Transverse Colectomy: Hand-Assisted Laparoscopic Surgery Technique
Daniel Albo
DEFINITION
Transverse colectomy refers to removal of the portion of the colon between the hepatic and the splenic flexures. The transverse colon derives its blood supply primarily from the middle colic vessels. In addition, the transverse colon receives collateral blood flow from the left and right marginal arcades (marginal artery of Drummond and arch of Riolan, respectively).
Hand-assisted laparoscopic surgery (HALS) is a minimally invasive surgical approach that uses conventional laparoscopic-assisted (LA) surgery techniques but with the addition of a hand-assist device that allows for the introduction of one of the surgeon’s hands into the surgical field. The hand-assist device is placed at the projected specimen extraction site. HALS in colorectal surgery retains all of the same advantages of conventional LA surgery over open surgery, including less pain, faster recovery, lower incidence of wound complications, and reduction of cardiopulmonary complications, especially in the obese and in the elderly.
HALS has significant advantages over conventional LA colorectal surgery, including
Reintroduces tactile feedback into the field
Shorter learning curves; easier to teach
Shorter operative times and lower conversion to open rates
Allows for insertion of multiple ports through the handassist device
Allows for the introduction of laparotomy pads into the field (helps keeping the small bowel and omentum out of the way, particularly in the obese)
Higher usage rates of minimally invasive surgery
DIFFERENTIAL DIAGNOSIS
Focal inflammatory processes, localized trauma, or local perforation
Colon cancer located in the midtransverse colon. Cancers located at the flexures may necessitate extended right or left hemicolectomies in order to ensure adequate lymphadenectomy.
Other tumors locally extending into the transverse colon (i.e., gastric, pancreatic, adrenal tumors, sarcomas) may necessitate en bloc transverse colectomy when resecting the primary tumor to achieve negative margins.
PATIENT HISTORY AND PHYSICAL FINDINGS
Patients with colon cancer generally present with occult bleeding and anemia. Patients may also present with highgrade obstructing symptoms (crampy abdominal pain and constipation). More advance tumors may present with a complete large bowel obstruction. If these patients have a competent ileocecal valve, they develop a closed loop large bowel obstruction and present with severe right lower quadrant abdominal pain and abdominal distention secondary to a massive colonic dilation proximal to the obstructing lesion. These patients should be taken to the operating room emergently. Unopposed, this will ultimately cause an ischemic perforation of the cecum leading to a catastrophic fecaloid peritonitis and potential oncologic contamination of the abdominal cavity leading to carcinomatosis.
A detailed personal and family history of colorectal cancer, polyps, and/or other malignancies should be elicited. Physical examination should include a routine abdominal examination, noting any previous incisions.
IMAGING AND OTHER DIAGNOSTIC STUDIES
A full colonoscopy with documentation of all polyps should be performed. Lesions that are unresectable endoscopically and/or are suspicious for cancer should be tattooed to facilitate localization during surgery. If there is any concern for involvement of adjacent organs, such as the stomach, an esophagogastroscopy should also be performed.
A computed tomography (CT) scan of the chest, abdomen, and pelvis evaluates for potential metastases. In patients with a large bowel obstruction, the CT scan shows dilation of the right colon and cecum, collapse of the distal colon, and a paucity of fluid and gas in the small bowel (FIG 1).
A preoperative carcinoembryonic antigen level is obtained.
 FIG 1 • CT scan shows a large obstructing colon cancer in the transverse colon (A) with dilation of the cecum (B) and a paucity of fluid and gas in the small bowel (C). |
SURGICAL MANAGEMENT
Preoperative Preparation
Clinical trials have shown no need for mechanical bowel preparation.
Intravenous cefoxitin is administered within 1 hour of skin incision.
Use hair clippers if needed and chlorhexidine gluconate skin preparation.
Preoperative time-out and briefing is performed.
Equipment and Instrumentation
5-mm camera with high-resolution monitors
5-mm clear ports with balloon tips. They hold ports in the abdomen and minimize their intraabdominal profile during surgery.
Atraumatic graspers and laparoscopic endoscopic scissors
A blunt tip, 5-mm energy device
60-mm linear reticulating laparoscopic staplers with vascular and tan loads
We use the GelPort hand-assist device due to its versatility and ease of use. This device allows for the introduction/removal of the hand without losing pneumoperitoneum.
Patient Positioning and Surgical Team Setup
This is the single most critical determinant of success in laparoscopic colorectal surgery (FIG 2).
Place the patient on a supine position, with the arms tucked and padded (to avoid nerve/tendon injuries). The patient is taped over a towel across the chest without compromising chest expansion.
The surgeon starts at the patient’s right lower side with the scrub nurse to the surgeon’s right side. The assistant stands at the surgeon’s left side.
Align the surgeon, the ports, the targets, and the monitors in straight line. Place monitors in front of the surgeon and at eye level to prevent lower neck stress injuries.
Avoid unnecessary restrictions to potential team movement around the table. All energy device cables exit by the patient’s upper left side. All laparoscopic (gas, light cord, and camera) elements exit by the patient’s upper right side.
 FIG 2 • Patient and team setup. |
TECHNIQUES
PORT PLACEMENT AND OPERATIVE FIELD SETUP
Insert a GelPort through a 5- to 6-cm epigastric incision. This incision will be also used for specimen extraction, transection, and anastomosis. Placement in the epigastric area greatly facilitates dissection of the middle colic vessels through a supramesocolic approach (see step 7).
Insert three 5-mm working ports in the right upper, right lower, and left upper quadrants. Insert a 5-mm camera port above the umbilicus. Triangulate the ports so the camera port is at the apex of the triangle. This avoids conflict between the instruments and prevents disorientation (“working on a mirror”).
OPERATIVE STEPS
Our HALS transverse colectomy operation is highly standardized and it consists of nine steps:
Transection of the inferior mesenteric vein (IMV)
Medial to lateral dissection of the descending mesocolon
Transection of the left colic artery
Mobilization of the sigmoid off the pelvic inlet
Mobilization of the descending colon
Mobilization of the splenic flexure
Mobilization of the right colon
Transection of the middle colic vessels (supramesocolic approach)
Extracorporeal transection and anastomosis
Step 1. Transection of the Inferior Mesenteric Vein
This is the critical “point of entry” in this operation. At the level of the ligament of Treitz, the IMV is easy to visualize and is far from critical structures that can be injured during its dissection (no iliac vessels or left
ureter nearby). This will be the only time when a true virgin tissue plane is entered. Every step will setup the following ones, opening the tissue planes sequentially.
The patient is placed on a steep Trendelenburg position with the left side up. Using the right hand, move the small bowel into the right upper quadrant (RUQ) and the transverse colon and omentum into the upper abdomen. If necessary, place a laparotomy pad to hold the bowel out of the field of view especially in obese patients. This pad can also be used to dry up the field and to clean the scope tip intracorporeally. Make sure that the circulating nurse notes the laparotomy pad in the abdomen on the white board.
Identify the critical anatomy: IMV, ligament of Treitz, and left colic artery (FIG 3).
If there are attachments between the duodenum/root of mesentery and the mesocolon, transect them with laparoscopic scissors. This will allow for adequate exposure of midline structures.
Pick up the IMV with the left hand. Dissect under the IMV and in front of Gerota’s fascia with endoscopic scissors, starting at the level of the ligament of Treitz and proceeding toward the inferior mesenteric artery (IMA). The assistant provides upward traction with a grasper.
Transect the IMV cephalad of the left colic artery (which moves away from the IMV and toward the splenic flexure of the colon) with the 5-mm energy device (FIG 4), thus preserving intact the left-sided marginal arterial arcade and maintaining the blood supply to the descending colon segment.
 FIG 3 • Step 1: Key anatomy. Ligament of Treitz (A). IMV (B). Left colic artery (C) as it separates from the IMV and goes toward the splenic flexure of the colon (D). |
Step 2. Medial to Lateral Dissection of the Descending Mesocolon
The surgeon’s hand and the assistant’s grasper retract the IMV/left colic pedicle at the cut edge of the descending mesocolon upwards towards the enterior abdominal wall. He or she then dissects the plane between the mesocolon and Gerota’s fascia (readily identified by the transition between the two fat planes) with a 5-mm energy device (FIG 5). We like to dissect this space by gently pushing the retroperitoneum down with the blunt tip of the 5-mm energy device.
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