Right Colectomy Flashcards
Greater omentum - how does this come into play during surgery
it will be flipped over the stomach so that it does not interfere w/ the procedure. A portion may be mobilized off the transverse colon during the procedure
How is the grastrocolic ligament used during a procedure
Dr. Gamagami will transect the gastrocolic ligament and omentum to mobilize the transverse colon
What structure connects the stomach and the transverse colon and fold like an apron
The omentum
Approx. how long is the large intestines?
~ 5-6 feet (1.5 meters)
What is the function of the large intestines?
absorb water and vitamins (K), and store waste.
What are the 5 sections of the large intestines?
ascending colon, transverse colon, descending colon, sigmoid colon, and rectum
What is the cecum>
A cul de sac distal to the ileocecal valve
Where is the appendix located?
At the junction of the ileum and cecum
What is the bend of the colon on the right? Below the liver called?
Hepatic flexure
What is the name for a longitudinal band of muscles that run along the length of the colon?
Teniae coli
What is the mechanism that helps the waste material move ahead along the intestines?
Haustra
How does the haustra function?
When the teniae coli contract, the large intestine is compressed, forming pockets.
What are epiploic appendages? How does the surgeon manipulate them during surgery?
Fat filled pouches which extend from the surface of the large intestine. The surgeon can use graspers to hold the epiploic appendages in order to manipulate the bowel, thus avoiding causing trauma
What does the duodenum surround?
The head of the pancreas
What is the primary function of the small intestines?
complete digestion and absorb nutrients from food.
How is the duodenum used during Dr. Gamagami’s procedure?
As a landmark to make sure he has entered the retroperitoneal space where he intends to.
What are the 4 parts of the duodenum?
Superior, descending, horizontal, ascending
How is the VSE used during the procedure in regards to the duodenum?
Blunt dissection so as not to damage the duodenum
About how long is the jejunum?
100cm
Where does the ileum connect to?
the cecum
Where does Dr. G. perform the proximal transection?
The distal portion of the ileum
What is the mesentery
A double fold in the peritoneum
What is the main function of the mesentery?
attaches intestines and orgrans to post. abd. wall. Stores fat. Contains lymph nodes, vessels, and nerves. It also contracts and relaxes to move waste
How long is the mesenteric root? Where does it extend?
15cm Long and 20cm wide. It extends from the duodenojejunal flexure to the ileocecal junction
What is the line of Toldt
Where the ascending colon attaches laterally to the abd. wall at the left colic gutter.
Why is the line of toldt important for this procedure?
It will need to be taken down to free the colon laterally from the body wall.
What other ligament will need to be taken down to fully mobilize the colon?
The hepatocolic ligament
Where does the SMA (superior mesenteric artery) originate? Where does it run between?
the aorta, runs between the layers of the mesentery to supply blood to the lower part of the duodenum, jejunum, ileum, cecum, ascending color, and two thirds of transverse colon.
What does the SMA supply blood to?
the ileum
What does the Ileocolic artery vascularize
Ileum, the cecum, and a portion of the ascending colon
What does the right colic artery perfuse. What % of patients is it present in?
The ascending colon - present in about 30% of patients
What does the middle colic artery perfuse?
transverse colon - branches into L&R
What determines which branch or branches will be ligated during a colectomy?
The location of the tumor
What is the marginal artery?
The loop where two branches meet
How can you help in identifying the Ilecolic pedicle?
First identifying the ileocecal junction and then grasping and retracting the ileocecal valve anteriorly, superiorly, and laterally.
What anatomy is retroperitoneal
Right kidney, duodenum, pancreas, ureter, gonadal vessels
What does retroperitoneal mean?
behind the peritoneum - between the mesentery anteriorly and body wall posteriorly
What is Gerota’s or renal fascia?
Thick fibrous connective tissue that encapsulates the kidneys and separates them from surrounding structures
Why is gerota’s fascia important for the procedure?
The ascending colon mesentery will have to be dissected away.
What structure would still be vascularized if the superior mesenteric artery was ligated?
Splenic flexure
Two types of inflammatory bowel disease’s
Crohn’s & Ulcerative Colitis
Symptoms of Crohn’s -
Diarrhea and abdominal pain, stricture, fistula - frequently requires surgery
Symptoms of Ulcerative colitis
diarrhea and abd. Pain - rectal bleeding - can require a proctocolectomy with permanent stoma
Treatment for IBD?
Corticosteroids, immunosuppressants - often surgery is required
With both Crohn’s and ulcerative colitis, what are patients at a higher risk of developing?
Adenocarcinoma - more than 95% of colorectal cancers
diagnosis for colorectal cancer
Routine colonscopy for patients starting at age 45
Early detection
Removal of precancerous polyps
surgical treatment for colorectal cancer - 4
removal of section of bowel containing primary lesion
removal of lymph nodes within mesentery
reconstruction of healthy bowel
permanent colostomy is performed if reconstruction is not possible
How long can precancerous polyps take to progress into cancer?
10-15 years
Colo. Cancer Stage 0
Abnormal cells w/in the mucosa. May be treated w/local excision
Colo. Cancer Stage 1
Cancer present in submucosa
Colo. Cancer stage 2
Cancer present in muscle wall or beyond
Colo. Cancer Stage 3
Cancer present in muscle wall or beyond
lymph node invasion
Colo. Cancer Stage 4
Distant spread in lymph nodes or organs
colorectal surgical principles - 2 ways
Remove malignant tissue - negative margins (proximal & distal end) remove lymph nodes
Prevent anastomotic leak - adequate blood supply, tension free anastomosis, ensure closure is secure
Patient criteria for early cases
- Good performance status (ASA l-ll)
- Non-obese patients (BMI <30)
- AGe 18-80
- Suitable for laparoscopic
- small non-bulky tumors that have not metastasized
- Uncomplicated case
- no previous intra-abd. or pelvic surgery
R. Cole. Patient Positioning
- Supine
- Iliac crest at table break
- flex table at 15*
- Tuck arms at patient side
- secure patient to table
- sterilely prep and drape patient
What is your target anatomy for a R. colectomy
Hepatic flexure
How do we measure the line Where the ports will be places?
left anterior axillary line, ~ 1-2 cm inferior to the sub-costal margin. Make a line from this point to the superior border of the pubic symphysis at the midline. = Should be 15-20cm from Hepatic flexure
How do I gain access to the abd.
on the L anterior axillary line under optical guidance using a laparoscope / dV handheld camera through 5mm trocar
Which arm will have the stapler? Which port will the specimen be extracted?
Arm 4, Port 1
What should be done before docking?
laparoscopic adhesiolysis - sweep the omentum into the right-upper quadrant. Move bowel to the lower left quadrant
What is the cart approach and patient anatomy?
Lower abd. and patient right
What instruments are used in a R. Colectomy?
Cadiere Forceps
Endoscope
Permanent cautery hook
Tip-up fenestrated grasper
Vessel sealer extend
Large Suture cut needle driver
Sureform 45
Fenestrated bipolar
MCS
M-L Clip applier
Procedure steps 1-5
- Identification of the ileocolic pedicle
- Identification of the duodenum
- Medial to lateral mobilization
- Division of ileocolic, right colic, right branch of middle colic pedicles
- Division of the small bowel mesentery
Procedure steps 6-11
- Division of the terminal ileum
- mobilization of the cecum and ascending colon to the hepatic flexure
- mobilization of the hepatic flexure
- Division of the transverse colon and transverse colon mesocolon
- Ileocolic anastomosis
- Specimen extraction
How do surgeons identify the ilocolic pedicle?
- Sweep the greater omentum above the transverse colon
- Sweep sm. bowel into the lower L quadrant. to expose ileocecal valve
- Grasp and retract the ileocecal valve anteriorly, superiorly, and laterally
How do you identify the duodenum in a R. colectomy?
- Retract the mesocolon (mesentery of the colon) of the right colon anteriorly
- Use cautery to enter the retroperitoneal space posterior to the ilecolic pedicle
- The duodenum should be visible almost immediately, if not, you entered too high and will need to dissect toward the root of the mesentery
Explain what happens during the medial to lateral dissection
- Continue to mobilize with the VSE
Retract mesocolon anteriorly and superiorly. Use VSE to blunt dissect to develop the avascular plane along the outer curvature of the anterior horizontal portion of the duodenum
Bluntly dissect laterally toward the hepatic flexure
Continue dissection until the white line of toldt is reached.
Who is your most favorite ever?
Bubbies is.
What vessels are taken during a R. cole.
Ileocolic pedicle & right branch of middle colic
What part of bowel is removed during a R. cole
Distal-most ileum, cecum, ascending colon, hepatic flexure and first portion of transverse colon
Why do you need to perform a R. Cole
Unresectable polyps, Crohn’s disease, cancer, cecal volvulus
What are the branches and artery that Dr. Gamagami transects
Ileocolic pedicle - from the superior mesenteric vasculatrue using VSE
Right colic pedicle - done near its origin
Right branch of middle colic pedicle - if needed, best to be done after division of the transverse colon
How does he divide the small vowel mesentery?
Using the VSE (in arm 3) starting at the origin of the divided ileocolic pedicle and he works toward a point 7-10 cm proximal to the ileocecal valve.
What is used to divide the terminal ileum?
SureForm 45 stapler with a blue reload. This is roughly 7-10cm proximally from the ileocecal valve
What happens is step 7?
Mobilization of the cecum and ascending colon to the hepatic flexure.
How does he mobilize the cecum and ascending colon to the hepatic flexure
retracts the inferior edge of the cecum and vermiform appendix superiorly and anteriorly and cauterizes to release the cecum form its lateral and posterior attachments, working superiorly
What is identified during the mobilization of the cecum and ascending colon to the hepatic flexure?
R. Ureter and gonadal vessels
What is the main goal of the dissection
to have the medial and lateral dissection meet and the bowel fully mobilized from the mesentery and retroperitoneal
What happens after the mobilization of the hepatic flexure?
Mobilization of the hepatic flexure
How does he mobilize the hepatic flexure
mark a point 5cm medial to the GB. This point will mark the location of the transverse colon transection and the border of the partial omentectomy on the specimen side.
How is the division of the transverse colon and transverse mesocolon performed?
The large clip applier is used. A penrose drain is used to identify the transverse colon location.
What happens during the ileocolic anastomosis
The specimen is moved to the upper abd. to allow for easy access to the ileum and transverse colon.
Ensure the transverse colon is not twisted
What are the two ways to perform intracorporeal anastomosis
Isoperistaltic or antiperistaltic
Isoperistaltic
Same peristalsis: the peristalisis of the colon and the small bowel are in parallel
Antiperistaltic
Opposite peristalisis; the peristalisis of the colon and the small bowel are not in parallel
How would an extracorporeal anastomosis be performed>
- Extend incision at a desired port
- insert wound retractor
- externalize mobilized ileum and colon
- Mark points of transcection on ileum and colon
- use linear cutter stapler to divide ileum and colon
- create enterotomies
- perform side by side anastomosis utilizing stapler
- close enterotomies using suture
- Reinsufflate and inspect abdomen
- check for bleeding
- check to make sure bowel is not twisted
- reorient small boel and omentum as necessary
What ligaments may be taken down in a Sigmoidectomy
Splenocolic
Phreniocolic
gastrocolic
What does the Left colic artery perfuse
The splenic flexure and the descending colon
Inferior mesenteric vein
drains blood from the large intestines and joins the splenic vein
Where do the superior mesenteric vein, inferior mesenteric vein, and splenic vein drain into?
The hepatic portal vein
What is diverticular disease
Weakening of the colonic wall which leads to the formation of small sacs or pockets
What are the two types of diverticular disease
Diverticulosis - generally symptomless
diverticulitis - inflammation of the bowel
What factors can contribute to diverticulitis
Diet
age
exercise
smoking
obesity
medication
symptoms of diverticulitis
diarrhea or constipation
tenderness or painful abdominal cramps
fever with our without chills
treatment for diverticulitis
lifestyle changes
medications
bowel resection
Suggested patient selection criteria for early cases
Good performance status
Non-obese patients
Age 18-80
Must be a suitable candidate for a similar laparoscopic surgery
Patient with small non-bulky tumor
un-complicated diverticulitis
no previous intra-abdominal or pelvic surgery
Port placement - how do you find what line to place ports - sig.
mark a line from left anterior iliac spice through the umbilicus. continue the line 3-5 cm past the umbilicus. Make a second perp. line to and intersecting the line through the umbilicus. Ports will be placed on the second line
Procedure steps - sigmoidectomy
- Lateral-to-medial colon mobilization
- Splenic flexure mobilization
- preparation of the distal specimen transection location
- Inferior mesenteric artery division
- prep. of the proximal specimen transection location
- distal transection of the specimen
- prox. transection of the specimen
- end to end anastomosis
- closure
How do you perform lateral to medial dissection for sig
adhesiolysis to access colon
Begin dissecting line of toldt at the level of sacral promontory - moving superiorly
How to mobilize the splenic flexure
you need to increase lateral reach (adjust flex joint to the max)
Make sure you dont apply excessive tension on the spleen
