R sided colon or appendix cancers
Perforated caecal diverticulum with established infection.
Supine, arms tucked in.
Stand on patients right.
Midline approx 15cm
Depending on body habitus
Laparotomy inspection by vision and palpation.
Handling the tumour as little as possible.
Pack off small bowel to patients left.
Have the assistant retract the colon up to them for tension, work in
a flat plane
Divide peritoneal reflection along white line of Toldt
If the tumour invades the abdominal wall, excising a disc of
peritoneum and some underying muscle en-bloc with the specimen.
Develop the avascular plane between retroperitoneal fat and
embryological mesentery of right colon.
- as far as the duodenum with aid of a sponge.
- watching for and preserving the gonadal vessels and the ureter,
which are often deeper to the plane of dissection.
I routinely inspect for the R ureter because it is safe and good
practice to do so.
Dived any attachments at the ileum.
Take down the hepatic flexure.
- this is done by passing the operators fingers in layers and using
diathermy; often a few vessles here that need clips and ties.
- avoiding downward tension so that the communicating veins at the
head of the pancreas are not torn (these pass to the anterior
inferior pancreaticoduodenal vein)
Mobilise the lateral edge of the omentum off the flexure and
- this is done in a thin avascular plane tetween transverse colon
and gastrocolic ligament.
Now all colon is mobilised, determine resection and anastomosis
points, typically end of first third of transverse to around 10cm of
- (5 cm if tumour higher in ascending colon)
Score the mesentery along the resection line, noting positions of
right branch of middle colic, right colic if present and the
Develop avascular windows in the mesentery, using transillumination.
Take serial bites using fingers to feel vessels, diathermy to fat
and Harrison or cryle clips to vessels
Tie these with 2-0 vicryl ties.
Identify the ileocolic arterial pedicle, which is often visible as a
ridge with palpable pulsation.
- close to superior mesenteric artery in cancer to ensure good lymph
- closer to bowel if not cancer.
- doubly ligated with Harrison's clips and doubly tied with 0
Separately ligate the R colic artery if present.
- (90% of time it comes off the ileocolic).
And the R branch of middle colic is usually divided.
- (be careful to preserve the middle colic).
Clean the bowel ends of fat ~ 2cm at the anstomosis site.
I perform a side-side stapled anastomosis for its speed and for the
size and integrity of the join.
Bring colon and small bowel together at the site of anastomosis, put
in two stay sutures, make adjacent enterotomies at their
Insert nTLC along these ends.
Ensure no intervening mesentery and that stapler pointing straight
down the bowel.
Hold for fifteen seconds to force out extracellular fluid and then
- watch as stapler removed to ensure no bleeding in the lumen.
Grasp bowel ends with 3 babcocks, including one placed over the
Reload and fire across bowel, excluding the enterotomies, and
ensuring staple lines are not opposed.
Hand the specimen off the table.
I place 2 single 3-0 pds sutures to support the integrity of the
1 trouser stitch at intersection point of the staples.
2. imbricate the crossed staple line
+/- inverting the edges of the staple line
Close mesenteric defect with interrupted 3-0 pds
Cover anastomosis with omentum.
Check for haemostasis.
Mass abdominal closure with Loop 1 PDS.
Skin with monocryl unless contaminated then clips.
Alternative: hand sewn anastomosis.
I perform a side to side anastomosis in 2 layers
Non crushing bowel clamps, bowel only, one click.
3-0 pds stay sutures to the lateral bowel margins.
Running back wall seromuscular suture, tie, leaving suture on but
protected for anterior wall.
Double-armed 3-0 pds. Starting at mid point of back wall.
Pass through colon and small bowel seromuscular layers, ensuring got
wall, a small bite of mucosa.
Tie at mid point of pds.
Continue to one side of back wall in running fashion taking full
thickness bites but only small bites of mucosa; around 3mm apart.
Many other Alternatives, e.g.
Else end to end if no staplers
may need a Cheatle's cut at antimesenteric small bowel border
Interrupted single layer seromuscular sutures.
I give free fluids initially, progressing to diet as soon as
SB takes well; leak 1% in most series.
Alternatives and Controversies