Chapter 48: Right Hemicolectomy

INDICATIONS

Laparoscopic right hemicolectomy is appropriate for pathology in the cecum, ascending colon, or hepatic flexure.

PREOPERATIVE EVALUATION

During laparoscopy, loss of tactile sensation makes it harder to find small lesions. Before a laparoscopic procedure, an endoscopist must tattoo the colon just distal to the lesion, so the surgeon can be confident that the lesion will be within the specimen. Further, the colon should be tattooed in each quadrant circumferentially, so that the tattoo may be visualized before the ascending colon mobilization is performed, even if the polyp or small cancer is located in the retroperitoneal portion of the colon.

For malignancies, conventional computed tomography of the abdomen and pelvis with oral and IV contrast is helpful. Although laparoscopy is sensitive for very small surface liver lesions, one cannot effectively palpate the liver.

In most situations, a mechanical and antibiotic bowel preparation is administered preoperatively unless the lesion to be removed is near obstructing.

ANESTHESIA

Thromboembolism prophylaxis, either pharmacologic or mechanical, is started prior to induction of general anesthesia. Prophylactic antibiotics that cover intestinal flora are given within 1 hour prior to skin incision. After induction of general anesthesia, an orogastric tube is placed and urinary catheter are placed.

POSITIONING

A beanbag under the patient to facilitate positioning. The patient should be placed into a low lithotomy position with Allen stirrups. Each ankle, knee, and opposite shoulder should be aligned. No pressure should be placed on the peroneal nerves or calves. The angle between the thigh and the plane of the bed should be between 0 and 10 degrees. Any more flexion will limit range of motion for the instruments. Any more extension may lead to an anterior dislocation of the hip.

Each elbow (ulnar nerve) is covered with a gel pad, and both arms are carefully adducted. Care must be taken to avoid compromising or kinking the intravenous lines. The beanbag is carefully cradled above both shoulders and around the arms to prevent the patient from falling while in extreme positioning. A gel pad covered by a towel is placed on the upper chest. Tape is placed under the bed, over each shoulder, and across the padded chest to the other side of the bed. Prior to draping, security of the patient on the table should be confirmed using maximal Trendelenburg and left-side-down positioning.

After placement of the trocars, the surgeon and camera driver will both be on the patient’s left. The camera driver will be near the patient’s left shoulder. Hence, one monitor should be placed at the feet, and another one should be placed at the patient’s right (Figure 1).

INCISION AND EXPOSURE