INTRODUCTION

The operative choices available for right colectomy expanded in May of 2004. With the publication of Clinical Outcomes Surgical Therapy (COST),¹ laparoscopic or minimally invasive surgery (MIS) for the treatment of malignant disease had the evidence needed to ethically offer it to patients with cancer. Since the early 1990s, laparoscopic colectomy for benign and, more importantly, malignant disease suffered from poor adoption. The reasons for this are many, including technical difficulty, poor instrumentation, and concerns over the oncologic impact of laparoscopic surgery. These important factors and concerns crystallized the importance of open right colectomy as the standard by which MIS is judged. Despite the slow growth of MIS, the evidence supplied by trials like COST, Conventional vs. Laparoscopic Assisted Surgery in Colorectal Cancer (CLASICC), and Colon Cancer Laparoscopic or Open Resection (COLOR)^1–3 have allowed for the dramatic increase in the use of this technique.

Right colectomy remains a classic and standard operation that results in outstanding outcomes with relatively few lasting complications. However, even well-known and successful operations have pitfalls. These potential problems can be avoided by careful planning and meticulous technique. The best data to date would suggest that morbidity associated with this procedure is around 20% with 2% to 4% of these occurring intraoperatively.^1,3 Most complications from this operation involve two areas: those common to all operations of the right colon and those important to cancer specifically. The complications common to all operations of the right colon include trocar complications (<1%), bleeding (1%–4%), bowel injury (1%–2%), ureteral injury (1%), wound infection and dehiscence (2%–5%), anastomotic failure (2%–3%), deep vein thrombosis (DVT; 1%–2%), and death (0.5%–5%).^1–3 Complications related to oncologic concern arise mainly from the risk of trocar site implants and the inability to adequately assess the abdomen for metastatic disease. Trocar site recurrences have been reported as high as 24%,⁴ although with the publication of recent randomized trials, the percentage, in the setting of well-trained surgeons, should approach only 1%.¹ This rate of recurrence is similar to that seen in open surgery. Although failure to detect metastatic disease is a risk, with proper preoperative work-up, this risk remains small and can be attested to by the results of the COST, CLASICC, and COLOR trials.^1–3

INDICATIONS

Pathology of the right colon includes a number of benign and malignant conditions.

OPERATIVE STEPS

OPERATIVE PROCEDURE

Positioning and Trocar Placement

All operations begin with positioning. It is our practice to position patients on the table in a supine position. Ankle straps are utilized in both open and laparoscopic techniques to allow for Trendelenburg position. The surgeon stands on the patient’s left and across from the first assistant. Trocar placement can be seen in Figure 23-1.

Figure 23-1 Trocar site placement.

(By permission of Mayo Foundation for Medical Education and Research. All rights reserved.)

Trocar Injuries and Future Wound Site Recurrence

• Consequence

Injuries associated with trocar placement can be life-threatening. Although relatively uncommon, bowel injury and intra-abdominal or abdominal wall bleeding can occur. Likewise, the association of port site recurrence with malignancy secondary to poor technique remains an important aspect of trocar use. The consequences and repair of such injury are self-evident.

Grade 2–5/5 complication

• Prevention

We suggest that the placement of the first trocar be performed in either an open or a modified open technique. The modified open technique of placing the camera through a transparent trocar and passing it under direct vision through the abdominal wall provides a significant advantage in many obese patients or those with a “hostile abdomen.” Once the first trocar is placed and secured, all other trocars are placed under direct vision after appropriate insufflations. Care must be taken when placing any lateral port to avoid the inferior epigastric vessel. If bleeding from the abdominal wall occurs, cautery, suture ligation, or tamponade can be used. Specifically, the use of a small Foley catheter placed through the trocar with subsequent inflation of the balloon and back-pressure on the abdominal wall will stop most bleeding.

Prevention of port site recurrence includes making sure all trocars are securely in place and allowing gas to escape only through the trocars. By preventing gas or irrigation from exiting the abdomen around or through an unprotected trocar site, you will prevent the so-called chimney effect, which has been theorized as the cause for the high rates of recurrence.

Exploration

Exploration is a critical step in the surgical management of both benign and malignant disease. It remains most critical for malignant disease because rates of unsuspected M1 disease range from 1% to 4%.¹ Once the abdomen is entered, a thorough exploration of the abdomen is the first order of business. The liver must be palpated or visualized in the case of laparoscopic surgery, the gallbladder must be assessed for stones, and the surrounding organs of the upper and midabdomen must be examined. The small bowel is run from the ligament of Treitz to the ileocecal valve. In women, the uterus and ovaries must be inspected for any pathology because metastatic disease may occur in up to 3% of patients. One must remember that intraoperative ultrasound can also be used to enhance the hepatic evaluation for metastasis. During exploration, we determine whether adhesions, altered anatomy, or tumor characteristics will require conversion to open surgery. If so, conversion is performed promptly.

• Consequence

Improper exploration will lead to incomplete operation in both malignancy and IBD.

Grade 2–5/5 complication

• Repair

If metastatic disease is identified, surgical resection of isolated metastatic disease or biopsy of unresectable metastatic disease may take place. In the setting of multisite IBD, further surgical intervention such as strictureoplasty, resection, or bypass may be used.

• Prevention

In the setting of malignant disease, preoperative staging with computed tomography (CT), laboratory evaluation, and physical examination will have lower than 1% risk of identifying unsuspected M1 disease, as attested to by COST.¹ Special consideration should be given to locally aggressive tumors. If adjacent organs are involved such as duodenum, small bowel, omentum, or retroperitoneal structures such as the ureter or gonadal vessels, every attempt must be made to complete an en-bloc resection. The surgeon must not violate oncologic principles by attempting to separate intra-abdominal structures from the tumor because this would adversely affect patient outcome. A R0 resection must be the goal of every operation regardless of technique.

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