Right and extended right colectomy: Minimally invasive techniques

INTRODUCTION — Minimally invasive approaches to colon and rectal resection have resulted in earlier tolerance of diet, accelerated return of bowel function, lower analgesic requirements, and shorter length of hospital stay compared with open surgery. Large multicenter randomized trials have also shown comparable disease-free and overall survival between open and laparoscopic approaches for colon cancer [1-3]. (See "Overview of colon resection", section on 'Minimally invasive colon resection' and "Surgical resection of primary colon cancer", section on 'Open versus laparoscopic colectomy'.)

Minimally invasive colorectal resection can be performed with laparoscopic, hand-assisted laparoscopic, single-incision laparoscopic, or robot-assisted techniques. Various minimally invasive techniques differ in instrumentation and setup but not operative principle.

The authors' techniques of minimally invasive right and extended right colectomy will be described here, although recognizing that these are not the only viable techniques that can be used for such procedures. Other topics related to colorectal resection techniques include:

●(See "Right and extended right colectomy: Open technique".)

●(See "Left colectomy: Open technique".)

●(See "Minimally invasive techniques: Left/sigmoid colectomy and proctectomy".)

●(See "Overview of colon resection".)

●(See "Radical resection of rectal cancer".)

●(See "Surgical treatment of rectal cancer".)

●(See "Abdominal perineal resection (APR): Open technique".)

ONCOLOGIC PRINCIPLES — The tenets of colon cancer surgery include removal of the tumor-bearing colon with en bloc resection of an intact mesentery to the origin of the named primary feeding vessel [4,5].

Anatomical resection — The vascular anatomy of the right colon is variable (figure 1) [6]. The ileocolic artery can emerge either posteriorly or anteriorly to the superior mesenteric vein (SMV). The right colic artery, present in approximately 60 percent of people, almost always emerges anteriorly to the SMV. The middle colic artery typically separates into right and left branches. Careful analysis of preoperative computed tomography (CT) scans can delineate this vascular anatomy and significantly facilitate efficient and safe operative dissection.

●For a standard right colectomy for tumors of the cecum or right colon, we ligate the ileocolic artery, right colic artery, and right branch of the middle colic artery. (See 'Laparoscopic/robotic right colectomy' below.)

●For hepatic flexure tumors, we typically perform a standard right colectomy unless there is evidence of nodal disease beyond the right branch of the middle colic artery, in which case we perform an extended right colectomy.

●In an extended right colectomy, we ligate the ileocolic artery, right colic artery, and both branches of the middle colic artery, either separately or by ligating the main middle colic trunk. This is appropriate for many tumors of the transverse colon. We do not routinely ligate the right gastroepiploic artery unless there is evidence of nodal disease along its distribution. The venous ligation is similar to that in the standard right colectomy: the ileocolic vein is ligated as it enters the SMV, and the superior right colic vein is ligated as it drains into the gastrocolic trunk of Henle. The middle colic vein is also ligated in an extended right colectomy. (See 'Laparoscopic/robotic extended right colectomy' below.)

Lymphadenectomy — Anatomical resections include regional mesenteric lymph nodes along the course of major mesenteric vessels and along the vascular arcades (intermediate and central nodes), as well as those adjacent to the colon along its mesocolic border (pericolonic nodes). The Japanese Society for Cancer of the Colon and Rectum (JSCCR) would classify this as a D2 dissection [7].

The concept of complete mesocolic excision (CME), analogous to that of complete mesorectal excision, attempts to further standardize colectomy to ensure anatomic resection of the mesentery with intact visceral peritoneum, removal of tumor-free bowel proximal and distal to the tumor, and central vascular ligation (CVL) [8].

However, the definition of CVL and extent of lymphadenectomy have not been consistent. As it was originally described, CVL included performing a Kocher maneuver of the duodenum and an extensive lymphadenectomy around the SMV. Subsequently, CVL has been defined as high ligation of the feeding vessels and an extended lymphadenectomy encompassing the tissue overlying the SMV and superior mesenteric artery [9], or "root vessels," analogous to a D3 lymphadenectomy in the JSCCR classification [7].

There remains controversy if an extended lymphadenectomy should be performed in all patients. The JSCCR recommends D3 dissection for T3 and T4 tumors [7], whereas the American Society of Colon and Rectal Surgeons (ASCRS) recommends extended lymphadenectomy for patients with bulky adenopathy at the root of the feeding vessels [5]. Since determining the extent of tumor invasion into the colon wall and predicting locoregional lymph node involvement is limited by current imaging modalities, our practice is to perform minimally invasive CME with CVL (including D3 dissection) for most colon cancers. For malignant polyps, CME with ligation of all vascular pedicles alone (D2) is our preferred approach.

Current evidence suggests that CME with CVL may lead to improved oncologic outcomes for patients with colon cancer, though data from several prospective trials are eagerly awaited [10-13].

Although early studies demonstrated an increased risk of morbidity after CME with CVL, subsequent publications suggest that the procedure can be accomplished with comparable postoperative morbidity [12,14-17]. The short-term outcomes of the prospective, multicenter, randomized RELARC trial demonstrated a higher risk of high-grade complications with standard lymphadenectomy compared with D3 lymphadenectomy [13]. Vascular injuries were more frequent in D3 dissection but still uncommon (3 versus 1 percent). Interestingly, there were no isolated central lymph node metastases in the D3 group.

Lymph node dissection in colon cancer surgery is discussed in detailed elsewhere. (See "Surgical resection of primary colon cancer", section on 'Regional lymphadenectomy'.)

LAPAROSCOPIC/ROBOTIC RIGHT COLECTOMY

Patient positioning — The patient is placed on the operating room table in supine position with both arms padded and in a tucked position. At our institution, we use a steep Trendelenburg positioner table pad and a chest strap to secure the patient to the table (figure 2). For a robotic approach, the da Vinci Xi system is positioned on the right side of the patient, perpendicular to the operating room table.

Trocar placement — We typically use a Veress needle inserted in the left upper quadrant two fingerbreadths below the costal margin, in the midclavicular line, to gain access to the abdomen. The abdomen is insufflated through the Veress needle to 12 to 15 mmHg. Other techniques can also be used to gain initial access to the peritoneum. (See "Abdominal access techniques used in laparoscopic surgery".)

Robotic three arm — Our preference is to perform both right and extended right colectomies with an intracorporeal anastomosis, using a Pfannenstiel incision as the extraction site. With this approach, we do not place any trocars in the supraumbilical midline. After insufflation, we first place our camera port (8 mm robotic trocar) just above the umbilicus, but to the left of midline by 1 cm (arm 2) (figure 3). If an extracorporeal anastomosis is planned, this camera port can be placed in the supraumbilical midline, and this incision will be extended for the anastomosis and specimen extraction.

The remaining trocars are placed under direct visualization. We standardly use an 8 mm trocar in the left lower quadrant, at the halfway point of an imaginary line connecting the left anterior superior iliac spine and the umbilicus (arm 1). Care is taken not to injure the inferior epigastric artery during placement of this trocar. A second 8 mm trocar is placed in the left upper quadrant, two fingerbreadths below the costal margin (arm 4). This port is upsized to a 12 mm trocar for stapling in intracorporeal cases. Finally, the 5 mm AirSeal trocar is placed midway between the left-upper-quadrant and left-lower-quadrant ports, just lateral to the left-upper-quadrant trocar. In this configuration, only three of the robotic arms are docked for the entirety of the case. To decrease the possibility of external and internal collisions, we follow the recommendation that trocars be 6 to 8 cm apart when using the Xi system.

Robotic four arm — An alternative approach, in which all four robotic arms are docked, includes the placement of an additional 8 mm robotic trocar in the right lower quadrant, at McBurney's point (figure 4). This can be advantageous whenever the cecum/right colon needs to be retracted in a static fashion to facilitate exposure. Specifically, we use this approach when performing a superior mesenteric vein (SMV)-first approach. (See 'SMV-first approach (with video)' below.)

Laparoscopic — For a laparoscopic approach, we prefer to use a 5 mm 30 degree camera. Similarly to the robotic approach, we place the camera port just off the midline when planning for an intracorporeal anastomosis with a Pfannenstiel extraction site. A 5 mm trocar is placed in the left lower quadrant, and a 12 mm trocar is placed in the left upper quadrant for stapling. Alternatively, a 5 mm trocar can be placed in the left upper quadrant in the case of a planned extracorporeal anastomosis. We place a third 5 mm trocar in the suprapubic midline, two fingerbreadths above the pubic tubercle as a third working port, regardless of our planned extraction site (figure 5).

Setup — We begin with a thorough laparoscopic inspection of the abdomen for evidence of metastatic disease and to confirm the location of the tumor. Next, we position the bed at 12 degrees of Trendelenburg with the patient in 12 degrees right side up/left lateral decubitus position. Before docking of the robot, the omentum is retracted cephalad to the transverse colon and the small bowel is positioned so that the right mesocolon, ileocolic pedicle, and duodenum can be more easily visualized. Dense adhesions may be lysed laparoscopically before docking of the robot.

After docking the robot, we begin the operation with a fenestrated bipolar or comparable grasper through the left-lower-quadrant port and a monopolar scissor in the left-upper-quadrant port. In laparoscopic cases, we begin with an energy device such as the laparoscopic LigaSure or Harmonic scalpel through the left-lower-quadrant port and a bowel grasper through the suprapubic port.

Initial approach — We standardly perform the dissection using a medial-to-lateral approach. A lateral or inferior approach can also be used depending on the anatomy. The vascular dissection may begin at the ileocolic pedicle or over the SMV:

Ileocolic approach (with video) — The mesocolon is retracted off the retroperitoneal structures so that the ileocolic pedicle can be visualized. The peritoneum under the vessels is scored, and a combination of blunt and sharp dissection is used to enter the mesocolic plane (movie 1). This dissection is continued laterally until reaching the abdominal sidewall. The dissection then proceeds medially over the duodenum and pancreas, which should be easily distinguishable by its distinct color and texture compared with the mesocolon.

SMV-first approach (with video) — For this approach, we prefer the alternative trocar configuration described previously, where an additional 8 mm robotic trocar is placed in the right lower quadrant (see 'Robotic four arm' above). A grasper is used to put the cecum on tension, so that the ileocolic pedicle can be visualized. The assistant then retracts the transverse colon mesentery cephalad and anteriorly so that the middle colic vessels can be seen. The location of the SMV can be visualized after this exposure. Scoring of the peritoneum begins just distal to the border of the ileocolic vein and continues in a cephalad orientation. As before, the soft tissue overlying the SMV, and including the central nodes, is carefully dissected, and the vasculature of the right colon is exposed (movie 2). Medial-to-lateral dissection follows, starting at the ileocolic pedicle. On completion of this dissection, the vascular structures are ligated, followed by the transverse colon mesentery.

Inferior approach — An inferior approach can also be used at the beginning of the operation if the anatomy is not easily visualized, as in the case of significant intra-abdominal adiposity or dense adhesions. The retrocolic plane is developed as far medially as possible until the vascular anatomy is well defined. The remainder of the dissection is then performed. (See 'Ileocolic approach (with video)' above.)

Vascular dissection — After completing the medial-to-lateral dissection, we return to the ileocolic pedicle to begin vascular dissection. Whether a D2 or D3 dissection is performed depends upon the tumor stage. (See 'Lymphadenectomy' above.)

D2 vascular dissection (with video) — For a D2 lymphadenectomy, the bare area in the right colon mesentery overlying the duodenum is incised so that the ileocolic pedicle can be isolated for ligation (movie 3). Dissection is then continued along the mesentery until encountering the right branch of the middle colic.

D3 vascular dissection (with video) — For a D3 lymphadenectomy, dissection is carried from the inferior border of the ileocolic pedicle cephalad and slightly medial over the SMV so that the lymph nodes overlying this main vessel are included in the specimen. By taking the soft tissue over the SMV, we sequentially expose (from caudad to cephalad) the roots of the ileocolic vein, ileocolic artery, right colic artery, and middle colic artery (movie 4). Additional careful dissection in the transverse mesentery can delineate the right and left branches of the middle colic artery.

We then continue the dissection cephalad along the SMV until the trunk of Henle is visualized. The trunk of Henle can be easily recognized as it drains into the lateral surface of the SMV. Care must be taken to avoid bleeding here, which can be due to excessive traction or nonvisualization of the superior right colic vein as it enters obliquely into the trunk of Henle.

Multiple modalities can be used to ligate the vascular structures of the right colon. We typically use the vessel sealer, although staplers, clips, and sutures may be appropriate in select situations, as in the case of heavily calcified vessels. After all vascular structures are ligated, we complete our resection of the transverse mesocolon with the vessel sealer to a planned point of resection.

Omentum and hepatic flexure — With the vascular dissection complete, the omentum is dissected off the transverse mesocolon and the lesser sac is entered. For hepatic flexure cancers, we take the omentum of the proximal transverse colon en bloc with the specimen but leave the gastroepiploic arch intact. The dissection is continued laterally to complete the mobilization of the hepatic flexure and right colon down to the terminal ileum.

Terminal ileum — In order to mobilize the terminal ileum for creation of a tension-free anastomosis with the transverse colon, the ileal mesentery must be dissected off the retroperitoneum. To do this, we retract the terminal ileum cephalad and develop this plane with sharp and blunt dissection.

Colon transection and anastomosis (with video) — For an intracorporeal anastomosis, the bowel is transected proximally and distally using the da Vinci EndoWrist 60 mm stapler or a laparoscopic Endo GIA 60 mm stapler. The terminal ileum is positioned along the transverse colon in an isoperistaltic fashion. A stay suture can be placed to maintain this alignment, although we do not find this helpful.

A colotomy is made approximately 7 cm from the transected colon edge (far enough to accommodate the full length of the stapler) on the antimesenteric border. An enterotomy is made at the antimesenteric border of the small bowel. The stapler is introduced into the lumens, and the anastomosis is created. The common enterotomy is closed in one or two layers and a crotch stitch is placed (movie 5). The specimen is then extracted through a Pfannenstiel incision.

Stapling for an intracorporeal anastomosis can be accomplished from different sites, including from a suprapubic port, which is then converted to a Pfannenstiel incision for specimen extraction. However, we find that the left-upper-quadrant trocar is the best situated for engaging the less mobile transverse colon and the mobile small bowel. Placing this port in a lateral location can allow for easy entry of the stapler into a colotomy in the mid- to distal transverse colon. In these cases, we still use the Pfannenstiel incision to extract the specimen.

For an extracorporeal anastomosis, we make a 4 to 5 cm incision in the midline, above the umbilicus. A wound protector is placed, the bowel is exteriorized, and a stapled or handsewn anastomosis is created.

LAPAROSCOPIC/ROBOTIC EXTENDED RIGHT COLECTOMY

Initial approach — The operative approach for an extended right colectomy follows that of a standard right colectomy. Dissection usually begin at the ileocolic pedicle or over the superior mesenteric vein (SMV). Unlike in the standard right colectomy, the peritoneum is scored overlying the middle colic vessels and extending toward the splenic flexure. (See 'Initial approach' above.)

Vascular dissection — The vascular dissection proceeds as in right colectomy, except that the middle colic branches and/or main trunk must be meticulously dissected and adequately visualized before ligation. To do this, we first complete the vascular dissection to the right of the middle colic vessels (see 'Vascular dissection' above). We then proceed to enter the lesser sac above the pancreas to the left of the ligament of Treitz and work medially until the left branch of the middle colic is encountered.

The vascular dissection for an extended right colectomy can be technically challenging. Care must be taken to avoid injuring the first jejunal vein, which can be encountered if the dissection of the middle colic vessels begins too close to the root of the mesentery. In addition, a thick mesocolon can make identification of the middle colic vessels challenging. By retracting the mobilized transverse colon inferiorly, the vessels can be more easily visualized from the posterior aspect of the mesocolon.

Finally, an additional trocar can be placed in the right lower quadrant to assist in a challenging vascular dissection. Operating from the left and right lower quadrant trocars with the camera in the midline allows for a more direct approach to the middle colic vessels.

Colon transection and anastomosis — Transection in an extended right colectomy is at the distal transverse colon. For this reason, the left-upper-quadrant trocar must be placed laterally enough to permit transection of the colon and anastomosis. If this is not possible, the anastomosis can be completed with an additional port placed in an optimal location and a laparoscopic Endo GIA stapler. (See 'Colon transection and anastomosis (with video)' above.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Colorectal surgery for cancer" and "Society guideline links: Laparoscopic and robotic surgery".)

SUMMARY AND RECOMMENDATIONS

●Minimally invasive techniques for colon resection have been shown to be feasible and to result in superior early postoperative outcomes and comparable oncologic outcomes to that of open surgery. (See "Overview of colon resection", section on 'Minimally invasive colon resection' and "Surgical resection of primary colon cancer", section on 'Open versus laparoscopic colectomy' and 'Introduction' above.)

●The vascular anatomy of the right colon is variable (figure 1). Careful analysis of preoperative imaging can help delineate this vascular anatomy and facilitate efficient and safe operative dissection. (See 'Oncologic principles' above.)

●For oncologic resections, we ligate the ileocolic artery, right colic artery, and right branch of the middle colic artery for a standard right colectomy. We ligate the ileocolic artery, right colic artery, and both branches of the middle colic artery, either separately or by ligating the main middle colic trunk for an extended right colectomy. (See 'Anatomical resection' above.)

●The authors' techniques for minimally invasive right colectomy and extended right colectomy are described and illustrated but should not be regarded as the only viable techniques for these procedures. (See 'Laparoscopic/robotic right colectomy' above and 'Laparoscopic/robotic extended right colectomy' above.)