Laparoscopic-assisted single-port right colectomy: a standardized top-down technique and tricks to perform a better anastomosis

Introduction

In recent years, there has been a notable increase in colorectal cancer, which is now the third most diagnosed cancer, posing a significant risk to public health. Various surgical approaches have been developed to treat this type of cancer, ranging from laparoscopic techniques to robotic surgery. The concept of complete mesocolic excision (CME) with central vascular ligation (CVL) for the treatment of right colon cancer was first introduced by Hohenberger et al. (1) in 2009, marking an advancement in surgical methods.

This approach involves a precise dissection between the visceral and retroperitoneal planes, with the goal of preserving the visceral fascia to minimize the risk of tumor spread within the peritoneal cavity. The procedure involves mobilizing the colon and mesocolon along the embryological mesocolic plane, with an extensive regional lymph node dissection. This allows for clear exposure and central ligation of the colonic arteries at their origins, including the vessels supplying the colon.

Additionally, laparoscopic colectomy with intracorporeal anastomosis for right colon cancer has gained popularity due to improvements in laparoscopic stapling devices and enhanced techniques and skills among laparoscopic surgeons.

In this article, we demonstrate how to perform a laparoscopic single-port right colectomy, offering useful tips and strategies for young surgeons or those new to minimally invasive colorectal procedures.

Surgical technique

The procedure is performed with the operating surgeon positioned between the patient’s legs, using an assisted single-port access device inserted through a suprapubic incision (Figure 1). As a first step, the gastrocolic ligament is divided towards the hepatic flexure. Cephalad traction by the assistant on the gastric arcade and downward traction on the transverse colon by the operator are crucial to visualize the sheet connecting the stomach and the transverse colon. This step ends with the visualization of the underlying duodenum. At this stage, a surgical sponge is placed upon the duodenum and the transverse mesocolon is positioned upwards. Appropriate traction in proximity of the ileocolic junction exposes the ileocolic vessels, a peritoneal incision is performed and dissection between Toldt’s and Gerota’s fasciae is performed. The right part of the superior mesenteric vein and the duodenum are clearly visible, the origin of the ileocolic vessels is exposed, and both the vein and the artery are divided between clips. Dissection is carried on upwards, and, if right colic vessels are present, they are isolated and transected between clips.

Figure 1 Single-port placement and surgeon’s position.

Then, the last ileal loop is isolated, the mesentery is divided, and the bowel is transected using a linear stapler. The transverse colon is also divided, and the surgical specimen is placed upon the liver. At this stage, we perform an intracorporeal latero-lateral ileo-colic anastomosis. Using a barbed suture, several stitches are passed between the ileum and the transverse colon. This running suture has the double purpose of prophylactically closing the posterior corner of the future anastomosis and of facilitating the introduction of the linear stapler. Small enterotomies of the colon and ileum are made and the branches of a 60 mm linear stapler, for thin tissues, are carefully introduced. The previously placed running suture helps very much during this phase, helping to stretch the bowel in the right way. After the anastomosis is fired, the posterior corner of the anastomosis has been prophylactically closed using the previously placed running suture, which is now employed to close the enterotomy.

The surgical procedure ends with specimen extraction from the suprapubic incision, used to place the single-port device.

Intraoperative quality control involves the surgeon carefully checking the anastomotic blood supply and tension after completion, which are important steps in preventing anastomotic leakage (Video 1).

Discussion

The goal of CME is to extend the lymphadenectomy by excising a larger portion of intact mesentery. With the increasing use of laparoscopic surgery in clinical practice (2), CME has become a more challenging and complex procedure, requiring significant surgical experience and a steep learning curve. One of the main challenges lies in the central ligation of the vessels that supply and drain the right colon. The vascular anatomy of this area is highly variable, with most variations occurring at the level of the right colic artery and vein, the right branch of the middle colic artery and vein, and the Henle’s trunk (3). In particular, both the right branch of the middle colic artery and Henle’s trunk are crucial anatomical structures in the management of right colon cancer and other colorectal surgeries. Their careful handling ensures appropriate vascular control, minimizing the risk of complications like ischemia, while maintaining blood supply to the affected areas.

Our standardized approach is safe and simple and could be very useful for both young and expert surgeons. The main advantages of our surgical procedure are:

• The use of single-port access, which allows to have only a suprapubic abdominal incision, with better aesthetic outcomes and lower incidence of abdominal wall hernia.
• Surgeon placement between legs allow to have direct visualization of the superior mesenteric vessels and facilitate the vascular dissection.
• Starting the dissection at the gastrocolic ligament allows for visualization of the plane between the stomach and the transverse colon, ending with the visualization of the underlying duodenum.
• Our strategy to perform an intracorporeal latero-lateral ileo-colic anastomosis, with the placement of a small, barbed suture, which is left inside, before performing enterotomies, allows for closure of the posterior corner of the ileo-colic anastomosis, which is the site where anastomotic leaks occur more frequently. Of course, it is fundamental that the surgeon ensures that the posterior wall of the common enterotomy is completely closed, because a defect could occur even with a similar technique and result in a leak.

To conclude, in single-port laparoscopic surgery, the limited working space and the potential for instrument crowding are significant challenges (4). For less experienced surgeons, these challenges can make procedures more difficult and less precise, leading to possible complications and longer operation times. Proper training and practice are essential to overcome these issues and to perform successful surgeries in this minimally invasive format (5).

Acknowledgments

None.

Footnote

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-34/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-34/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was approved by the institutional review board of Fondazione Cardinale Panico. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this study, the accompanying image and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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