the middle colic artery and vein (if involved) are ligated and divided
Careful identification and preservation of the marginal artery of Drummond are important.
Enteral Division And Anastomosis:
The terminal ileum and the colon (proximal to the planned resection margin) are divided using an endoscopic stapler
The specimen is removed through a specimen retrieval bag via a port site incision
An intracorporeal anastomosis is then constructed using a linear cutting stapler or a circular stapler, depending on the technique (e.g., side-to-side stapled anastomosis or end-to-end stapled anastomosis).
Checking Anastomosis:
The anastomosis is inspected for adequate blood supply, leak, and tension
Air insufflation and methylene blue test can be performed if there is suspicion of a leak, though visual inspection is often sufficient.
Postoperative Care
Pain Management:
Multimodal pain control including intravenous or oral analgesics
Epidural analgesia may be considered in select cases.
Fluid Management:
Intravenous fluid resuscitation
Monitor urine output
Gradual return to oral intake based on bowel function.
Mobilization And Ambulation:
Early mobilization and ambulation are encouraged to prevent deep vein thrombosis and improve pulmonary function.
Monitoring For Complications:
Close monitoring of vital signs, abdominal examination, and laboratory parameters
Watch for signs of ileus, anastomotic leak, or bleeding.
Complications
Early Complications:
Anastomotic leak: a serious complication requiring re-exploration or conservative management
Bleeding from staple lines or mesentery
Ileus
Injury to surrounding structures (ureter, duodenum, small bowel)
Wound infection
Port site hernia.
Late Complications:
Intestinal obstruction due to adhesions
Anastomotic stricture
Incisional hernia
Recurrence of disease (in case of malignancy).
Prevention Strategies:
Meticulous surgical technique, adequate mobilization, tension-free anastomosis, careful hemostasis, judicious use of staplers, proper bowel preparation, early postoperative mobilization, and appropriate antibiotic prophylaxis.
Key Points
Exam Focus:
Indications for laparoscopic vs
open right colectomy
Steps of mobilization and vessel ligation
Techniques of intracorporeal anastomosis (stapled vs
hand-sewn, side-to-side vs
end-to-end)
Management of complications like anastomotic leak.
Clinical Pearls:
Preserve the marginal artery of Drummond to ensure adequate blood supply to the bowel remnant
Ensure sufficient length of both bowel ends for a tension-free anastomosis
Use a specimen retrieval bag to prevent tumor spillage during extraction.
Common Mistakes:
Inadequate mobilization leading to tension on the anastomosis
Injury to adjacent organs during dissection
Failure to identify and ligate critical vessels
Incomplete resection of diseased bowel
Poor stump closure technique leading to leaks.